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Title
Public Health Autonomy A CRITICAL REAPPRAISAL

Permalink
https://escholarship.org/uc/item/90f006bt

Journal
HASTINGS CENTER REPORT, 47(6)

ISSN
0093-0334

Author
Zimmerman, FJ

Publication Date
2017

DOI
10.1002/hast.784

Peer reviewed

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University of California
Public Health
Autonomy & A CRITICAL REAPPRAISAL

BY FREDERI CK J. ZI MMERMA N

The relational view of autonomy recognizes the need to collectively organize society’s resources so

as to enable human flourishing, and it has much in common with the mission of public health.

T
he ethical principle of autonomy is among of public health ethics more rigorous, incisive, and
the most fundamental in ethics, and it is effective. Even more importantly, bringing modern
particularly salient for those in public health, concepts of autonomy into public health ethics can
who must constantly balance the desire to improve showcase the many areas in which public health
health outcomes by changing behavior with respect and autonomy have the same goals, face the same
for individual freedom. Although there are some threats, and can be mutually advanced by the same
areas in which there is a genuine tension between kinds of solutions.
public health and autonomy—childhood vac- Scholars in bioethics have begun to identify what
cine mandates, for example, or motorcycle helmet Bruce Jennings has termed a “relational turn” in
laws—there are many more areas where not only is our understanding of autonomy.1 This view of au-
there no tension, but public health and autonomy tonomy rejects a centuries-old belief that the indi-
come down to the same thing. These areas of overlap vidual can or does somehow stand apart from his or
are often rendered invisible by a thin understanding her community, social circumstances, and political
of autonomy. environment. As the philosopher John Christman
Better integrating newer theoretical insights about puts it, “In any number of ways we are constituted
autonomy into applied ethics can make discussions by factors that lie beyond our reflective control but
which nonetheless structure our values, thoughts,
and motivations.”2
Frederick J. Zimmerman, “Public Health and Autonomy: A Critical
Reappraisal,” Hastings Center Report 47, no. 6 (2017): 38-45. DOI: Much of the most exciting work on autonomy
10.1002/hast.784 comes from feminist philosophers.3 Although there

38 HASTINGS C E N T E R R E P ORT November-December 2017

© 2 0 1 7 Th e H ast i n g s C en t er . P erm i ssi o n i s r eq u i r ed t o r ep r i n t .


