There Isn't Enough Moral Philosophy in Public Health

I know philosophy gets a bad rap these days. Many people think it's just a bunch of useless navel-gazing. Saying there isn't enough philosophy in something practical like public health is like saying there isn't enough interpretive dance in civil engineering, or there isn't enough basket weaving in meteorology. But this is a mistake. Without some kind of philosophical grounding, it's impossible to say which decisions are correct. It's impossible to figure out how to trade off one cost versus another, and it's impossible to justify curtailing people's freedoms, as public health institutions often do.

I've criticized the term public health in multiple previous posts. As far as I can tell, the term doesn't have a coherent definition, at least not one that justifies the existence of government "public health" institutions in any serious way (the FDA, the CDC). Public Health is like a magic incantation that lets the government interfere with our decisions without actually justifying itself. It's as if the goal were to expand human lifespans at any cost, or reduce this or that morbidity rate regardless of people's actual preference for risk. In fact public health officials often explicitly use this kind of language.

If you want examples, read anything by Jacob Sullum on the FDA's misguided efforts to regulate vaping. (Here and here for example.) Sullum repeatedly points out that any restrictions placed on vaping will cause some number of adults to decline to switch from cigarettes to vaping. Vaping is almost certainly safer than smoking cigarettes (though I think there are legitimate concerns that there might be unseen long-term effects), so any missed opportunity to make the switch is bad news even from a strict public health perspective. Sullum even quotes Gottlieb, the FDA chief:

"It's implausible for me to say that there aren't kids out there who are using e-cigarettes instead of combustible tobacco and probably, if they never had this opportunity, would have used combustible tobacco." But he added that it's hard for the FDA to consider that as "a public health justification" when "our mandate is that no child should be using a tobacco product." That suggests the FDA's mission to reduce underage vaping may conflict with the public health goal of minimizing morbidity and mortality.

Even if "public health" means something narrow like "minimizing overall mortality and morbidity across the population," then the FDA is apparently bad at it. They have to follow their mandate off a cliff, without even considering other public health considerations. This doesn't even get into any of the philosophical questions about how to weigh the costs and benefits of restricting people's freedoms. Suppose people really like vaping, even though it turns out vaping removes, say, a year from the life of the average vaper. Vapers decide that the cost is tolerable. Does "public health" demand that we restrict vaping above and beyond the way people voluntarily restrict their own vaping habits? Or here's another philosophical consideration. The FDA seems so concerned with protecting children ("our mandate is that no child should be using a tobacco product") that it's willing to throw a large number of adults under the bus. (An infinite number, as Gottlieb's recitation of his mandate would seem to imply? I hope not, but I don't see what would constrain them.) But wait a minute. Is it so terrible if a "child" vapes? (Does "child" mean "anyone under 18"? Does anyone remember being this age and resenting their lack of autonomy? Does this get any weight at all in the social calculation?) Most of the health consequences of smoking, and presumably vaping, come much later when the child has become an adult and this adult has continued their bad habit for a lifetime. If smoking were acutely toxic, killing some random users instantly, there would be a much stronger case for restricting youth use. Admittedly, it's probably easier to prevent a child from ever starting the habit than it is for an adult to end their long-standing habit. But the framing of "We're protecting children" seems misguided. "We're protecting adults, who would otherwise have a harder time controlling their behavior" doesn't sound quite as compelling as "We're protecting the children." But it would be more honest.

Consider the so-called "opioid epidemic." From a public health perspective, people only see that upward-trending line showing the increase in opioid-related deaths. The only valid goal from a public health perspective is to mechanically bring that trend line back down. The CDC's initial reaction was to do something like this. They issued misguided prescribing guidelines, which completely ignored the variability in actual pain patients' responses to the medicine. These "voluntary" guidelines ended up being used as justification for law enforcement to harass doctors and patients who were prescribing/prescribed "too much." This was a foolish overreaction by the CDC to something that wasn't even a real "public health" crisis in any meaningful sense. Some patients were hurt by these restrictions, and by "hurt" I mean "cast into crippling agony." (I argue here, it was no more a "crisis" than increased driving leading to more driving deaths is a crisis.) And what is the public health benefit of these restrictions? That people who want to use opioids to get high have a harder time finding them? Is that even a benefit? Again, public health obliterates free choice with an all-trumping mandate bring the trend line down. Pleasure counts. It damn well ought to, at any rate.

In his book Good Calories, Bad Calories, Gary Taubes describes a miserably austere diet that would have a small impact on heart disease and obesity rates. You'd basically have to starve yourself for your adult lifetime in order to gain a few months of life. Some doctors and public health officials advocated for the diet anyway, apparently taking an "improve society's health metrics at all costs" perspective. This kind of "no man left behind" thinking is just indefensible.

I'm thinking of other examples that are not necessarily from our public health institutions. Here are several. Sometimes people at my jiujitsu school get injuries, and they ask their doctors how to deal with them. Sometimes they get the clueless response, "Well, quit doing the thing that's getting you injured!" (Some doctors are better than others. One of my injured colleagues found a sports doctor who had worked with the American Olympic weightlifting team, so he understood the notion of training though injuries and training to overcome injuries.) To this doctor, this hobby was all cost. If you can't understand the love of the sport, you won't understand why someone would risk injury to continue it. Russ Roberts has mentioned on Econtalk (I can't find the episode right now) a friend who likes to ride his motorcycle, but who broke his arm in an accident once. His doctor told him to stop riding or he'd stop treating him. Russ' friend, bless him, said, "What the hell do you mean? I love riding my motorcycle." To Russ' friend, cycling was an enriching hobby, and the risk was a price worth paying. I spoke to one older gentleman who was on testosterone treatment. On a high dose, he could get away with less sleep, but on a lower dose, the one that his doctor ultimately prescribed to him, he had to sleep for 11 or 12 hours a day. Suppose we get more total hours of waking life under one treatment regime, even if technically we die at a younger age. Does "public health" have anything at all to say about this trade-off? If it does, and if it conflicts with an individual's preference for "more total waking hours, but a shorter overall life", does public health trump individual choice? (I can't say that any official public health policy led to any of the above examples, but the "better health at all costs" mindset is pervasive anyway.)

I think we really need to realign the mission of our public health institutions so that they are consistent with a free society. (First step: realign them so they are actually coherent.) Doing this might require some squishy moral philosophy. All that public health data is useful, and props to the CDC for collecting it and making it publicly available. But what society ultimately does with that information is not their call.