摘要：With attention to the field of public health ethics growing, significant time has been devoted to identifying a sound ethical justification for paternalistic interventions that override individual autonomy to prevent people from adopting unhealthy behaviors. Efforts focused on specifying the conditions that warrant paternalism, however, are largely misplaced. On empirical and ethical grounds, public health should seek instead to expand individual autonomy to improve population health. To promote autonomy, the field should redirect current efforts toward clarifying principles of justice. Although public health’s most highly visible stance is associated with an egalitarian conception of “social justice,” it is imperative that public health professionals address gaping divisions in public understandings of justice. I present recommendations for initiating this process. THERE HAS BEEN A SURGE OF interest in public health ethics in recent years. Whereas medicine focuses on individual health, public health is concerned with the health of the entire population. Thus, in contrast to the primary fiduciary duty to the individual patient found in clinical medicine, public health ethics is founded on a societal responsibility to protect and promote the health of the population as a whole. 1 On the basis of this distinction, many commentators have suggested that one major issue that distinguishes public health ethics from clinical ethics is identifying when paternalistic interventions that override individual autonomy are justified. 2 – 9 The considerable attention paid to identifying plausible justifications for restricting individual autonomy to change unhealthy behaviors is largely misguided. This focus fails to give sufficient weight to the shift from infectious to chronic diseases as the leading causes of morbidity and mortality. In light of this shift, public health would be better served by seeking to expand autonomy through promoting justice. Although the call for social justice is frequently voiced in public health, it is critically important for the field to address major differences in definitions of justice found among the general public. The issues of promoting autonomy and clarifying principles of justice are significant for several reasons. Undue attention to justifying interventions designed to limit and control unhealthy behaviors distracts attention from potentially more fruitful strategies. Currently, excessive time and energy are devoted to questions about whether “sin” taxes are inherently regressive, debating the efficacy of advertising bans, and the like. 10 A related concern is that seeking to shore up support for paternalistic interventions may result only in undermining trust of public health authorities. 10 – 13 More importantly, to achieve public health goals, greater consideration must be directed toward promoting a common understanding of a just society, about which there are gaping divisions in modern American society.