are variations within this tradition in philosophy of autonomy is both deep of which has different implications
the understanding of autonomy, they and rapidly changing, public health for autonomy. The field of economics
all recognize that individuals’ beliefs has often both operated with and is used as the frame in this section be-
and values are arrived at through so- been critiqued through very elemen- cause economics has sold itself—to a
cial processes. Jennifer Nedelsky calls tary understandings of autonomy. As very large extent successfully—as the
the notion of autonomy as isolation a result, public health debates often theory of choice. Economists study
from outside influence a “pathology” invoke the concepts of freedom and not just traditional economic spheres
and observes, “[I]f we ask ourselves liberty without any clear sense of like employment and prices but also
what actually enables people to be what these terms mean. choices around many health-relevant
autonomous, the answer is not isola- The purpose of this article is decisions concerning, for example,
tion, but relationships—with parents, to provide a schema for relational food; physical activity; medication
teachers, friends, loved ones.”4 Partly autonomy in a public health con- adherence; insurance; risky sexual
for this reason, the external environ- text and to give concrete examples behavior; and drug, alcohol, and
ment must promote autonomy. of how autonomy can be served cigarette use, abuse, and addiction.
Feminist philosophers have ar- through public-health interventions. Modern economics has to some ex-
gued that once we recognize that in- Rachel Haliburton has argued that tent incorporated insights about
dividuals are all constituted by others, autonomy requires an external en- decision-making from psychology.
notions of autonomy shift from isola- vironment that offers an adequate Economic models of choice begin
tion to processes of self-reflection that range of choices as well as a process with the rational choice model.
enable individuals to choose among of reflection that is not influenced by Rational choice. The rational
the norms and beliefs that the exter- manipulation, exploitation, or decep- choice model assumes that people
nal world makes available to them.
Marina Oshana and others have Bringing modern concepts of autonomy into
pointed out that the external world
makes genuine choice possible.5 At public health ethics can showcase the many areas
the same time, individuals must have
the capacity to engage in a process of in which public health and autonomy can be
self-aware and self-respecting reflec-
tion about their own motivations, mutually advanced by the same kinds of solutions.
values, and beliefs.6
In the relational way of thinking, tion.10 Building on this conception, have fixed preferences that they un-
autonomy is understood, not as indi- this article marshals insights from so- derstand perfectly—in the sense that
vidual isolation, but as individual em- ciology, psychology, and philosophy they know how particular choice op-
powerment. This approach reaches to advance a theory of autonomy and tions will sit with them—and that
back at least as far as the institutional coercion that recognizes three po- people carefully weigh the affective
economists of a hundred years ago, tential threats to autonomy: threats costs and benefits of all choice op-
who mocked the notion of an isolat- to choice sets, threats to knowledge, tions and then choose the one that
ed individual as “a globule of desire.”7 and threats to preferences. The goal best aligns with their preferences. (On
More recently, the capability theory is to provide greater clarity about top of these assumptions, economists
of Jean Drèze and Amartya Sen em- public health challenges that impli- often layer additional assumptions
phasizes how social and economic cate autonomy, including protecting about perfect information, friction-
structures can either succeed or fail to autonomy in a public-health policy less markets, perfect enforcement of
provide the individual with means to context, identifying the desiderata of agreements, smooth investments,
basic needs as well as to the kinds of autonomy when balancing autonomy and so on. These additional assump-
accomplishments and freedoms that against the principles of beneficence tions are not necessary to the rational
constitute well-being.8 or justice, and engaging in ethics- choice model, but the rational choice
From this starting point, the rela- based advocacy in the political realm. assumptions are essential to all of or-
tional view of autonomy recognizes thodox economics.)
the need to collectively organize so- Theories of Choice In rational choice theory, only the
ciety’s resources so as to enable hu- most flagrant coercion is possible.
man flourishing, and it has much in
common with the mission of public
health, which has been defined as
A n understanding of autonomy
will depend on one’s understand-
ing of how the mind works. Modern
Short of having a gun pointed at one’s
head, a choice once made is a choice
made well, a doctrine formalized in
“[w]hat we, as a society, do collec- conceptions of the mind can be sum- the theory of revealed preference. It
tively to assure the conditions for marized through three alternative is rational choice theory that has sup-
people to be healthy.”9 Yet while the choice theoretical frameworks, each ported the negative view of autonomy

