The first way: Doing good and the problem of instrumental rationality

There are many challenges to the public health. Obesity is a world-wide problem; pollution causes many thousands of deaths; HIV spreads over the world; infectious diseases, once conceived of as being eradicated, threaten modern societies; burnout and stress endanger wealth and prosperity and the young and women increasingly drink and smoke. In the early 1980s, carefully controlled, scientifically designed health promotion interventions Ð such as the many heart disease prevention programs (the Stanford three- and five-community studies, the Minnesota Heart Health plan, the Pawtucket trials, the Karelia intervention, the highly intensive and individualized Multiple Risk Factor Intervention Trials (MRFIT) Ð did not produce much success. Thus, the public health community urgently felt the need for some wins in improving the public health approach. One of the main thrusts to achieve this was via reduction in tobacco consumption. The evidence on the morbidity and mortality associated with smoking is clear (although still disputed by some in the tobacco lobby). By presenting

this evidence to the public and use of various incentives and restrictive measures, public health professionals have succeeded in reducing smoking prevalence from 70% in the 1950s to 30%. As a consequence harm from smoking related disease is prevented.

The pessimistic view on public health is exposed by critical thinkers such as Buchanan⁴⁴. The optimistic view is held by communitarian thinkers such as Beauchamps. Both views can be found in the public health community, although the science driven health promotion paradigm dominates. This unstable opposition between the pessimistic and the optimistic view on public health will not be resolved in this chapter. On the contrary, we have to delve deeper, because this analysis will show that a common theme underlies both sides. A good start is to analyze one critical thinker, namely Buchanan.⁴⁴

The major line of argument against current public health practice Buchanan derives from the philosopher Charles Taylor Ð particularly his analysis The Malaise of Modernity (1992) Ð which traces two important principles, on the one hand the dark side of individualism and on the other hand the primacy of instrumental reason. The latter is especially picked up by Buchanan. Instrumental reason is the separation of ends and means, hence determining the best available means for the ends set by public health. As defined by Taylor: ÒBy Ôinstrumental reasonÕ, I mean the kind of rationality we draw on when we calculate the most economical applications of means to a given end. Maximum efficiency, the best cost-output ratio, is its measure of successÓ (p10). Indeed, many of the ends set by the public health seem to be fixed and indisputable: stop smoking, avoid fat, exercise more, eat healthy food, etc. The only remaining issue then is what the best and most effective means are. On this basis Buchanan criticizes the public health community: Òthe quest for a science of health promotion both reproduces and reinforces the instrumental outlook that Taylor and others see at the core of our modern moral malaiseÓ (p11). Indeed, relevant passages can be extracted from the public health field to sustain this claim: Òresearch programs have been established to identify and test the most effective methods for achieving individual behavioral changeÓ Òrandomized control trials are the most rigorous tests of health behavior interventionsÓ, and Òthe search for truth and for an ultimate understanding of the forces that make humans think, feel, and act as they do is the long-term goalÓ⁴⁵. In these and other cases there is no discussion on the ends themselves. The criticism Buchanan⁴⁴ exposes is to focus again on the values underlying the process of setting the ends: well-being, virtues, autonomy, solidarity, etc. We do see here how Buchanan departs from KantÕs philosophy stating that in scrutinizing public health ends, as Buchanan says quoting from KantÕs philosophy: ÒAct so that you treat humanity, whether in your own person or that of another, always as an end and never as a means onlyÓ.

KantÕs categorical imperative indeed forms an important yardstick for evaluating the ends set by the public health community. However, BuchananÕs⁴⁴ main argument here is that if, and only if, the ends have been set reasonably, through some sort of deliberative process, then the rest follows. Thus, as Buchanan says, ÒIt does make a difference, for example, whether young people consciously and deliberately choose not to use drugs, or whether their attitudes are effectively altered through Ôindirect influence techniquesÕ and Ôconditioning in low thought situationsÕ.Ó Likewise, people may lose weight by taking pills, but they will not gain the dignity and self-respect that comes through exercising self-control. Buchanan⁴⁴ quotes the sociologist Robert Bellah at length who spells out the implications for health promotion: ÒThe purpose É is not to produce or control anything but to discover through mutual discussion and reflection between free citizens the most appropriate ways, under present conditions, of living the ethically good life É It is precisely the point about praxis [social practice] that it

has no extraneous product. It has an end, namely, the good of human beings, but that end is attained through itself, that is, through action or practice that is ethical and political É. For Ôhelping professionalsÕ, this would involve toleration of high levels of uncertainty in trying to aid people to improve their own skills of practical autonomy, rather than categorizing them in terms of preconceived theories with resulting automatic formulas for treatment.(p19)Ó

