Smoking has long been declared a health hazard. In 1964, the U.S. Surgeon General revealed that smoking was related to lung cancer. Subsequent reports linked smoking to numerous other health problems. Recent statements by the Surgeon General indicated smokers do have the right to decide to continue or quit; however, their choice to continue cannot interfere with the nonsmoker's right to breathe smoke-free air.The full impact of adverse health consequences of involuntary smoking may not be recognized (...) yet. Smoke is now known to affect everyone who breathes it. Even when one doesn't smoke, the nonsmoker is susceptible to the ill effects because of inhaling smoke. (shrink)

Public reason demands that policies are justified to all reasonable citizens. Public health aims at protecting or improving aggregated health outcomes. Since health is not an uncontroversial value, an insurmountable chasm between public reason and public health seems to preclude any viable synthesis between the two outlooks. For any given public health policy, some reasonable citizen seems to have a reason to support ‘no policy’ over ‘some policy’, meaning that the policy cannot be justified to all. The paper first (...) spells out what exactly this conflict is about. Then, using smoking as a case, the paper outlines a model of reconciliation between public reason and public health that should give us some optimism if we want to have public health policies that are compatible with treating citizens as free and equal in the public reason sense. (shrink)

This paper offers a relatively comprehensive assessment of government anti-smoking policies (both taxation and other regulatory measures). I conclude that interventions to engender in smokers and prospective smokers an accurate perception of tobacco's health risks are justified, that except in the case of adolescents addiction by itself does not justify intervention beyond providing adequate information, that the proper goal of tobacco taxation policy should be to recoup only the extra costs that smokers place on others (at most a (...) $1/pack tax on cigarettes), and that passive smoke's imposition of harm on unconsenting others strongly supports at least the development of a safe-to-others smokeless cigarette, if not direct intervention. (shrink)

This study addresses whether businesses discriminate against employees who smoke, which for the purposes of this study is called smokism. It began with a description of the employers' costs which led to the development of these smoking bans and examined several company policies as a result of these costs. The viewpoints from several perspectives toward these policies and their perceptions about smokers were also reviewed. This was followed by surveying the corporate smoking policies of 76 (...) companies representing 287 employees in the New York City metropolitan, as well as the viewpoints of these employees on these smoking policies. Several laws regarding the rights of smokers and nonsmokers were discussed and along with the company smoking policies described earlier were compared to those firms surveyed. Next, the philosophies of Locke, Kant, Rawls, and Nozick were examined to determine whether the current smoking policies would be deemed just or discriminatory. Conclusions and implications of this research then followed the analysis of these philosophical and legislative findings. (shrink)

Smoking is disproportionately common among the disadvantaged, both within many countries and globally; the burden associated with smoking is, therefore, borne to a great extent by the disadvantaged. In this paper, I argue that this should be regarded as a problem of social justice. Even though smokers do, in a sense, ‘choose’ to smoke, the extent to which these choices can legitimise the resulting inequalities is limited by the unequal circumstances in which they are made. An analysis of (...) the empirical literature reveals a variety of factors—such as targeted advertising, unequal dissemination of information about the health risks of smoking and inequalities in smoking norms—that make the disadvantaged more likely to become smokers and less likely to quit successfully. The paper then considers a range of common tobacco control policies from the perspective of social justice. The social justice perspective developed here poses a challenge for policy-makers: on the one hand, social justice concerns strengthen the case for tobacco control policies because such policies disproportionately benefit the health of the disadvantaged. At the same time, however, we must be particularly sensitive to any harms associated with such policies because such burdens, too, will fall largely on the disadvantaged. (shrink)

The Indonesian Ulema Council (MUI) has issued an illegitimate fatwa against smoking in mosques because it endangers the health of worshippers and interferes with the comfort of worshippers. This study aims to investigate smoking behaviour in mosques and violations of fatwas from ulama and governor regulations. This study follows a cross-sectional design conducted by interviewing 531 Muslims who have prayed in the mosque for the last 14 days and observed the compliance of the mosque in implementing a smoke-free (...) policy in 315 mosques. Frequency distribution and cross-tabulation were carried out using JASP 16 software using cross-tabulation. The results of this study indicate that the implementation of the smoke-free policy for mosques in Medan has been violated many times (57.8%), especially the violation regarding smoking in mosques (32.1%); cigarette butts were still found in the yard of the mosque (44.1%). Violations of the policy of fatwa smoke-free areas occurred in public mosques (61%) and muhammadiyah mosques (46.5%). Smoking behaviour in mosques was seen in the last 2 weeks, namely smoking behaviour carried out by worshippers (57.6%), smoking behaviour carried out by mosque administrators (39.2%), smoking behaviour carried out by community leaders in mosques (19.4%) and smoking behaviour that ulemas carried out in mosques (14.3%). Worshippers must comply with the rules against smoking in mosques because it can endanger the health of other worshippers. Cigarette smoke in the mosque will make other worshippers uncomfortable to worship so that it can damage the solemnity of the congregation to worship in the mosque. Contribution: This study is expected to explain smoking behaviour in mosques, violations of smoking behaviour in mosques that violate the ulama’s fatwa regarding smoking behaviour in mosques and the governor’s regulation on smoking behaviour in mosques. (shrink)