November-December 2017 H AS TI N GS C EN TE R REPO RT 39


as a state of individual isolation and Two-brain theory has been criti- because of some innately superior
atomistic independence. In politi- cized on ethical grounds,20 but it is moral quality,25 but because, unlike
cal and popular discourse, moreover, unsatisfying for other reasons as well. non-MIT students, they have a cog-
rational choice theory is often taken It is empirically weak (in that it can- nitive habit readily available that lets
to imply that the power of coercion not be falsified as a causal model), them solve for x when x + (x +1.00)
is limited to government, so that au- and it is descriptively false—even its = $1.10. Developing such a cogni-
tonomy becomes a simple matter of proponents recognize that there are tive habit requires dedication over
limiting government power. not actually two distinct structures in the long term, along the lines of Jimi
The rational choice model is wide- the brain.21 By preserving an assump- Hendrix practicing guitar or Michael
ly embraced in the United States and tion of complete rationality on the Jordan layups.
serves as the default model—often part of one of the two brains, two- In multilevel theory, people’s cog-
unacknowledged although nearly al- brain theory also preserves all the nitive habits evolve over the lifespan
ways present—for policy-making. For conceptual and empirical flaws of the to better manage the decisions and
some narrow uses—such as predict- rational choice model itself while of- challenges people face. Faced regu-
ing the reduction in demand that will fering no new advantages or insights. larly with math problems, people
follow an increase in a consumption Multilevel theory. Against the will develop more elaborate cogni-
tax—the model is a close-enough ap- two-brain model is multilevel theory, tive habits for math. Bus drivers faced
proximation. But as a conceptualiza- which reaches back to conceptions of regularly with complicated spatial
tion of how the mind works, rational habit at the origins of psychology22 to and social challenges of steering a bus
choice is completely wrong. A huge suggest that people’s thinking is orga- through a crowded city will develop
body of research in public health,11 nized by cognitive habits, or chains elaborate cognitive habits that en-
psychology,12 sociology,13 philoso- of related thoughts that are, in the able them to avoid crashes. Cognitive
phy,14 institutional economics,15 and words of one modern neuroscientist, habits promote well-being in people’s
behavioral economics16 has demon- “chunked together”23 for greater effi- usual environments.
strated that the rational choice theory ciency, much like subroutines within Because cognitive habits are both
has both conceptual and empirical a computer program.24 Each has its learned from others and adapted to
fatal flaws. job to do and is maximized for that a particular environment, multilevel
Two-brain models. A common ex- operation. theory supports the relational turn in
ample of the failure of rational choice Language use is an example of autonomy in “reject[ing] the notion
occurs when people are asked how cognitive habits, with more sophis- that an individual can be abstracted
much a ball costs if a ball and a bat ticated and abstract words learned from social being and ecological
together cost $1.10 and the bat costs through the use of—and ultimately place.”26
$1.00 more than the ball.17 Most replacing—longer chains of simpler
people get the answer wrong, guess- and more concrete words learned ear- A Conceptual Model of
ing 10 cents. ly on. Cognitive habits are inherently Autonomy
To explain results like these, many social, as others constantly influence
scholars have resorted to a theory of
two brains: we are said to have a fast
brain and a slow one, or an intuitive
the development of our own cogni-
tive habits. In multilevel theory, we
don’t so much have fixed preferences
T he field of public health wishes
to move people’s cognitive habits
toward healthy behavior, but it is also
one and a reasoning one, or an emo- as cognitive habits that we reach for ethically bound to respect autonomy.
tional one and an effortful one.18 as the situation demands. As we con- Public health accordingly has a strong
Two-brain theory leads us to believe front more and more complex situa- interest in developing a sophisticated
that there is a perfectly good ratio- tions, these cognitive habits become understanding of autonomy. The re-
nal brain that is interfered with by a more elaborate, and they evolve over lational turn suggests that autonomy
dogged competitor that is somehow time so as to direct our actions to- is rooted in securing an environment
both dumber than the rational brain ward that which serves our own true in which people have the capacity to
yet also able to regularly outfox it. In interests. We are not rational in every choose lives that are authentic in the
the ball-and-bat example, students at decision, but, left undisturbed, our ways sketched above. This is a very
the Massachusetts Institute of Tech- cognitive habits ensure that generally consequential difference in what au-
nology are far more likely than oth- we get it right in the long run. tonomy means for public health.
ers to provide the right answer, and People make mistakes because A good starting place to enrich
on this basis, it has been argued that they use cognitive habits that were our understanding of autonomy is to
those who do poorly on questions developed for one situation in other recognize three threats to autonomy
like these are lazy thinkers, “impul- situations that are superficially simi- that can come from other individu-
sive, impatient, and keen to receive lar. The MIT students are better at als, but also from social, political, or
immediate gratification.”19 the baseball-and-bat question not economic structures. These threats to

