This idea is critical because the political community does not have a clear sense of the concept of public health apart from the discourse around health care reform.
Efforts to assure access to high-quality health care are certainly an important part of improving the public’s health, but they play a relatively minor role compared to broader efforts to assure equitable access to healthy living conditions. Society faces threats from emerging and resurgent infectious diseases such as Zika virus, declining vaccination rates, antimicrobial resistance, and the threat of bioterrorism (for example, from anthrax and smallpox).
Bioethics, because of the premium it places on individual rights, has had limited relevance to the ethical dilemmas of public health, which often involve balancing individual rights against the needs of the community as a whole.
Under the public health tradition, individual interests may have to yield to those of the broader community when necessary for the public’s health, safety, and well-being.
In competent individuals, harm to self or immoral conduct is insufficient to justify state action.
Consequently, “risk to self” is a much more controversial justification for public health regulation.
More recently, restrictions on tobacco, fast food, and sugary drink manufacturers and retailers have riled critics who claim these actions invoke a public health “nanny state.” Opponents of paternalism value freedom of choice, arguing that individuals should be allowed to decide for themselves, even if they make what experts might deem the “unhealthy” or “unsafe” choice.
Supporters of paternalism point out that there are both internal and external constraints on people’s capacity to pursue their own interests.
At the same time, public health law and ethics are evolving to address the mounting burdens of noncommunicable disease such as cancer, cardiovascular disease, diabetes, and chronic respiratory disease, injuries or deaths (for example, related to drug overdose, guns, and motor vehicles), and the social determinants of health (for example, the impact of household income, community resources, and structural racism on population health).
Efforts to address these burdens more broadly prompt political opposition from people who would prefer a narrower scope for public health law.