It is axiomatic that tobacco smoking is hazardous to health. The statistics are well documented and often very grim. For example, the 2008 World Health Organization Report on the global tobacco epidemic presented the following statistics: a hundred million people died of tobacco-related diseases globally in the 20th century; there are approximately over five million tobacco-related deaths every year; and an estimated one billion could die of tobacco-related diseases in this 21st century.Significantly, no other risky, self-indulgent addictive behaviors such (...) as cocaine abuse directly endanger bystanders as much as cigarette smoking or tobacco use endangers nonsmokers through secondhand tobacco smoke or inhaled environmental tobacco smoke. Environmental tobacco smoke comprises sidestream smoke and mainstream smoke. About 85 percent of environmental tobacco smoke is sidestream smoke, while the remainder is mainstream smoke. (shrink)

Are the risks of smoking exaggerated? Has there been an open and rational discussion about the risks of smoking? This book attempts to answer these and many other questions about smoking. It provides a detailed empirical presentation on smoking behavior as a risky consumer decision. Using new empirical data based on several national and regional surveys, Viscusi addresses several issues, including: the sources of information that people have about the risks of smoking, the accuracy of (...) their perceptions of risks associated with smoking, and the consistency of smoking decisions with other risky behavior--scrutinizing issues such as whether smokers value risk differently than those who wear safety belts. Viscusi also looks at the differences in age groups and how they assess these risks based on public information. He provides new insight into the degree to which individuals understand smoking risks and take these risks into account in their smoking behavior. With its detailed empirical data and its examination of individual decision-making processes, this work will interest researchers in public health, public policy analysis, psychology, and economics, as well as anyone concerned with this important issue. (shrink)

Experimental vaccines are being developed for the treatment of ‘unhealthy lifestyles’ and associated chronic illnesses. Policymakers and other stakeholders will have to deal with the ethical issues that this innovation path raises: are there morally justified reasons to integrate these innovative biotechnologies in future health policies? Should public money be invested in further research? Focusing on the case of an experimental nicotine vaccine, this article explores the ethical aspects of ‘lifestyle vaccines’ for public health. Based on findings from a (...) qualitative study into a vaccine for smoking cessation, the article articulates possible value conflicts related to nicotine vaccination as an intervention in tobacco control. The ‘vaccinization’ of lifestyle disease piggybacks on the achievements of classic vaccines. Contrary to expectations of simplicity and success, quitting smoking with a vaccine requires a complex supportive network. Social justice and public trust may become important ethical challenges when deciding whether to use further public funds for research or whether to implement these innovative vaccines in the future. (shrink)

As a result of workplace clean air regulations and strict guidelines imposed by the Joint Commission on Accreditation of Healthcare Organizations in 1993, most hospitals in the United States are now virtually smoke free. Although evidence suggests that these restrictions both cause smoking employees to consume fewer cigarettes per day and induce some employees to quit smoking entirely, the policies have also driven many healthcare providers—including physicians—onto the public sidewalks for their cigarette breaks. Patients entering many hospitals (...) pass white-coated medical students and residents puffing away at the curbside. (shrink)

This chapter contains sections titled: Moral Argument Science and Health Argument Social Policy Argument.

New Zealand and Malaysia have abandoned plans to introduce a generational smoking ban because of concerns that such a policy is incompatible with liberal democracy as it undermines autonomy. This paper challenges this claim by showing that smoking is not an autonomous act. Autonomy requires a deliberation of preferences, wills and inclinations. This does not occur in smokers because of three related factors: nicotine addiction, cognitive biases and psychosocial development in addiction. Nicotine addiction results in strong physical and (...) psychological desires to seek pleasure and to avoid withdrawal. This is further potentiated by conditioned behaviour. Cognitive biases explain why smokers act in ways that are detrimental to their health. Psychosocial development explains how the brains of smokers are unable to make rational decisions. This combination renders smokers unable to reflect on their actions and thus act autonomously. This stance is compatible with Mill’s view that actions that devalue autonomy cannot be considered autonomous. Defenders of liberalism should not be quick to dismiss a smoking ban and can instead foster autonomy by supporting it. (shrink)

Smoking is frequently presented as being particularly problematic when the smoker is a pregnant woman because of the potential harm to the future child. This premise is used to justify targeting pregnant women with a unique approach to smoking cessation including policies such as the routine testing of all pregnant women for carbon monoxide at every antenatal appointment. This paper examines the evidence that such policies are justified by the aim of harm prevention and argues that (...) targeting pregnant women in this way is likely to do more harm than good. Routine carbon monoxide testing is particularly problematic as it sends a message to pregnant women that they cannot be trusted either to truthfully answer questions as to whether or not they smoke, or to make decisions in the best interests of themselves and their future children in the way that non-pregnant individuals are. Further, if the aim is to reduce rates of prenatal harm, the evidence suggests that adopting a supportive and empowering approach to prenatal care is the most effective way to achieve this, something that the current policies aimed at pregnant women are in conflict with. (shrink)

Considerations of objective-value freedom and status freedom do impose constraints on policies that restrict access to cigarettes. As to the objective-value freedom, something of value is lost when anti-alcohol policies lead to pub closures interfering with valued life styles, and a similar, though weaker, argument can be made for cigarettes. As to status freedom, non-arbitrariness requires consultation with vulnerable populations to learn what might aid them with smoking cessation.