40 HASTINGS C E N T E R R E P ORT November-December 2017


autonomy may be categorized into around the country have stopped would and do choose to bike.28 Im-
three non–mutually exclusive mecha- serving milk that contains milkfat. proving the reliability and frequency
nisms: threats to a person’s choice set, The resulting impoverishment of of buses also expands the choice set,
threats to a person’s preferences, and choice sets has meant that kids have as do safe-routes-to-school initia-
threats to the knowledge a person to choose between tasteless skim milk tives. Yet many governments at the
has to make decisions. Concrete ex- or sugared skim milk. Public health local, state, and federal levels priori-
amples of each of these threats follow. experts have justified this manipula- tize road-building and road-widening
Threats to choice sets. In a clas- tion of children’s choices on the basis expenditures that serve only a subset
sic case of coercion, a fellow with a of beneficence. Yet there has never of the population (without in fact
gun approaches a mark in a dark al- in fact been any solid evidence of a producing the benefits claimed29)
ley and, brandishing his weapon, de- health benefit associated with replac- and do nothing to expand the trans-
mands, “Your money or your life!” ing consumption of whole milk with portation choice set. The result is
This scenario is unambiguously co- consumption of skim milk, soda, or that even when people prefer active
ercive. Even though the victim is of- even water. The idea that skim milk transportation as a way of getting to
fered a choice, and even though this is less fattening than whole milk was work, school, or a store, they are un-
choice has many of the hallmarks of pushed by the dairy industry as a able to choose it: their choice set does
an individual decision, the options in means of selling the otherwise useless not include biking. In the context of
the victim’s choice set are poor. And byproduct of butter production.27 transportation, expanding the choice
in fact, the choice set has been made Restricting choice sets to achieve a set would promote autonomy.
poor through the deliberate actions particular behavioral end cannot be And indeed, many public health
of someone else, who hopes to influ- ethically justified in the child’s in- actions work best when they expand
ence the choice made.
George W. Bush made a similar Threats to autonomy can exist even in the absence
threat to Saddam Hussein in the run-
up to the second Gulf War, saying of frank coercion, especially if a choice set is
that Saddam should fully cooperate
with United Nations weapons inspec- limited to unappealing or harmful options.
tions or face bombing by the United
States. “It’s his choice,” said Bush re- terest if the public health commu- people’s choice sets—creating more
peatedly. Severe limitations on abor- nity has not done its due diligence paths to healthy behavior. For ex-
tion providers limit the choice sets to make certain that the behavioral ample, when farmers’ markets accept
available to women with unplanned change is in fact beneficial. In this food stamps, the purchase of fruits
pregnancies. In this example, claims example, public health did not wish and vegetables among low-income
of beneficence are made that, if valid, ill for the children, but, out of insuf- shoppers increases. The public health
would qualify the limits on choice ficient professional attention to be- benefit operates, not through any
sets as not being manipulative or co- neficence, allowed itself to be used by form of coercion, but through the ex-
ercive. Yet these claims of beneficence the dairy industry. Restricting choice pansion of choice sets.
are contestable, and whatever benefi- sets is ethically suspect and should be Examples of threats to choice sets
cence there is could be secured by a understood as requiring particularly are rife in public health and in public
less extreme limitation of the choice careful justification. policy generally. Some, like food des-
set. The result is a form of manipu- In many situations, such as the erts, are relatively obvious and have
lation: the restriction by others of examples above, the constriction of received considerable attention in
women’s set of choices constrains choice sets is obvious, and it’s a delib- public health. Others, like a lack of
women’s autonomy. erate goal of policy. But in other situ- affordable housing that causes people
These scenarios illustrate the first ations, the constriction of choice sets to experience low disposable income,
threat: constriction of the choice set. may be less obvious and not as tightly extreme crowding, or long com-
They are all rather stark in that they tied to a particular end. mutes—thereby limiting capabilities
involve the deliberate manipulation A community that simply hasn’t for active living and healthy eating—
of a choice set to achieve a particular gotten around to building a network are subtler.
end. But threats to autonomy can ex- of safe bike trails is not guilty of coer- When autonomy is understood as
ist even in the absence of frank co- cion. Yet at the same time, expanding broadening choice sets, it dovetails
ercion, especially if the choice set is the bike network will unambigu- with public health’s goal of promot-
limited to unappealing or harmful ously foster autonomy by broadening ing full engagement with society.
options. the choice set. Installing protected Threats to preferences. There is
Acting on the advice of pub- bike lanes significantly increases the a large literature in philosophy and
lic health experts, school cafeterias percent of commuters who say they institutional economics about what

