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"H~e~a-I~th P~romot[on af~ :P~t~b,lie Pol|cy~ The N:eed for Moral Groundings''= ~EDMUND D. PELLEGRINO CONTEXT OF THE DEBATE The promotion 9f health, was a central tenet of Hippocratic medicine and of Paidea, the Greek educational ideal ~2). Today, in the midst of the golden ag~ of cura~iv~ med~icin~,.the time of this ~a~ien~ ideal seems t~ have come again. Ther¢ are mountin~ pl~a:s, rot extensive ~atio'~al pragrams or prevention and health pro- motion. They promise to compete for expenditures with curative medicine. A publlc~ debate over' the allocation of funds is in the 0~ng. - - The debate will focus on the choice betweenseveral go0d things~cure and prevention, personal freedoms, and social and economic welfare of the nation. It wilt turn on such questions as the allocation of scarce resources, the potential C0tiflictdf in~lividiJ~fand ~o'cial gdod and the e~tent/6-w-hi~h e,~eri the m-0st benign :.::--_:.::::government.mayinterveneJnour personal-lives to_improve:our~health habits (9)._- 0038 These are. moral questions not to be ~ettled on economic and political grounds alone. They involve our conceptions of the good life. Their resoiutlon requires some moral principles against which to measure conflicting goals and obligations. An ethics of preventive medicine and health promotion is part of the expansion of ethical concerns to include a broad range of health-related public policy deci- sions (5, 8). No formal ethics of prevention is currently at hand to set the normative guidelines for the forthcoming debate. This essay offers some tentative principles that might ground the choices. It is tentative and sketchily developed. [ hope only to underscore the need for a more formal and fully developed ethics of prevention. The Surgeon General's report of July 1979 t I) urges us to take action as a nation to modify drastically our personal behavior. It points out, as did the Lalonde report of a few years ago (3), that billions of dollars.could be saved if we eliminate smoking, control obesity, curb alcohol and drug use, modify work and living environments, drive safely, exercise regularly, and cope reasonably with emo- tional stress. It confirms, too, that the cumulative effects of medical cures on national health are small compared with what could be accomplished by more hygienic living (4). Aristotle's conviction that the good society is not possible without healthy ' Reprinted wilh permission from "'Working for a Healthier America," copyright It380, Ballinger Publishing Company. = Presented at the 50th Anniversa~" Symposium. Blue Cross: Blue Shield. Wa',hingtun, D.C., De- .... 371 0091-7-t35i81/030371-08,$0L I{0T|CE: THIS MATERIAL MAY BE PIIOTECTED BY. COPYIIIGHT LkW (TITLE 17 U. S. COPE) TI05280114

372 EDMUND D. PELLEGRINO F~t~¢,nz, se¢,~bs to I~ eapturi~' h.~~,n~tio~ once again. Unalike ~he ~nc,ients, "however, we are motivated~y'the enormous economic burdens of the unhygienic life-styles rather than the inherent good of a healthy li~e or its necessity for the go~ society. We live in a mo~ priori, zeal ~d interdependent societ~ i~ which ~,g~ go, ~e~~. ;t~e-~b~s m~se~ of ~-at~on. quarantine, and immuniza- tion. Their success depends upon massive changes in personal behavior and on an energetic pursuit of the public health. Our national experiences with the energy and environmental crises, with gun control, and with c~me, however, show all too painfully our collective proclivity for short-term satisfactions over long-term social benefits. To modif~ personal health habits implies not only some effective form of persuasion but even some coercion in selected instances. The proposed measures rang~ from the mildest kinds of coerci~on, li.ke education a, nd~ opinion manipulation through the mass reed:in, to the more [orceful, like tax ~nd insurance dollar incentives and disincen- tiu~, to the most coercive, legal prohibition. ~e s~cia,l~ an:d moral implicatt~,ns ofrhese proposed measures are of the utmost sign,ificance in a democratic and pluralistic society. They touch on the kind of life we think worth living, on the things we are willing to trade for good health and economic security, on the balance between libertarian autonomy and government dictates. There is unlikely to be universal consensus on these matters inn demo- cratic ~0ciety that promises a maximal degree of personal choice. Yet we must define what constraints, ifany, we can accept to enhance the common good