Cross-post: Fairness and Freedom in Public Health Policy – On the need for a Humanities-based approach to public health policy

by Alberto Giubilini

Originally posted on the Oxford Medical Humanities website

Multidisciplinary Conference, Oxford, 23 and 24 Oct 2023

This conference explored two distinct but related issues in public health. One is the extent to which individual freedom could be restricted in the pursuit of public health goals. The other is whose freedom could be restricted. That is, freedom and fairness in public health policy.

The tension between freedom and public goods pervades our lives. Public goods such as functioning healthcare systems or environmental resources depend on actions we collectively take. Collective actions raise issues about whether and how each of us ought to contribute to them by giving up some of our own personal interests. Pandemic policies simply made that tension more salient. However, our living together is a constant negotiation of the boundaries between us as individuals and us as members of communities, often (but not necessarily) through the mediation of Governmental restrictions.

Public goods cost freedom or, if you prefer, freedoms can erode public goods.

This tension manifests itself increasingly more often with regard to health. As ‘public health’ becomes institutionalized as an explicit goal of various organizations and Governments, more freedom restricting measures are introduced in the name of it. Environmental policies restricting freedom of movement and the smoking ban recently announced in the UK provide the two clearest examples in the past few months.

Questions of fairness arise because the way such policies strike that balance affects the life of different people differently. Some of us pay more than others the costs of restrictions, for instance in terms of economic impact. And some of us benefit more than others from the goods promoted by restrictions, for example in terms of containment of a virus outbreak. Public health restrictions that apply equally to everyone might exacerbate such differences. Equality and fairness can come apart in interesting ways.

Moreover, we have different political and ethical views about the permissible tradeoffs between freedoms and public goods and between freedom and health. These differences often track political partisanship. Any restrictive policy will inevitably prioritize some such views over others. Thus, the issue of fairness is also an issue about how democratic institutions should consider diversity of political views when implementing restrictions – especially in situations of crisis when the scope for public consultation and deliberation is limited.

These are questions about human values, practices, behaviours. An approach to fair public health governance cannot be based solely on facts about diseases and prevention thereof. Those questions require a broad Humanities approach to be fully understood, addressed, and sometimes even answered. This conference aimed at building bridges across different Humanities disciplines to address those issues with shared, or at least compatible, conceptual tools and methodologies. Which is a fancy way of saying: to have a meaningful discussion across disciplines. Asking the right questions is a good way of making discussions meaningful.

For instance, a question we might want to ask is whether, or to what extent, freedom restrictions are quantifiable. Anna Petherick, Associate Professor in Public Policy at the Blavatnik School of Government at Oxford, co-led the Oxford COVID-19 Government Response Tracker, which she presented in the opening talk of the conference. The tracker was aimed at measuring the level of restrictiveness of different pandemic policies around the world.

However, quantifying restrictiveness only accounts for one dimension of freedom. As well as asking how much freedom is restricted, we could ask what type of freedom is restricted. Hohee Cho, historian of medicine at Oxford, talked about the Central Leper Hospital, an intercolonial island hospital in the Pacific Islands in early 20th Century, where people affected by Hansen’s disease were transferred against their consent. Some narratives authorities used to justify this practice were indeed based on the idea of freeing people in the islands from diseases. This raises interesting questions about how different meanings of ‘freedom’ can be and have been used to justify not only very permissive, but also very restrictive policies. Indeed, similar narratives around freedom from risks, from disease, or from fear are sometimes used today to justify public health restrictions.

Needless to say, restrictive policies can be very divisive, not least because political partisanship affects which kind of freedom different people value the most. Seung-Hoon Chae, from the Department of Politics at Oxford, presented some results from his research on how this dynamic affected compliance with pandemic restrictions in South Korea. Relevant differences between right-wing and left-wing leaning individuals were often informed by cultural and political influences coming from abroad, rather than by views on freedom entailed by political partisanship in the South Korean tradition.

However, this point raises even more questions. Do public responses to restrictions track underlying political divisions, or do they create new political partisanships? In wrapping up the morning session, Mark Harrison – Professor of the History of Medicine at Oxford – pointed out how, especially in the UK, pandemic policies themselves often generated political divisions and partisanships that didn’t previously exist.

The following session was focussed on how uncertainty and expert disagreements about costs and benefits of restrictions affect both public health discussions and policy making. Kevin Bardosh, Medical Anthropologist at the University of Washington, detailed the various types of costs that pandemic restrictions entailed, for instance in terms of economic loss, educational gaps, and mental health. As was the case with restrictions themselves, this raised questions about the extent to which it is possible to quantify the costs of restrictions.