November-December 2017 H AS TI N GS C EN TE R REPO RT 41


preferences are or even whether they demonstrated the effectiveness of a sequence. You know, I am so busy
exist in any meaningful sense. It is variety of marketing techniques, in- jumping in, pulling them to shore,
easy to believe that we have strong cluding advertising, but also product applying artificial respiration, that
likes and dislikes and that these are placement, bundled pricing, product I have no time to see who the hell
consistent and well understood. Yet location within a store, store location is upstream pushing them all in.35
both empirical evidence and critical within neighborhoods, and packag-
theory suggest that our preferences ing. Such marketing has a strong Today, the term “upstream factors” is
are not this simple. influence on people’s food choices,31 typically used for factors like educa-
Economist Dan Ariely has con- as well as on patients’ and physicians’ tion or income and less commonly
ducted a fascinating experiment choices around medical treatment.32 for population-level factors such as
falsifying the notion of stable prefer- Although these threats to prefer- the built environment. It’s as if the
ences.30 After reading a bit of poetry ences are ubiquitous, they are not field has understood the task as one
to his classes, he announces that he’ll always evenly distributed. One study of going upstream to teach people to
be giving a poetry reading a few days found that advertisements for obesi- swim before the river becomes too
later and would like to invite his stu- genic foods and alcohol are six times treacherous. McKinlay’s radical point
dents to attend. In some classes, he as prevalent (on either a per-person was closer to the opposite of this ap-
tells the students that he is worried or per-square-mile basis) in low-in- proach: he insisted that someone is
that no one will show up and, to come minority neighborhoods as in pushing people in, and he called these
avoid embarrassment, he is willing to high-income white neighborhoods.33 agents “manufacturers of illness.” As
pay them to attend. He takes a sur- (Both race and income independent- examples of these manufacturers
vey of this class, asking how much ly contributed to this disparity.) of illness, McKinlay offered adver-
they would have to be compensated Because many effects of advertis- tisers and political lobbyists—two
to listen to his poetry reading. In ing operate at the unconscious lev- groups whose job it is to manipulate
other classes, he tells students that el—as they are purposefully designed preferences.
the venue is overbooked but that, to do—much of consumers’ behavior Threats to information. “It was a
for a price, he can get them in. His in response to it cannot fit under even very smart thing the sugar industry
survey to these students asks how the minimum definition of autono- did, because review papers, especially
much they would be willing to pay my offered by feminist philosophers, if you get them published in a very
to attend the reading. The results are which requires that there be a process prominent journal, tend to shape the
fascinating. The students who were of conscious and thoughtful decision- overall scientific discussion,”36 said
told that they would have to pay to making in determining the contours medical researcher Stanton Glantz,
get in are willing to pay, and the stu- of one’s life.34 discussing revelations that the sugar
dents who were told that they would In one of the most widely in- industry paid Harvard researchers in
be compensated for showing up de- voked—and perhaps most misre- the 1960s to emphasize the role of fat
mand payment. What’s more, there is membered—articles in public health, in heart disease and minimize the role
a strong dose-response relationship: John McKinlay introduced the con- of sugar.
students demand twice as much pay- cept of “upstream factors” in the Anyone who can convincingly tell
ment—or are willing to pay twice as determinants of health. McKinlay’s a lie can make a few bucks conning
much—when the poetry reading is article begins with an allegory: the naïve. Anyone who can get an
six minutes long as when it is only expert to tell a lie can make a mint
three minutes long. Not only can There I am, standing by the shore getting people to do things that aren’t
preferences be manipulated; in this of a swiftly flowing river and I hear in their interest—taking Avastin for
experiment, they are essentially cre- the cry of a drowning man. So I breast cancer, taking supplements to
ated de novo. jump into the river, put my arms ward off disease, widening roads to
Poetry may be an area in which around him, pull him to shore and reduce traffic. And anyone who can
people don’t have fixed notions. Yet apply artificial respiration. Just manipulate the production of scien-
even on more consequential matters, when he begins to breathe, there tific evidence can control huge seg-
people’s preferences can be easily ma- is another cry for help. So I jump ments of our lives for decades.
nipulated. The research demonstrat- into the river, reach him, pull him Everything we know—except
ing this—in the context of university to shore, apply artificial respira- perhaps our most immediate experi-
studies—is subject to careful safe- tion, and then just as he begins ence—is socially constructed. Does
guards designed to limit any poten- to breathe, another cry for help. high sugar intake lead to diabetes?
tial damage from the deception and So back in the river again, reach- Is global warming happening? Is the
manipulation. Of course, there are ing, pulling, applying, breath- earth round? Questions like these
no such limits in the broader world ing and then another yell. Again are too large to be answered exclu-
of advertising. A host of studies have and again, without end, goes the sively through individual personal