In line with BellahÕs reasoning Buchanan⁴⁴ asks for modesty on behalf of public health professionals and rightly so. High levels of uncertainty should be the credo as well as the aim to interact and deliberate over the ends to be set. This has a strong HabermasÕ kind of ring, which indeed can be extracted from KantÕs philosophy as Habermas did. But Kant is quite sceptical about this approach of social deliberation as it stands alone. The reason is that any practice which aims at doing good has a drive of domination and control. As Dahrendorf writes, Òit is difficult to think of human association without an element of domination. Where there is society, there is powerÓ.^viii

This approach set by Buchanan⁴⁴ and others is deeply flawed. It avoids the fundamental problem. The public health community feels intrinsically responsible for promoting public health and rightly so. If smoking leads to morbidity, and particularly in innocent people, e.g.

children, pregnant women, asthmatic people etc., then certainly one would like to develop programmes and policies to promote the good and to prevent the bad. If providing healthy food programs in schools and at work improve health, one would surely enact such programs.

ÒNevertheless, É the inherent exercise of power [in developing techniques to effect behavior change] remains a problemÓ.^ix The key tenet here is that both sides identify the problem of domination, power and control at the same level, namely at the level of the relationship between ends and means. Buchanan and other critics of the public health endeavour to solve the problem by improving the setting of the ends. Thus, Buchanan refers to Selznick^x: ÒThe claims of efficiency are strong, but they cannot justify practices that reduce human beings to Ômeans onlyÕ. Such practices make them victims of dominationÓ. Domination is the key term here, indeed, but cannot be rescued in terms of social deliberation for setting the ends alone, since it still aims at benevolence alone. The proponents of the public health paradigm hope to solve the problem through relaxing the methods, that is by flexibly moving between the offerings of methods on a voluntary or a mandatory basis, but again lacks the legitimate basis by denying justice. Both approaches will not do as KantÕs philosophy exposes. For, public health intrinsically engages in a practice of doing good, that is, to aim at making people do

viii Marshall TH, Bottomore T. Citizenship and Social Class, London: Pluto Classic Press, 1992, p. 26. In the public health literature this is also known as the Ôdemocracy problemÕ, that is should experts of the public set the ends of public health policies (cf. Murray CJL, Salomon JA, Mathers CD and Lopez AD, eds. Summary

measures of population health Ð concepts, ethics, measurement and applications. WHO Geneva 2002, particularly part 12 and 14.)

ix quoted from Buchanan, p. 15 c.f. Nordenfelt L. Towards a new paradigm for health promotion. Medicine, Health Care and Philosophy 2000; 3:317-319, who makes the argument that Buchanan does not criticize the biological kind of public health, say for instance environmental policy or biomedical prevention. The problem is however deeper, because it affects both sides, e.g. enacting laws for banning smoking relates both to behaviour of people and Ôbiological effectsÕ, i.e. the reduction of lung cancer caused by passive smoking. It is about the question of making to do people what one wants them to do through more or less persuasive or even compulsive measures (referring to Nordenfelt p.319).

x Buchanan claims that Selznick Ôbrings home the Kantian pointÕ. In fact, he doesnÕt as is argued in this paper:

the setting of the ÔendsÕ should be captured within the framework of KantÕs political philosophy, which claims that the setting of the ends cannot be based (in any politics or policy) on the notion of benevolence alone, but has to be framed within the notion of the just or the right.

what one wants them to do through more or less persuasive or even compulsive measures.^xi Kant offers here a painstaking analysis in stating that enacting policies to do good can never be based on benevolence itself, as utilitarianism, communitarianism, or (egalitarian) liberalism would have it.^xii

Admittedly, many public health programmes and policies do not aim at promoting good behaviour only, proposing health and related conditions in terms of equity and fairness, say by promoting equal opportunities and defining health as a resource for social participation. If so, then such programs and policies cannot frame the issue in terms of benevolence. The benevolent policy should also be a just policy, a policy that performs the right thing.

In this sense the passive smoking case is such an intriguing case. For, few public health officials seem to acknowledge that the end of reducing passive smoking should be disputed Ð this is the point of Buchanan⁴⁴ Ð whence compulsive measures are ethically justified because the harm to be prevented is so huge. Even raising questions with regard to this strict banning policy provokes disbelief and disdain amongst public health professionals.

Here is the problem: where is the injustice which should be repaired and compensated for or which should be prevented? Those who think that this is a silly question, might get the boomerang back. For, anyone who defies this question, claims that doing good is by itself the legitimate ground for enacting public policies. Yet, this would implicate that all kinds of behaviour considered deviant by the majority of the population Ð ranging from homosexuality to nasty fat people to eccentric artists Ð can be banned under the label of doing good to society. Reversely, this implies that all kinds of behaviour considered virtuous by the majority of the population can be the legitimate ground of public policies.

This leads to the moralizing of politics, whether this is inspired, in the words of Taylor, by the dark side of individualism or the bright side of communality. This leads to a political philosophy which starts from the distinction between the individual and the social, instead of the distinction between the private and the public, which plays a crucial role in KantÕs political philosophy and which has been taken up by Dewey more than a century later.