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Safe and healthy housing conditions are critical to improving population health, particularly for the most vulnerable – young children, senior citizens, and individuals with chronic illnesses and disabilities – who spend more time at home and are more susceptible to illness and injury. Across the country, millions of Americans are exposed to lead, radon, asbestos, volatile organic compounds, pests, mold, carbon monoxide, and tobacco smoke in the home, affecting the air they breathe and the water they drink. These household hazards (...) are also associated with a wide range of illnesses and injuries, including asthma, cancer, falls, respiratory infections, and mental health issues. Legal and policy interventions can assist communities grappling with the adverse impacts of poor housing conditions and improve the health and safety of all residents, including vulnerable populations. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general (...) public, as well as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (shrink)

Bitton and Eyal's lengthy critique of our article on unassisted cessation was premised on several straw-man arguments. These are corrected in our reply. It also confused the key concepts of efficacy and effectiveness in assessing the impact of cessation interventions and policies in real-world settings; ignored any consideration of reach (cost, consumer acceptability and accessibility) and failed to consider that clinical cessation interventions which fail more than they succeed also may ‘harm’ smokers by reducing agency. Our article addresses each (...) of these problems, concluding that any consideration of the ethics of promoting smoking cessation in low-income nations should begin and end with the question of whether the strategies to be adopted have any prospect of influencing significant numbers of smokers to quit. (shrink)

In this paper, we examine the importance of two different peer effects as determinants in the adolescent’s decision whether or not to smoke. One is measured at the class level and the other reflects the smoking behaviour of the adolescent’s best friends. A nationally representative wave of Spanish data, collected in different state and private centres of secondary education and vocational training, and several linear probability models are used to estimate the role of peer effects. We find that a (...) 10 % increase in the proportion of classmates is associated with a 3.6 points increment in the probability of smoking. Similarly, if the smoker’s friends go from “only some” to “the majority”, the probability of smoking increases by 39 points. Although both peer effects are significant if introduced separately, the class peer variable is not significant once the closer peer effect is introduced. Our work provides evidence to support the hypothesis that peer effects are important determinants of smoking among adolescents. This has implications for policy-makers, since the existence of peer effects would amplify the effects of interventions. (shrink)

Corporate social responsibility has become a potential path to legitimacy and improved public relations for both companies that produce mainstream products and those that sell vice, such as the tobacco industry. Since the early 1990s, the tobacco industry has sought to bridge the gap between the public perception it has earned as a merchant of death and its goal of gaining corporate legitimacy and normality by promoting programs, positions, and policies it hopes the general public will believe are aimed (...) at preventing or mitigating some of the societal ills that smoking causes, such as youth smoking. There is, however, an intractable problem that corporate social responsibility efforts can mask but not resolve: the tobacco industry’s products are lethal when used as directed, and no amount of public relations or funding of ineffective youth smoking prevention programs can reconcile that fundamental contradiction with ethical corporate citizenship. The focus of this study is to better understand the tobacco industry’s corporate social responsibility efforts and to assess whether there has been any substantive change in the way it does business with regard to the issue of exposure to secondhand smoke. (shrink)

The ‘tobacco-free generation’ policy, which bans cigarette sales based on birth year, presents a bold public health initiative but raises significant ethical and practical concerns. As behaviours like drug use become legal and criminal penalties are reduced, singling out smoking for generational restriction appears inconsistent within an increasingly permissive society. Kniess1 critiques this approach for creating inequities by selectively limiting freedoms, conflicting with principles of fairness and adult autonomy. A more balanced public health strategy could involve uniform restrictions on (...) harmful substances or prioritising informed personal choice, supported by harm reduction and education to encourage healthier alternatives. The generational smoking ban targets specific birth cohorts, prohibiting tobacco sales to those born after a certain year. Unlike universal bans, it creates two distinct adult classes—those permitted to smoke and those who are not—resulting in an apparently arbitrary division. Critics, including Schmidt,2 point to the ethical inconsistency of restricting liberties for some while leaving others untouched. This policy design has been defended as a pragmatic compromise, aiming to protect future generations without infringing on the established habits of current smokers (Grill and Voigt).3 Kniess1 evaluates this selective restriction through relational egalitarianism which emphasises the importance of equal social relationships. The cut-off, …. (shrink)