which promises to elude us. unless we do alter our deleterious life style~. ~ - _.:. • Thd d~bate promises to be as difficult as it isindispensable. There are true believers on all sides 0f the question: some who See health as a new salvation theme for mankind, and others who would willingly run the risks of bodily dam~e and economic disaster so they can pursue their own version of the good life, however deleterious it may be. Still others place fiscal and economic health as the first needs of a good society and convert economics into ~deology (6). The line of argument that is. and will be. debated is simple enough: certain life-styles result in disease, disability and death with economic consequence~ damaging to the whole of society. Thus, there is a social mandate to encourage healthier life-styles in all ~itizens. But completely volunta~ measures promise to be ineffective. Therefore, for the good of all, measures to enforce personal com- pliance are justi~ed. This line of argument is customarily advanced or attacked on economic and political grounds because these aspects are more hmiliar and urgent to decision makers than moral discourse. Granting their obvious importance, economic and political philosophies are themselves grounded in more fundamental human values and these must be more explicitly examined if moral choices'are to be ran'de among policy alternatives, If the forthcoming debates about health promotion are to be better grounded. two things are required at a minimum: ~a~ Whatever measures are selected for universal a~plicatioa musl be demonstrably effective. This is to say, ~he probabil- Tt05280115

ity of success is high enough to warrant making difI~cult choices among competing goo~ tbi,ngs,, and (b)~ the c:hoiees, the.m-sel~e.s~ mu~t be gi'ounded, in some set of Deba'tes about the ethical use of new knowledge or techniques often go awry because of unrecognized uncertainties in the data supporting their application. To distinguish what is known with certainty, ffhat is unknown and what is problem- atic is admittedly difficult but it is the first step in any debate. Experts who are the guardians of"the facts" all too often are "'true believers.'" They are easily tempt- ed to screen out uncertainties in their favored technique or to confuse technical with moral authority.' ,B'ut ~:taeta~r.tia~,~e ~o. speci,al l~rerogatives ~-mitling them to 'make value judg- t~ts t~0~ r,l~# ~ o'g~hum.ankind. Their ffisgr~iohar~; space is n~¢ssarily limited (~)~'~The~,r l~'m~u~g~pon~tbtl,~ty ~s to p~,o>x~/d~.~,lid~ f~ct smtem~za.ts and to outline pr6perly weighed. 'Po.licymakers and moralists working with uncertain facts can go dangerously and foolishly astray. - With respect to health promotion there are two preeminent fact questions in deciding whettaera proposed modification of personal behavior is morally defen- sible;. (a) How good is the causal connection between the suspect behavior and. disease? And (b) Does the method proposed to modify deleterious behavior actu- ally do so? Decisions about the justifiability of a preventive measure or a method ofc~anging behavior must start with reliable facts about causal connection and effectiveness. The effectiveness of preventive measures and advisffbility of widespread pro- motion depends on the strength of the evidence linking certain personal habits to specific illnesses. Some of the relationships are firmly establish.ed, others are suggestive but not proven, and others merely speculative.~ For example, there is no doubt now that smoking causes cancer of the lung, larynx, esophagus, tongue, lip, coronary disease, emphysema; that alcohol is linked to cirrhosis, automobile and airplane accidents, and coupled with smoking, increases the incidence of laryngeal and esophageal cancers; that caries is linked to carbohydrates in the diet: that salt and hypertension, obesity, and increased morbidity go hand in hand; that asbestos, radiation, and certain industrial chemi- cals are linked to cancer; that early multiple sexual contacts and herpes simplex viruses are linked -to cancer of the cervix; that higher auto speeds, and driving without seat belts, or a motorcyclist without a helmet are associated with fatal accidents. In these instances the evidence is direct and obtained from observa- tions in man. In other examples the evidence is suggestive but not well substantiated in man. = No at,tempt is made here to cite the voluminous llteralure supporting these statements. Nor is a special case b~ing made for the cla,,sification. What is esscnlial is that there are v.'tr~ing degrees of certitude as to causation and in each instance that degree must be a~certained as precisely, as possible or moral implications cannot be correctly weighed. TI05280116