42 HASTINGS C E N T E R R E P ORT November-December 2017


experience, and so we depend on an information to make decisions con- milk is healthier than whole milk, the
elaborate social apparatus for answers sistent with autonomy is well rec- petroleum industry’s false notion that
we believe we can trust. We hide the ognized in clinical ethics yet largely climate change is uncertain, and the
social part of this apparatus behind a ignored in public health ethics. The neoconservative movement’s deeply
thick velvet curtain by calling it sci- history of ethics recognizes that it incomplete notion that markets are
ence, but in fact, science is only as is an impingement on autonomy to efficient.43 But the biggest and best
strong as scientists—individually and present people with false informa- example of deep capture is the belief
collectively—and scientists can be tion relevant to a choice they must that deep capture itself doesn’t exist—
swayed. make. For the same reason, it should that science is a teleological force in-
Some believe that they are on solid be seen as an impingement on au- dependent of powerful meddling,
ground when they put their trust in tonomy to interfere in the social pro- that people make up their own minds
an evidence-based scientific consen- cesses through which information is about preferences, and that everyone
sus, rather than in, say, Jenny McCar- produced. has free choice.44
thy. But as the history of the sugar When a government agency funds
industry’s role in medical research an academic review to determine False Autonomy
illustrates, even a strong scientific whether spinal fusion reduces back
consensus can rest on shaky founda-
tions. In 2017, a major review of the
evidence base for dietary guidelines
pain, the resulting analysis contrib-
utes to informed decision-making.
But when a group of orthopedic sur-
I n 2010, the Federal Trade Commis-
sion charged Pom Wonderful with
false advertising because of its un-
around sugar intake37 was assailed geons successfully lobbies Congress supported claims that its pomegran-
immediately after publication for
its omission of key studies and arbi- Autonomy requires an environment in which each
trary evaluation of evidence quality.
The review had been funded by the person is free to choose life options—such as
food industry but had undergone
a rigorous peer-review process and healthy behaviors and health investments—out of a
been published in a top-tier scientific
journal. Even if the major findings of self-confident and self-aware process of reflection.
this review are ultimately vindicated,
there is no doubt that the vast quanti- to reduce funding for the agency that ate juice prevents heart disease and
ties of self-interested money washing funded the research, that violates au- erectile dysfunction and can “cheat
through the scientific process cannot tonomy.40 The surgeons are using pa- death.” In response, Pom placed large
be good for the quality of evidence.38 tients as means to the surgeons’ ends, banner ads at the top of major news
What one scholar has called “a cul- not as ends in themselves. websites, inviting customers to reach
ture of influence and accommoda- Similarly, evidence is now emerg- their own conclusions: “FTC vs.
tion that naturalizes the presence of ing that the pharmaceutical industry POM: You be the judge.”
commerce within medicine”39 vitiates misled physicians about the addic- This is not merely an isolated in-
medical information. tiveness of opioid pain medication. cident, but an example of a much
These problems are exacerbated This subterfuge involved both threats larger problem. In what has been
by the public’s common misconcep- to information and—through tra- called an “extreme form of epistemo-
tion of the scientific process, which ditional pharmaceutical marketing logical relativism,”45 people are en-
is of course neither rapid nor direct. campaigns—threats to preferences. couraged to believe that they should
Frequent dead ends and faulty theo- As a result, opioid abuse is one of the decide not merely what they want to
ries are a necessary part of science, leading causes of lost life years in the do, but what the facts are about cli-
yet these problems can be taken by United States. The pharmaceutical mate change, the health dangers of
a cynical public as implying that sci- companies are almost literally manu- smoking, and the adverse effects of
entists don’t know what they’re talk- facturers of illness. vaccines.
ing about. As a result, science can The process of manipulating sci- The truth about matters like
be misunderstood both as being too ence or public agencies to change these—in fact, in most matters—is
good—immune from self-interested the types of information that people never knowable in any immediate or
meddling—and yet also not good know has been called “deep cap- absolute sense. Instead, philosophers
enough—slow and inherently full ture.”41 Examples of deep capture in the pragmatic tradition have ar-
of errors even without the effects of include the food industry’s false nos- gued that the truth is a hypothetical
self-interest. trum that obesity is mainly the result construct—never reachable but ever
Oddly, the idea that decision-mak- of inadequate physical activity,42 the more approachable—that we are fat-
ers must have access to high-quality dairy industry’s false notion that skim ed to believe after careful inquiry and