Butte, Montana, lies at the headwaters of the nation's largest Superfund site. Donald MacMillan's book is a morality tale about this environmental travesty—a story of damaged health and environment, futile efforts by citizens and government to halt that damage, and demoralization resulting from those failed efforts.MacMillan's story covers the period from the 1880s to the 1930s. In the first phase, he describes the struggle between the young city of Butte and negligent smelter owners. In the second, the smelter owners shifted (...) the problem to a nearby town and surrounding farmers. In the third, the federal government attempted to enforce conservation policy.When miners first settled Butte in the 1860s, they found a lush valley high amid the peaks of the Continental Divide. By 1890 Butte was a major source of copper for a growing nation. Ore was roasted in open heaps a city block long. Sulfur and arsenic fumes killed vegetation for miles around. When winter inversions trapped smoke, residents suffered nosebleeds and vomited in the streets. Up to eighty people a month died in this town of just 40,000.The city sent abatement notices. Mine owners ignored them, arguing, “No smoke, no wages for workingmen.” Though open heap roasting ended because it was inefficient, new roasting furnaces did little to ease the problem. The growth of the Anaconda Copper Mining Company did end the problem—at least for Butte residents. By 1906 nearly all of Butte's ore was shipped twenty‐six miles down the valley to ACM's Anaconda smelter. Each day it belched thirty tons of arsenic and 2,500 tons of sulfur into the air. Whole herds of horses, cattle, and sheep lay wasted in the fields. ACM paid $330,000 for damages within five miles of the Washoe but refused compensation to more distant farmers.Afflicted farmers filed a lawsuit, offering to settle for a $1,175,000 buyout of their 60,525 acres. ACM declared their land not worth $500,000 and then spent nearly $1 million to prove it. Farmers lost when the judge—who socialized with ACM executives—found against the farmers in 1909. ACM had utilized “best known methods” and therefore should not be liable for any damages.Smoke poisoned national forest lands as well as farmers' fields. Trees within twenty‐five miles of Anaconda were dead or damaged. President Theodore Roosevelt and Chief Forester Gifford Pinchot initiated an investigation through the U.S. attorney general's office that eventually sought $4 million in damages from ACM. The company stalled, hoping for a more tolerant administration following the elections of 1908. In 1911 President William Howard Taft, trusting industry to do the right thing, created the “Anaconda smoke commission”—a group of industry and government advisors—to oversee ACM's implementation of pollution controls. In 1916 ACM's smelter still emitted sixty‐two tons of arsenic and 1,700 tons of sulfur each day.In 1924 ACM finally took effective steps to remove most of the arsenic from its emissions. Because of high demand for arsenic insecticides to fight boll weevils, ACM made considerable profit on arsenic recovery. Problems with farmers ended when the farmers, financially bankrupt from their lawsuit, sold “smoke rights” or easements to ACM. Problems with the federal government ended after 1928 when President Herbert Hoover, who promoted government‐industrial partnership, approved the swap of healthy ACM timberlands for damaged national forest.As a resident of Butte, it is hard for me to keep in mind that this is a historical account. Although ACM's smelting operations ended in 1974, the legacy of cultural and environmental damage lingers on. The morning newspaper reported forty‐six homes in Butte contaminated with lead and arsenic: “The federal Agency for Toxic Substances and Disease Registry is conducting an investigation, and encourages all children to be tested.”. (shrink)

This is lightly edited and referenced version of a presentation given at the 20th International Philosophy of Nursing conference in Quebec on 23rd August 2016. Philosophical texts are not given the same prominence in nurse education as their more valued younger sibling, primary research evidence, but they can influence practice through guidelines, codes and espoused values. John Stuart Mill’s harm principle, found in On Liberty, is not a universal law, and only a thoroughgoing libertarian would defend it as such, though (...) it, or its remnants, can be seen can be seen in policy documents. But its influence is weakening. Smoking bans in enclosed spaces were initially justified with other‐regarding considerations, but judgements from unsuccessful legal challenges from patients in UK psychiatric hospitals rely on preventing harm to the smoker, even when smoking outside, which does not harm others. In the wake of legislation, no‐smoking policies enacted by hospitals are becoming more aggressive, banning smoking both inside and outside, and extending the use of power gained through employment to prevent nurses assisting patients enjoy a lawful habit. Mill’s dictum has been subverted, and this speaks to the fundamental purpose of nursing. Should nurses collude and willingly exert their power for their version of the good of the patient? Or should they instead reaffirm values that support and facilitate life choices made by autonomous people? The paper supports the latter option, and this has wider application for nursing which can be illuminated, if not settled, by revisiting Mill and his famous dictum. (shrink)

ABSTRACT There is a fierce debate about nonsmokers-only hiring policies, also referred to as no-nicotine hiring policies and “tobacco free” hiring policies. The favorable outcomes of no-nicotine hiring policies include reduced health costs, improved worker productivity, enhanced organizational image, and symbolic messaging. The unfavorable consequences of such policies include violating personal liberty, risking a “slippery slope” to other health-compromising behaviors, exacerbating socio-economic disparities, and discriminating against smokers. No-nicotine hiring policies have not been adequately evaluated (...) and a new approach is warranted. The new conditional employment policy for smokers is described with stipulations for the probationary period. Autonomy and fairness are frequently cited as ethical principles to analyze no-nicotine hiring policies. An analysis of ethical principles is presented for no-nicotine hiring policies and the new conditional employment policy. The ethical principle of fairness is rooted in the effectiveness of any policy. Therefore, an evaluation plan is described for the conditional employment policy to assess effectiveness and efficiency. The proposed policy provides a powerful incentive to overcome smoking addictions, preserve the ethical principles of autonomy and fairness, as well as bridge the divide between personal liberty and personal responsibility. (shrink)

Individuals can often take steps to preserve or improve their own health. They can eat appropriate quantities of healthy foods, exercise, and refrain from smoking. They can obtain preventive care and adhere to their physicians’ advice about how best to manage their health. But they often fail to take these steps.A widespread failure to adopt healthy behaviors can significantly erode public health while increasing health care costs. Obesity, for example, increases the risk of heart disease, stroke, liver disease, and (...) certain cancers. By one estimate, it is responsible for almost 10 percent of medical spending in the United States, or about $147 billion per year. Smoking increases the risk of heart disease, stroke, lung disease, and cancer; it accounts for nearly 20 percent of deaths each year in the United States and about $96 billion in health care expenditures. (shrink)

