Daniel Weinstock (2016) notes two significant problems with applying liberalism to public health: (i) liberals tend to be individualists, while public health is predominantly focused on populations and (ii) many public health measures involve interventions that can be seen as being in tension with liberal values such as autonomy, liberty and privacy. He examines whether civic republicanism can provide a more promising means of reconciling these concerns. Despite Weinstock’s proposed solution to the problem of potential domination with its institutional and ethical solutions, I suggest the individualism at the core of liberalism and civic republicanism means both political theories will continue to have conceptual and normative problems with public health’s population-level perspective.
Liberalism, Civic Republicanism and Individualism
Both liberals and civic republicans take individual liberty to be a dominant moral and political value. While both theories have a strong concern for an individual’s negative liberty, the promise of civic republicanism is that its conception of liberty is more nuanced and sharper in scope. Such a conception, it is maintained, is more advantageous in relation to justifying public health activity because it only seeks to render public health measures that dominate individuals as being unjustifiable. The civic republican focus on domination, however, remains an individualist concern. As we see throughout Weinstock’s paper, the focus on public health activity concerned with health promotion is predominately analysed in terms of how these interventions affect individual agency as a condition of their justifiability. The individualism inherent in both liberalism and civic republicanism is underpinned by particular ontological, methodological and ethical claims that create tensions and raise problems in relation to evaluating and justifying the enterprise of public health. So long as civic republicanism remains focused on individual liberty and non-domination, it lacks a substantive advantage over liberalism when it comes to adopting public health’s population-level perspective.
Individualism Versus the Population-Level Perspective: Some Problems
Individualism does not deny the existence of communities or populations per se, but it does maintain that the individuals that compose these collectives are ontologically prior to the resulting groups these individuals create. Thus, our idea of ‘public’ or ‘population’ in ‘public health’ or ‘population health’ does not refer to any unit or entity up and above of the aggregate of individuals that compose it. As Jeremy Bentham (1996: 12) famously said
the community is a fictitious body, composed of the individual persons who are considered as constituting as it were its members. The interest of the community then is, what?—the sum of the interests of the several members who compose it.
This last sentence also speaks to why this ontological individualism raises problems for public health in terms of how we should understand the interests that can be served by public health activity—as this will play an important role in how we justify public health measures. If our ontological commitments presuppose that collectives cannot possess independent worth and collective interests are wholly determined by the sum of individual interests, then this threatens to rule out public health activities that do not (at least) protect or promote the private interests of people who currently exist.1 This falls afoul of a number of public health agendas.
This individualism also shapes how we understand what makes something a public versus private matter, as well as shaping the concept of health itself—both the concepts of ‘public’ and ‘health’ are essential to our understanding of the nature, aims and justification of public health activities (Verweij and Dawson, 2007; Coggon, 2012). It is not so much a politicalization of health—health is inescapably political with competing conceptual and ideological considerations involving how we understand what health or healthy lifestyles are, whether health is an objective or subjective matter and what imperatives might follow from such understandings—but the presumption that we should situate notions of health and disease at the individual level (Skrabanek, 1994; Crawford, 1980).
Understanding liberty as a dominant value also shapes the methodology of an individualistic approach, especially with respect to its explanation of human behaviour and the regulatory measures by which we seek to shape such behaviour. This methodological individualism seeks to explain phenomena, including health phenomena, in terms of the properties of individuals, such as their mental states or actions (Elster, 1982). By making individuals and their properties the entire focus of public health activity, there is a strong tendency to ignore or underestimate the importance of structural and social determinants of ill health that do not directly map to the beliefs, motivations and actions of individuals.
Both liberalism and civic republicanism also share a problem when it comes to moral methodology. Most liberals are committed ethical individualism, in which individual worth, values and choices are what determine the morality of particular actions or policies. This raises a whole host of problems, especially in the area of health promotion (Goldberg, 2012, 2013). Civic republicans fare better in this respect, incorporating civic obligations and civic engagement requirements, nevertheless the focus remains on individuals and their non-domination. This individual-level focus is a problem when it comes to moral theorizing at the population level. The population-level perspective that is required for public health policy and practice will necessitate a reinterpretation and translation of traditional ethical concepts, which have typically been deployed within single individual or small group interactions. Core moral concepts that liberalism and civic republicanism often rely on in their analysis—such as consent, autonomy, paternalism—do not easily translate to the population-level. Further, the normative implications that arise from technical concepts and methods central to a population-level approach—such as Rose’s prevention paradox, cluster randomized trials and non-identifiable, statistical victims—can be difficult for liberalism and civic republicanism to adequately accommodate within their individualistic moral and political analysis.
Bringing political theory to bare on public health is an important project that merits further exploration and development. Given public health’s population-level perspective, however, merely applying traditional political theories predicated on individualism to public health remains problematic.
1. Crittenden (1992: 3) expands on what this commitment means, in identifying individualism as ‘… the theory of society constituted by individuals whose goal is to fulfill private ends, largely through relationships constituted by individuals and whose principal characteristic is the possession of individual rights that have priority over societal needs’.
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