E DM UN'D D. PELLF-GRIHO fi~i~e~d to ~ib$¢~, ,of t=he 1~ op~l~ti:oa, or,o,b~i:ned in test systems who~se ~ruence in the diet, the utility of vigorous exercise, the damaging eff.ects of stress, the re[ati~oR to, cancer of.the n~tr,~es~ cyclamates, the cost-benefits of mu~tip|e more study before preventive measures can reasonably be prescribed. Here we might include the evidence linking a wide variety of"food additives, chemicals, and drugs to human cancer, or the epidemiological evidence for higher or lower inci- dences of cancer, coronary disease, or longevity in certain populations where the interactions of genetic, environmental, social, and cultural factors have yet to be separated, or the relationship of certain emotional and attitudinal states to mor- bidity and mortality--or the highly debatable status of high doses of vitamins C and E i~n~ human disease, to mention a, few hotly contested relationships. Where th~ evidence is very strong as in the first group, concerted governmental and: ~_u.blig ,Ore~grams would seem ju$~tiBable to urge voluntary compliance and ew-e:@ t~.~a~l~.iy coercive measures off varying types. Wher~ the evidence is sugges- tive but not tully .established. public programs should be undertaken, with great caution. Involuntary measures would be difficult to defend morally. Prudent ad- vice through education to ~nd~vlduals might be more in order allowing each person to decide whether he wishes to erron the side of safety and in how many situations he. wo.uld do so. When the evidence is merely speculative, only information under- scoring the uncertainties would be justified. Eve~ this must be done with caution because if too many_ common practices or substances are condemned, ~he public becomes cynical, throws up its hands, and says. "everything causes cancer." This becomes an easy excuse for not changing personal habits, even when such changes would be truly effective. Even if causal relationships are established, personal behavior must be modified accordingly if health is to be promoted. However. the same questions must arise about the effectiveness of the methods propos.ed to bring about a given change in life-style. Education is the most widely used means for eliciting voluntary compliance with recommendations that promote health. Its effectiveness is difficult to assess and often dubious. There are few studies with controls that would show that behavioral change Is actually the result of educational intervention. Health habits are tightly woven into the fabric of a person's entire life--his emotional needs. self-image, social, fatuity.and peer pressures, changing public opinion about what is chic. sophisticated, or "'macho." Movements like the current fashion in joggling and running, the increase of smoking in young girls, the cult of leanness, the vegetarian trend, and the one-a-day vitamin craze, arise in complex matrices in which education may play a major, minor, or insignificant role. Changes in smok- ing habits among the educated may be an exception• But the precise role of education is still difficult to ascertain in determining most life-style changes. Nor is the ['ormal transfer of information about health sufficient. Complemen- T105280117

tary measures are usually necessary--group discussions, clubs, buddy systems, individual and group psychotherapy, follow-up ~i~si~, hy~aosis, biofeedback, so- :i~a[ly som~ of th-e mos~ impotent factors correlating with heaRh habits are insusceptible to education or behavior modi~cation, like marital status,-sex, in- come, social class, ~amily size, geog~phy, race, culture and ethnic identi~ation, or personality type. These are more powefl~l delerminants o~ response and re- lapse ~tes than modifiable ~actors like ~nformation. They are changed only with difficulty'and at considerable risk to personal freedom and the character o1" our entire society. None o:f ~his ~s ~ suggest t'~at s~O~:~isti~ted:, mu~ltimedi.a educational methods s-~ou.ld ~ot be u~e~. I~ do~ s:u:~g~t th-at s~lect~d~ co~i~:~[o~s Of methods are us~a~ll:y n¢,ge~y~ B'ut m~'r~ s~rff~ntl~, ~e .m¢~t griti.ca, i;[y assess the effective- them before u~enaking ex,pen~[ve national programs. Moreover. it is on these