Health behaviors such as tobacco use contribute significantly to poor health. It is widely recognized that efforts to prevent poor health outcomes should begin in early childhood. Biomedical enhancements, such as a nicotine vaccine, are now emerging and have potential to be used for primary prevention of common diseases. In anticipation of such enhancements, it is important that we begin to consider the ethical and policy appropriateness of their use with children. The main ethical concerns raised by enhancing children relate (...) to their impact on children’s well-being and autonomy. These concerns are significant, however they do not appear to apply in the case of the nicotine vaccine; indeed the vaccine could even further these goals for children. Nevertheless, concerns about broadly applying this enhancement may be more challenging. The vaccine may be less cost-effective than alternative public efforts to prevent tobacco use, utilizing it could distract from addressing the foundational causes of smoking and it might not be publically acceptable. Empirical research about these concerns is needed to ascertain their likelihood and impact as well as how they could be minimized. This research could help determine whether behavior-related enhancements hold promise for improving children’s health. (shrink)

E-cigarettes, sometimes referred to as ENDS, include a broad range of products that deliver nicotine via heating and aerosolization of the drug. ENDS come in a variety of forms, but regardless of form generally consist of a solution containing humectant, flavorings, and usually nicotine ; a battery-powered coil that heats the solution into an aerosol in an atomizing chamber; and a mouthpiece through which the user draws the vapor into the mouth and lungs. The devices may be closed systems containing (...) prefilled cartridges, or open systems, where the user manually refills a 1-2 ml. tank with solution. What started as closed-system cigarette-shaped devices marketed as an adjunct for smoking cessation, has transitioned rapidly to literally thousands of hip and funky-designed open-system hookah pens, vape pens, and modifiable devices. For younger people, these forms are the “in” thing, while traditional cigarette-shaped devices are “out.”. (shrink)

In recent work, Norman Daniels extends the application of Rawls's principle of ‘fair equality of opportunity’ from health care to health proper. Crucial to that account is the view that health care, and now also health, is special. Daniels also claims that a rival theory of distributive justice, namely luck egalitarianism (or ‘equal opportunity for welfare’), cannot provide an adequate account of justice in health and health care. He argues that the application of that theory to health policy would result (...) in an account that is, in a sense, too narrow, for it denies treatment to imprudent patients (e.g. lung cancer patients who smoked). In a different sense, Daniels argues, luck egalitarian health policy would be too wide: it arguably tells us to treat individuals for such brute-luck conditions as shyness, stupidity, ugliness, and having the ‘wrong’ skin colour. I seek to advance three claims in response to Daniels's revised theory, and in defence of a luck egalitarian view of health policy. First, I question Daniels's assertion regarding the specialness of health. While he is right to abandon his insistence on the specialness of health care, it is doubtful that health proper can be depicted as special. Second, I try and meet Daniels's objections to luck egalitarianism. Luck egalitarian health policy escapes being too narrow for it does not in fact require denying basic care to imprudent patients. As for it being allegedly too wide, I try to show that it is not, after all, counterintuitive to rid individuals of unfortunate and disadvantageous biological traits (say, a disadvantageous skin colour). And third, I question whether Daniels's own Rawlsian account is in fact wide enough. I argue that fair equality of opportunity fails to justify some standard medical procedures that many health systems do already practice. (shrink)

A recent trend in policy responses the rising public resentments with inequality is to prod the wealthy into spending a fraction of their profits on projects that promote social welfare. Legitimati...

In bioethics, the predominant categorization of various types of influence has been a tripartite classification of rational persuasion (meaning influence by reason and argument), coercion (meaning influence by irresistible threats—or on a few accounts, offers), and manipulation (meaning everything in between). The standard ethical analysis in bioethics has been that rational persuasion is always permissible, and coercion is almost always impermissible save a few cases such as imminent threat to self or others. However, many forms of influence fall into the (...) broad middle terrain—and this terrain is in desperate need of conceptual refining and ethical analysis in light of recent interest in using principles from behavioral science to influence health decisions and behaviors. This paper aims to address the neglected space between rational persuasion and coercion in bioethics. First, I argue for conceptual revisions that include removing the “manipulation” label and relabeling this space “nonargumentative]influence,” with two subtypes: “reason-bypassing” and “reason-countering.” Second, I argue that bioethicists have made the mistake of relying heavily on the conceptual categories themselves for normative work and instead should assess the ethical permissibility of a particular instance of influence by asking several key ethical questions, which I elucidate, that relate to (1) the impact of the form of influence on autonomy and (2) the relationship between the influencer and the influenced. Finally, I apply my analysis to two examples of nonargumentative influence in health care and health policy: (1) governmental agencies such as the Food and Drug Administration (FDA) trying to influence the public to be healthier using nonargumentative measures such as vivid images on cigarette packages to make more salient the negative effects of smoking, and (2) a physician framing a surgery in terms of survival rates instead of mortality rates to influence her patient to consent to the surgery. (shrink)