November-December 2017 H AS TI N GS C EN TE R REPO RT 43


undistorted debate. Critical to this defi- of health status (with subsidies to insur- 4. J. Nedelsky, “Reconceiving Autonomy:
nition is the notion of a social group. ers who enroll more than their share Sources, Thoughts and Possibilities,” Yale Jour-
nal of Law and Feminism 1 (1989): 1-45, at 7.
Solipsism and truth are incompatible. of high-risk people). These mandates 5. Nedelsky, “Reconceiving Autonomy”;
For that reason, it makes no sense to ask were explicitly and loudly criticized for M. A. L. Oshana, “Personal Autonomy and
individuals to decide whether the FTC infringing autonomy, but they also are Society,” Journal of Social Philosophy 29, no. 1
or POM has the truth. Autonomy is what makes the market possible. The (1998): 81-102; R. Haliburton, Autonomy and
not served by asking consumers to de- mandates make for autonomy in the the Situated Self: A Challenge to Bioethics (Lan-
ham, MD: Lexington Books, 2013).
cide on facts. On the contrary, this is a sense of creating options for people to 6. Nedelsky, “Reconceiving Autonomy.”
false autonomy—an appeal to individ- make self-reflective choices about their 7. G. M. Hodgson, “Institutional Econom-
ual choice that in fact limits informed own fate. As public health pursues this ics: Surveying the ‘Old’ and the ‘New,’” Metro-
decision-making, and therefore auton- mission, a respect for autonomy—pre- economica 44, no. 1 (1993): 1-28.
omy, because it specifically forecloses viously portrayed as a constraint on 8. A. Sen, “Capability and Well-Being,”
in The Quality of Life, ed. M. C. Nussbaum
the path through which philosophers public health—can instead be seen as and A. Sen (Oxford: Clarendon Press, 1993),
have argued we get closer to the truth. not only consistent with the mission but 30-53.
In this sense, asking individuals to make inherent to it. 9. Institute of Medicine Committee for
up their own minds about such matters Public health has long been fighting the Study of the Future of Public Health, The
serves ignorance, not truth. a kind of rear-guard action against those Future of Public Health (Washington, DC: Na-
tional Academy Press, 1988).
who accuse it of trifling with autonomy. 10. Haliburton, Autonomy and the Situated
Autonomy in Public Health Charges of nanny-statism are persis- Self.
tent toward public health, and some of 11. D. A. Cohen, R. A. Scribner, and T.