judgments 'of effectiveness that the more all.cult questions of moral justification - of coercive measures must depend. " These admonitions are especially pertinent when we recognize that some or" the most effective preventive measures have been Iess than voluntary--dropping the _speed limit 1o 55 miles per hour, immunization, fluoridation, childproof medicine botfles, flameproof pajamas, package labeling, to mention a t~w: Betbre commit-: ting ourselves ~o even the mildest coercive measures we must have reliable data demonstrating their unequivocal effectiveness. Voluntary measures can legiti- mately be initiated as experiments when the data are ambiguous but this is scarcely justifiable with involuntary measures. Involuntary and coercive measures will continue to be needed in specified areas of health promotion. They must be undertaken wi~h a clear perception of the dangers they pose to a democratic society~loss of personal freedom to choose a life-style, dependence upon governments to define values and concepts or" the good life, and the imposition of cultural homogeneity. Involuntary measures also assume a benign, wise. a~d responsive government~something history finds sin- gularly rare. Each time we partition resources ~br specific ends~let us say health prom~ tion vs curative medicine, or vs housing, security, crime, protection of vironment~we necessarily limit personal choices about what constitutes a good life. The~ is the additional question of injustice m ~hose who wan~ and need other good things~like curative medicine, life-support measures, and rehabilita- tion. The poor are at special risk for they cannot pay the costs of surtaxes, increased insurance premiums, and other "'disincentives." They cannot enjoy the "'luxury'" of the wealthy per~o~ to choose health, damaging habits. Nor must we forget that one person's prudent, healthy diet and exercise are another ~rson's version of hell, or at least purgatory. Again, these observations are not meant to argue against health promotion or Ti0528,0118

376 t~DMUND D. PELLEGRINO .a,~a_:[ws:l~ ~m_~em~ly ju~fig~h!e coercive m~¢~Ur~S.~ They do (~me t~e ~pe~[nent q,ues~ ~r~ ~agd d~'bat~ ff we seek a national poI[cy based on moral as well as economic and political considerations. l~n~ paper ~). Y~t some gu~d~l~es are needed ~f ~he Surgeon General's mendaHons are to be apoHed 9~ a ~a~ional scale. W~thout them. health promotion ~s easily susceofib[e to ~he extreme~ of overzealous application by enthusiasts on ~h~ one ha~ and ov~rprompt rej~c~o~ by Hbertad~ns on th~ other. Th~s ~ ~sp~- e~ally so when ~nvolunta~ measures mus~ be considered. S~nee I believe ~he so¢~al e~ono~ie benefits of ~revent[on and promotion will require so~e in~olunt~ ju.s~ifia~[e~ u~s¢ of eoe~ei~ measures. • h~:~ ~i~l~'t~ observed ~s that ~f proportionality. C~r~v~ ~re ~t0 ~:~onside,~¢d o~:ly when their effectiveness is unequivoc~ for large num- ~rS, '~:~;t:e ,a~'d ~h~n affecting cont,rol ¢<~tcnds over a limited sector of llfe. "'The game must be worth the candle." Examples would be such th~ngs ~s im- munization, sanitation, limiting carcinogenic food additives, speed limits, hel- mets for motorcyclists, nutrition of the newborn, fluoridation, bul[t-]n:seat belts. The inconvenience.of such measures is sm~ll, their social benefit is high,and their economic advantages ~nsiOerable. Even if a-measure meets the test of proportionality it must accommodate as closely as possible the democratic principle of self-determination. Voluntar~ mea- sures must be clea~ly inadequate at the outset or must have failed before coercive measures are contemplated, But even when justified, coercion should be of the mildest sort, compatible with achieving the desired change in behavior. To fore- stall the imposition of involuntary measures, individuals should be assisted to analyze the consequences of deleterious habits so they can see the value choices they must make and make those choices on the basis of valid information. This is a new realm of moral obligations for health professionals, especialty as we move into programs of self-care and personal promotion of health. There are several corollaries of the obligations to optimize self-determination. Inducements, for example, should be favored over disincentives, like tax sur= charges or increased premiums. Such disincentives pu~ the poor at a disadvantage. Remediable conditions that make choices less than free must be ameliorated as much as possible through education, by restraints