Whether or not such quantification is possible, one might observe that costs are apparent only retrospectively. There is often uncertainty and disagreement both among experts and among the public at the time of implementation. Which raises the further question of how to act in the face of disagreement and uncertainty. The talks by Lucie White, philosopher at Utrecht University, and Maja Graso, social scientists at Groningen University, addressed these two issues. Regarding disagreement, Maja Graso argued that pandemic policies created a very moralized and politically polarized society. This resulted in different narratives around the scientific evidence that was meant to inform policy, for example selective reliance on data that would support one policy over the other. With regard to uncertainty, Lucie White discussed at length the often invoked precautionary principle. Using methodologies from analytic philosophy (conceptual analysis), she reframed the principle in a way that holds promise for making it more action-guiding, avoiding paralysis in decision making.

Peter Horby, Professor of Emerging Infections and Global Health and Director of the Pandemic Science Institute at Oxford, emphasized the importance of creating synergies between the Institute and the Humanities, also referring to his own background in history of medicine. It is only through such synergy that public health can become an inclusive enterprise serving human needs.

Providing some final thoughts at the end of the day, Erica Charters – Professor of the Global History of Medicine at Oxford and academic lead of Medical Humanities – discussed, among other things, the problematic nature of the notion of ‘public’ in the concept of ‘public health’. Who or what is the relevant public? Who is included and excluded? These questions go to the core of the issue of fairness. The idea of ‘a public’ risks being insensitive to differences in the perception of restrictions and of health goods by different individuals and groups.

On day 2, Samuel Director – philosopher at the University of Florida Atlantic – and Sadie Regmi – DPhil candidate in bioethics at Ethox, Oxford – discussed extensively civil liberties. Samuel addressed the issue of whether widespread public support for policies that restrict civil liberties in the name of public health can, by itself, justify such restrictions, raising several doubts about it. Sadie approached civil liberties from the perspective of fairness. She showed how policies that infringe on freedom of intimate association often resulted in unfair discrimination of people whose intimate associations do not conform to certain societal norms (for instance, same-sex relationships).

One interesting question that this point raises is whether some human dimensions, such as intimate relationships, can be defined for the purpose of policy making in ways that can account for their complexities – for instance, what relationships count as intimate?

The last two talks focussed on freedom and fairness in vaccination policies. Sorin Baiasu, philosopher at Keele University, discussed whether herd immunity can be considered a public good that generates fairness-based individual moral obligations to be vaccinated, ultimately rejecting the fairness-based and vulnerability-focused proposals. Instead, he defended a recent Kantian account centred on individual freedom, and argued that a desert-sensitive reading of this more successful account may be used for questions of distributive justice in public health. Bridget Williams, DPhil candidate in Philosophy at the Oxford Uehiro Centre for Practical Ethics, presented her work on the ethics of selective vaccine mandates, a potentially fairer way of mandating vaccination than population-wide requirements. She argued that they might be ethically justifiable in some cases, if they are effective.

But that is, of course, a big ‘if’. Interestingly, this last point brought us back to the first talk of the conference, when Anna Petherick also presented some evidence suggesting that age-selective Covid-19 vaccine mandates were not very effective at increasing uptake. This is a good reminder that health policies – as Erica Charters also emphasized in her intervention on day 1 – do not happen ‘in a vacuum’: as we think about public health from a Humanities perspective, we should not lose sight of the reality of the different individuals to whom policies apply. Historians and Policy scholars made sure to remind us of that.

In the final talk of the conference, Michael Parker, Professor of Bioethics and co-director of the Wellcome Centre for Ethics and Humanities at Oxford, reiterated the relevance of interdisciplinary work in public health on two different dimensions: within the Humanities themselves and between the Humanities and the Sciences.

In this regard, this conference has shown that striving for interdisciplinarity is both promising and challenging. Promising, because Oxford offers lots of opportunities. Medical Humanities provide an ideal platform for developing new lines of research when Humanities scholars can think together over a specific topic. But it is also challenging, since different disciplines rely on different theoretical frameworks and ask different questions. Interdisciplinarity arguably requires some compromising in these respects. However, a discipline can only contribute meaningfully to the extent that it preserves its own identity, which methodological compromises can threaten. Compromise is a difficult art to master.

Thus, the conference was also an exploration of the ways in which methodologies of different disciplines within the Humanities can work together around common themes. It is a first step towards developing a broader research project on how to fairly distribute freedom restrictions in public health policy. Bringing scholars together for interdisciplinary debate and discussion certainly is a good start.