The stigmatization of some groups of people, whether for some characteristic they possess or some behavior they engage in, will initially strike most of us as wrong. For many years, academic work in public health, which focused mainly on the stigmatization of HIV-positive individuals, reinforced this natural reaction to stigmatization, by pointing out the negative health effects of stigmatization. But more recently, the apparent success of anti-smoking campaigns which employ stigmatization of smokers has raised questions about whether stigmatization may (...) sometimes be justified, because of its positive effects on public health. Discussion of the issue so far has focused on consequences, and on some Kantian considerations regarding the status of the stigmatized. In this article, I argue that further Kantian considerations regarding the treatment of the general public (the potential stigmatizers) also count against any public health policy involving stigmatization. Attempts to encourage stigmatization are likely to fail to appeal to the rational decision-making abilities of the general public, and the creation of stigmatized groups (even if they are stigmatized for their voluntary behavior) is an obstacle to the self-improvement of members of the general public. (shrink)

Does law matter regarding public health outcomes? Regardless of what one may think about the answer to this age-old question, in recent years the public health community has increasingly demonstrated and recognized the roles that public health laws and policies play in effectuating long-lasting and broad-based population-wide changes. Public health laws and policies have been instrumental in the following ways: reducing smoking prevalence; reducing underage alcohol-related drinking, driving, crashes, and fatalities; reducing exposure to second-hand smoke; eliminating vaccine–associated (...) paralytic poliomyelitis ; increasing seat-belt use and reducing traffic fatalities; reducing dental carries; and reducing access to and consumption of unhealthy foods and beverages sold in schools and to reductions in caloric intake and overweight. In fact, in a review of the ten greatest public health achievements in the 20th century, all were influenced by policy change. (shrink)

New York City has extensive public health regulations. Some regulations aim to reduce smoking, and they include high cigarette taxes and bans on smoking in public places such as bars, restaurants, public beaches, and public parks. Other regulations aim to combat obesity. They include regulations requiring display of calorie information on some restaurant menus and the elimination of transfats in much public cooking. One important issue is whether New York City officials -- including both public health officials and (...) other city officials -- have adequately explained the justification to the public. Explanation has practical importance; the public might not back controversial and restrictive regulations unless offered a good rationale. But explanation is also an official duty, since public officials should make their reasoning transparent to their constituents. This article argues that New York City has not adequately communicated the rationales for its regulations to the public. It then offers several suggestions for improving public communication. After laying out those suggestions, this article points out that even if communication were improved, New York City’s regulations would still raise difficult philosophical issues. Those issues are briefly discussed in the final sections. NOTE: this is a reprint of a conference presentation. (shrink)

Machine generated contents note: Preface; Introduction Angus Dawson; Part I. Concepts: 1. Resetting the parameters: public health as the foundation for public health ethics Angus Dawson; 2. Health, disease and the goal of public health Bengt Brülde; 3. Selective reproduction, eugenics and public health Stephen Wilkinson; 4. Risk and precaution Stephen John; Part II. Issues: 5. Smoking, health and ethics Richard Ashcroft; 6. Infectious disease control Marcel Verweij; 7. Population screening Ainsley Newson; 8. Vaccination ethics Angus Dawson; 9. Environment, (...) ethics and public health: the climate change dilemma Anthony Kessel and Carolyn Stephens; 10. Public health research ethics: is non-exploitation the new principle for population-based research ethics? John McMillan; 11. Equity and population health: toward a broader bioethics agenda Norman Daniels; 12. Health inequities James Wilson; Index. (shrink)

Smoking remains the leading cause of preventable disease and death in the United States, killing approximately 480,000 people each year. This crushing health burden falls disproportionately, and recent CDC data shows that large disparities in adult cigarette smoking remain. One factor in these disparities is the use of flavors. Menthol cigarettes and other flavored tobacco products are used at higher rates by vulnerable populations including youth and young adults, African Americans, women, Hispanics and Asian Americans. This is no (...) accident; the tobacco industry has long targeted these same groups. Given FDA's failure to act to ban flavored tobacco products, states and municipalities are considering taking matters into their own hands to protect their communities from these dangerous products. The authors will explore state and local authority to restrict the sales of these products and review the evidence base indicating that removing flavored tobacco products – and menthol combustible products in particular - from the market would significantly reduce the toll of illness and death caused by these products. (shrink)

Although the effectiveness of some tobacco programs and policies has been clearly demonstrated in reducing the overall population smoking prevalence, the health benefits are not equally distributed across all socio-economic classes; a situation that clearly runs against the equalitarian ethos of most modern states. In this article, we evaluate the benefits of using Sen’s Capability Approach as a theory of social justice to guide public health program and policy development in a way that would prevent the further increase (...) of inequalities in health outcomes. Starting from four consensual goals of tobacco control practice (i.e. that individuals live a smoke-free life, that smokers quit smoking, that non-smokers are protected from exposure to second-hand smoke and that smoking cessation support is accessible) we found that besides the standard interventions (e.g. education on the harms of smoking, policies to reduce exposure to SHS) an iniquity-proof tobacco control program needs also to address the lack of options of underprivileged people in affordable smoke-free settings and in leisure activities. We conclude that an ethical tobacco prevention program needs to address the broader social determinants of health such as the socio-economic policies that put a strain on people’s capacity to shun or quit smoking. (shrink)

