Elsevier

Public Health

Volume 129, Issue 8, August 2015, Pages 1092-1098
Public Health

Mini-Symposium
A balanced intervention ladder: promoting autonomy through public health action

https://doi.org/10.1016/j.puhe.2015.08.007Get rights and content

Highlights

  • Criticizes the Nuffield Council on Bioethics ‘intervention ladder’ for assuming that public health action reduces autonomy.

  • Summarises current models of autonomy in ethics and political philosophy.

  • Shows that public health interventions often promote rather than reduce autonomy.

  • Introduces a ‘balanced’ intervention ladder which reflects this fact.

Abstract

The widely cited Nuffield Council on Bioethics ‘Intervention Ladder’ structurally embodies the assumption that personal autonomy is maximized by non-intervention. Consequently, the Intervention Ladder encourages an extreme ‘negative liberty’ view of autonomy. Yet there are several alternative accounts of autonomy that are both arguably superior as accounts of autonomy and better suited to the issues facing public health ethics. We propose to replace the one-sided ladder, which has any intervention coming at a cost to autonomy, with a two-sided ‘Balanced Intervention Ladder,’ where intervention can either enhance or diminish autonomy. We show that not only the alternative, richer accounts of autonomy but even Mill's classic version of negative liberty puts some interventions on the positive side of the ladder.

Section snippets

Public health ethics and the intervention ladder

The 2007 Nuffield Council on Bioethics report Public health: ethical issues1 is a foundational document in the field of public health ethics. It was the subject of the opening editorial in the first issue of the journal Public Health Ethics2 and continues to be widely cited in that and cognate journals. Many of these authors take issue with elements of the report, as we do here, but it remains a key point of reference even for its critics. The Nuffield report developed a framework for

Theories of freedom and autonomy

The Intervention Ladder embodies a conception of freedom that can be termed negative, liberal, or libertarian and which equates autonomy with non-interference. On this conception, any intervention designed to promote public health necessarily comes at a cost to individual autonomy; and, consequently, stands in need of justification. This non-interference conception of autonomy means that the burden of proof is placed on public health advocates to demonstrate that the welfare benefits of any

Positive freedom and autonomy

Negative neo-liberal and republican conceptions of freedom contrast with ‘positive’ conceptions, according to which freedom requires not merely the absence of constraints but also sufficient power and resources—material, social and psychological—to pursue one's own ends effectively.12 Positive accounts of freedom regard non-interference—even resilient non-interference—as insufficient; by these accounts, freedom requires skills and substantive opportunities that do not exist de novo, but must be

A balanced intervention ladder

The richer perspectives on autonomy that we have reviewed in this paper are well known in contemporary ethics and moral psychology, and have been discussed in public health ethics.6, 23 If they are to have any influence on public discussion and on policy, however, they will need to be formulated in a manner as appealing as the original Intervention Ladder. This is readily done by a ‘balanced’ version of the ladder, in which inaction represents zero and actions may have either positive or

Acknowledgements

We would like to thank Pierrick Bourrat for comments on the draft and assistance with preparation of the manuscript.

Ethical approval

None sought.

Funding

None declared.

Competing interests

None declared.

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