on misleading adve~isem~nts, reducing peer and ~roup pressures, and treating emotional problems, True educa-" tion aimed at providin~ information to enable free choice must be distinguished from subtle use of the media covertly to manipulate decisions even for good purposes. When involuntary an&'or coercive measures are 6navoidable..they should be 'limited severely in matter~ that are almost personal and private, like sex. family. and personal amusements. Regulation should be confined to actions with direct public impact lest moralizing take the place of morality. Restrictions. likewise, should be placed on those who take deleterious actions and not on the victims of TI05280119

another's unhygienic habits. Those who wish the freedom to choose unhygienic hab:ts-l:ik~e smokig~sltou;~d be r~strained ,by so~ia[ quarantine from i~posing its ~of +~he+mm~t~ ~-~-p+mb]c=b~+havm'r, ~he would* apply to no[semaki~ and other forms of nonindustrial pollution of the local social environment. Regulations should always presume in favor of those whose consent cannot be obtained~infants, children, the retarded, and the'senile, or lhos~ who must work, let us say, in noisy or chemically polluted environments. In general, those who cannot de~ide should be gi.v~n the benefit of doubt by legislating effective mea- sles to promot~ health ~a [heir behalf. . Th~.~a~[~ all si.~p]y coro]lari~ of[h~ r~l¢ in ~ ~iv[lized and of li+~ a¢e ~.bjeet to jus,ti'fimble restriction. 'However, +no civilized society can abandon those who have chosen unwi~ely and fall victim to the physical and emotional disorders that result fr~ their damaging life-styles. They must be treated humanely even though at public expense and even when resources are scarce. The g~idelines suggested here in the most prelimihary Way illustrate- how deci- sions about health promotion might be mo~lly grounded. They obviously do :not, in ~hems¢lves, constitute an ethic of the promotion of health on a national scale. The need for some such g~idelines will become more urgent as the nation faces implementation of broad and impo~ant recommendations like those in the Sur- geon General's report. What is suggested here in the most preliminary way are some moral groundings for public policies in health promotion. They obviously do not in thems¢lws constitute an ethic of public health or preventive medicine. But the need lbr som~ such ethic will become urgent as the nation faces implementation of broad and impo~ani recommendations like those in the recent Surgeon General's report. Today's debates about national policies in health care are urgent enough and universal, enough in their effects to become paradigms of th~ value choices we must make in all policy decisions in a democratic and professedly humanc society. Our task is a continuous one--to balance equality and e~ciency, personal free- dom and social good, but to do so in morally defensible ways. An ethic of health promotion and prevention is but pa~ of an ethic of health care, and both are slops toward a larger enterprise--an ethic of responsible citizenship and moral governance. It is a mark of a civilized society that its citizens can perceive ~he tensions that conflicting good things may engender and yet balance them in reasonable and moral ways that avoid the easy seductions and evils o,f,the extremes. REFERENCES I. "'Healthy People: "['he Surgepn Generals Report on Health Promotion and Oi~ea~,e Pre'.ention.'" DHEW Publ..No. tPH$) 79-55071. U.$. Govt. Printing Office. V,,".,shingttm. D.C.. 1979. Tt05280120

378, EDMUND D. PELLt:GRINO 2'. J,ae~er, W_. ~'~ai~ea, T~e' 'ldea~ of G~ek Culture," Vol, IlL Chap. I. Oxford, Univ. Press. New 3. Lalonde. M. "'A New Perspective on the Health of Canadians.'" Government of Canada. Ottawa, April 1974. 6. MelKeo,wn,, T. "The Role of Medicine: Dream,. Mi~-ge or Nemesis?" Princeton Univ. Pre~, 7. Pellegrino, E. D. The expansion and contraction ofdlscretionary space,in "'Priorities for the Uses of Resources in Medicine." DHEW Publ. No. (NIH) 77-1288. DHEW Fogarty International Center Proceedings No. 40. pp. 99-112. 8. Tancredi. L, (.Ed.) "'Ethics of Health Care." N;it. Acad. Sci.. Washington, D.C.. 1974. See especially. Government Decision Making and the Preciousness of Life. Kenneth J, Arrow. and commentaries by Guido Calabresi and Edmund D. Pellegrino. pp. 34-64, 9; Wikler. D. I. "'Ethical Issues in Governmental Efforts to Promote Health," p. 37. Nat. Acad. Sci.. Washington. D.C.. 1978. T105280121