The tobacco industry’s involvement in the electronic cigarette research that informs public health policy is controversial. On the one hand, some are concerned that their involvement presents conflicts of interest that bias research outputs and invalidate the policies that use them. On the other hand, some have argued that the tobacco industry may support valid research and contribute to the goals of public health, for instance, if the interests of the e‐cigarette industry could be part of a tobacco (...) class='Hi'>smoking cessation policy. We approach this debate from the ethical perspective of the public interest and the public good, considering how legitimate researchers can square their expert opinion with validating tobacco industry‐funded research, given the perfidy of the tobacco industry and paucity of robust, conclusive evidence on the public health impacts of liberalizing e‐cigarette use. (shrink)

We propose a descriptive version of the classical multi-attribute utility model; to that end, we add a new parameter, momentary salience, to the customary formulation. The addition of this parameter allows the theory to accommodate changes in the decision maker’s mood and circumstances, as the saliencies of anticipated consequences are driven by concerns of the moment. By allowing for the number of consequences given attention at the moment of decision to vary, the new model mutes the criticism that SEU models (...) call for an omniscient decision maker. Use of the model is illustrated with a large-scale longitudinal study showing that adolescent smokers have higher utility for smoking than nonsmokers. We also propose to use the model hierarchically to describe everyday decisions that people deal with repeatedly. Big decisions, which set policy, guide a host of nested little decisions, which in turn lead to action. For a little decision, one of the options will be consistent with the policy, and will inherit its high utility. Accordingly, most little decisions will be made quickly and will follow the policy. However, people do sometimes decide to violate their own policies, and we describe how these lapses can lead to collapse of the policy. (shrink)

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons (...) and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being. (shrink)

Paternalist policies in public health often aim to improve people’s well-being by reducing their options, regulating smoking offering a prime example. The well-being challenge is to show that people really are better off for having their options reduced. The distribution challenge is to show how the policies are justified since they produce losers as well as winners. If we start from these challenges, we can understand the importance of the empirical evidence that a very high proportion of (...) smokers regret smoking. In short, it is important that they regret it and important that the proportion is so high. This paper explains how, philosophically, regret can relate to well-being and it considers some of the strengths and weakness in the empirical research that the explanation brings out. The regret case for regulating smoking is indeed strong, although not as strong as the empirical researchers think. It is much weaker for paternalistic intervention in other public health problems, such as obesity and binge drinking. (shrink)

There are many ethical decisions in the practice of health research and care, and in the creation of policy and guidelines. We argue that those charged with making such decisions need a new genre of review. The new genre is an application of the systematic review, which was developed over decades to inform medical decision-makers about what the totality of studies that investigate links between smoking and cancer, for example, implies about whether smoking causes cancer. We argue that (...) there is a need for similarly inclusive and rigorous reviews of reason-based bioethics, which uses reasoning to address ethical questions. After presenting a brief history of the systematic review, we reject the only existing model for writing a systematic review of reason-based bioethics, which holds that such a review should address an ethical question. We argue that such a systematic review may mislead decision-makers when a literature is incomplete, or when there are mutually incompatible but individually reasonable answers to the ethical question. Furthermore, such a review can be written without identifying all the reasons given when the ethical questions are discussed, their alleged implications for the ethical question, and the attitudes taken to the reasons. The reviews we propose address instead the empirical question of which reasons have been given when addressing a specified ethical question, and present such detailed information on the reasons. We argue that this information is likely to improve decision-making, both directly and indirectly, and also the academic literature. We explain the limitations of our alternative model for systematic reviews. (shrink)

The Ethics of Public Health Paternalism is about policies that try to stop people damaging their own health. From the point of view of public health advocates, if people did not smoke, or drank less alcohol, or kept off junk food and sugary liquids, they would tend to be healthier. Hence such tactics as taxing tobacco, restricting the sale of alcohol, and limiting the density of fast-food outlets. These tactics are often pejoratively described as the actions of a 'nanny (...) state' that overvalues health and wrongly infringes on the autonomy of adults. But many of us want to be healthy rather than ill, and alive rather than dead. Does a state really nanny us when it uses its power to make us healthier? If it does, should it stop? (shrink)

Encouraged by the success of smoking denormalization strategies as a tobacco-control measure, public health institutions are adopting a similar approach to other health behaviors. For example, a recent controversial ad campaign in New York explicitly aimed to denormalize HIV/AIDS amongst gay men. Authors such as Scott Burris have argued that efforts like this are tantamount to stigmatization and that such stigmatization is unethical because it is dehumanizing. Others have offered a limited endorsement of denormalization/stigmatization campaigns as being justified on (...) consequentialist grounds; namely, that the potential public health benefits outweigh any stigmatizing side effects. In this paper, I examine and reject the blanket condemnation of stigmatization efforts in public health. I argue that the moral status of such efforts are best evaluated within a contractualist, as opposed to a consequentialist, framework. Contractualism in public health ethics asks whether a particular stigmatizing policy could be justified to reasonable individuals who do not know whether they will be affected by that policy. Using this approach, I argue that it is sometimes permissible for public health institutions to engage in health-related stigmatization. (shrink)

In the United Kingdom, a number of National Health Service Clinical Commissioning Groups have proposed controversial measures to restrict elective surgery for patients who either smoke or are obese. Whilst the nature of these measures varies between NHS authorities, typically, patients above a certain Body Mass Index and smokers are required to lose weight and quit smoking prior to being considered eligible for elective surgery. Patients will be supported and monitored throughout this mandatory period to ensure their clinical needs (...) are appropriately met. Controversy regarding such measures has primarily centred on the perceived unfairness of targeting certain health states and lifestyle choices to save public money. Concerns have also been raised in response to rhetoric from certain NHS authorities, which may be taken to imply that such measures punitively hold people responsible for behaviours affecting their health states, or simply for being in a particular health state. In this paper, we examine the various elective surgery rationing measures presented by NHS authorities. We argue that, where obesity and smoking have significant implications for elective surgical outcomes, bearing on effectiveness, the rationing of this surgery can be justified on prognostic grounds. It is permissible to aim to maximise the benefit provided by limited resources, especially for interventions that are not urgently required. However, we identify gaps in the empirical evidence needed to conclusively demonstrate these prognostic grounds, particularly for obese patients. Furthermore, we argue that appeals to personal responsibility, both in the prospective and retrospective sense, are insufficient in justifying this particular policy. Given the strength of an alternative justification grounded in clinical effectiveness, rhetoric from NHS authorities should avoid explicit statements, which suggest that personal responsibility is the key justificatory basis of proposed rationing measures. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Hobbits as Buddhists and an Eye for an "I"Paul Andrew PowellWhen a medieval scholar friend of mine1 (knowing that I am a longstanding student of Zen), asked me if I would read J. R. R. Tolkien's famous fantasy trilogy The Lord of the Rings to see what Buddhism, if any, could be culled from it, I was not enthusiastic, especially after watching the movie (yes, I watched the movie (...) before I embarked on the text), so full of heroes, their passionate violence, monster-like foes, and fantastic scenarios.2 Hardly the compassion of the Buddha, I thought. The trilogy is as well replete with Christian references and Tolkien was a devout Catholic, and much has been written on these and that, but I decided that that literature would not b e germane to this short and singular investigation. At any rate, I was not encouraged about the project, and yet, a certain character did happen to exhibit one intriguing feature that caught my Buddhist attention from the beginning. And as I began to read deeper into the text, a larger—implausible, some would say—thesis began to form in my mind around this character's one particular attribute. And I thought that at least I might cultivate one's imagination and jar one's thinking in productive ways. So I confess that the inferences I make and conclusions I draw here may be a bit fantastic (perhaps to match the material). But, to answer the question: Is there any Buddhism in The Lord of the Rings? Please keep an open mind, and in the spirit of fantasy, indulge my commentary on this quest.Sauron's EyeSauron's Eye can be associated with at least two considered forms of consciousness: will and omnipresence. It is "The Eye: that horrible growing sense of a hostile will that strove with great power to pierce all shadows of cloud, and earth, and flesh, and to see you: to pin you under its deadly gaze, naked, immovable."3 Also, we find that "The Dark Lord was suddenly aware of him [Frodo], the Eye piercing all shadows... Its wrath blazed like a sudden flame and its fear was like a great black smoke, for it knew its deadly peril, the thread upon which hung its doom... [I]ts thought was now bent with all its overwhelming force upon the Mountain."4 But will (we will return [End Page 31] to "omnipresence" some other time) is a neutral force. And clearly, Sauron's will is not neutral; it is a profoundly malevolent will. For we can also read that Sauron is a "dreadful menace of power... brooding in deep thought and dreadful malice."5 He is full of "policies and webs of fear and treachery... stratagems and wars."6An Eye For An I?Buddhism is a practice which reveals the true nature of things: self, reality, suffering. So let's more deeply consider the nature of Sauron's corruption. It seems unlikely, from a Buddhist view, that the Oxford scholar's central villain is a simple stand-in for brute evil (as might appear upon a first reading), for if evil is ontological then the only reasonable response to it is to strategize how best to cope with its encounter. This, in fact, is the Christian response to evil. Evil is: it exists a priori as a supernatural force outside of human intervention and its temptations may be successfully resisted through self-discipline and moral strength, and possibly an appeal to the supernatural, but never defeated absolutely by a stratagem of human will. It is true that Frodo struggles to resist the Ring's power, but mere coping is not the Fellowship's strategy. The fact that Tolkien's Fellowship actually undertakes to destroy the Ring through stratagem admits that Sauron's corruption is an emergent property of an underlying and vulnerable source rather than a supernatural, a priori property outside of human intervention.Instructively, and like the Fellowship, Buddhists as well understand that human suffering possesses an underlying and vulnerable source that can be overcome in human terms, and this vulnerable source of suffering is the human I. The Buddha... (shrink)

Preemption is a powerful strategy used by special interest groups to undermine strong, local public health standards. Currently, 20 states in the U.S. have preemption ordinances in place related to clean indoor air initiatives. These preemption laws are the direct result of an ongoing and aggressive campaign of tobacco companies to thwart clean indoor air initiatives, which ultimately, according to tobacco industry internal documents, cause significant reductions in their annual revenues. Clean indoor air policies have arisen from a greater (...) understanding of the documented health risks associated with exposure to secondhand smoke and action by local government to protect the public from these hazards. The efforts of the tobacco industry undermine local authority and seek to shift policy action to the state and federal levels, where the industry has greater political influence. (shrink)