T he conceptualization of autonomy
advanced here—involving threats
to choice sets, threats to preferences, or
these charges, as in the whole-milk li-
bel, are indeed warranted. Public health
has occasionally overstepped its role in
A. Farley, “A Structural Model of Health Be-
havior: A Pragmatic Approach to Explain and
Influence Health Behaviors at the Population
Level,” Preventive Medicine 30, no. 2 (2000):
threats to information—implies that excessively limiting choice sets, and it 146-54.
autonomy is less about the absence of has skirted close to influencing prefer- 12. A. Tversky and D. Kahneman, “The
external influences than about creating ences in ways that clearly make people Framing of Decisions and the Psychology of
an environment in which each person uncomfortable. Yet, the three threats Choice,” Science 211 (1981): 453-58.
13. P. England, “A Feminist Critique of Ra-
is free to choose life options—healthy presented here suggest ways in which tional-Choice Theories: Implications for Soci-
behaviors; health investments; the time, public health can make an emphasis ology,” American Sociologist 20, no. 1 (1989):
place, and manner of living, working, on autonomy an asset rather than a li- 14-28.
playing, and praying—out of a self-con- ability. Public health can and should ad- 14. N. J. Smelser, “The Rational Choice
fident and self-aware process of authen- vance its goals by expanding autonomy: Perspective: A Theoretical Assessment,” Ra-
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is understood in reference to a struc- in people’s choice sets as it has always Dualism of Means and Ends: Why Rational
tured environment that provides many advocated for choices in medical care, Choice Theory Does Not Deserve Paradig-
options, good information, and the leveraging the value that Americans matic Privilege,” Theory and Society 31, no.
absence of manipulation of preferences place on free speech to continue to in- 3 (2002): 325-63; P. K. MacDonald, “Use-
ful Fiction or Miracle Maker: The Compet-
by self-interested outsiders. As Mildred fluence preferences but with more atten- ing Epistemological Foundations of Rational
Solomon and Bruce Jennings have suc- tion to evidence-based beneficence, and Choice Theory,” American Political Science
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interdependence.”46 knowledge as it has always safeguarded 15. D. W. Bromley, Sufficient Reason: Vo-
Such an understanding of autonomy supplies of food and water. The future litional Pragmatism and the Meaning of Eco-
nomic Institutions (Princeton, NJ: Princeton
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its core mission, that of “assuring condi- embrace of relational autonomy. “Elements of a Neo-Veblenian Theory of the
tions in which people can be healthy.”47 Individual,” Journal of Economic Issues 43, no.
Notes
Although there are many proposed pub- 1 (2009): 189-214; G. M. Hodgson, “The Ap-
lic health strategies that interfere with 1. B. Jennings, “Reconceptualizing Autono- proach of Institutional Economics,” Journal of
my: A Relational Turn in Bioethics,” Hastings Economic Literature 36, no. 1 (1998): 166-92.
autonomy as it is represented here, there 16. A. K. Sen, “Rational Fools: A Critique
Center Report 46, no. 3 (2016): 11-16.
are many more that, even if they seem 2. J. Christman, “Autonomy in Moral and of the Behavioral Foundations of Economic
to infringe isolationist autonomy, in Political Philosophy,” in Stanford Encyclopedia Theory,” Philosophy and Public Affairs 6, no.
fact support relational autonomy. One of Philosophy, ed. E. N. Zalta (Stanford, CA: 4 (1977): 317-44; D. Ariely, G. Loewenstein,
example is in the Affordable Health The Metaphysics Research Lab, 2015), 21. and D. Prelec, “Tom Sawyer and the Con-
3. N. Stoljar, “Feminist Perspectives on struction of Value,” Journal of Economic Behav-
Care mandates to the individual to pur- ior and Organization 60, no. 1 (2006): 1-10.
Autonomy,” in Stanford Encyclopedia of Phi-
chase health care (with ample subsidies losophy, ed. E. N. Zalta (Stanford, CA: The 17. D. Kahneman, “Maps of Bound-
for low-income people) and to insurers Metaphysics Research Lab, 2015), 7-36. ed Rationality: Psychology for Behavioral
to sell insurance to all comers regardless

44 HASTINGS C E N T E R R E P ORT November-December 2017


Economics,” American Economic Review 93, 2014); R. Marqués and V. Hernández-Her- 37. J. Erickson et al., “The Scientific
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18. D. Kahneman, Thinking, Fast and Tracks on the Risk of Cycling: The Case of Sugar Intake: A Systematic Review,” An-
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19. Ibid. 29. G. Duranton and M. A. Turner, “The 38. G. I. Spielmans and P. I. Parry, “From
20. F. J. Zimmerman, “From Choice Fundamental Law of Road Congestion: Evidence-Based Medicine to Marketing-
Architecture to Policy Infrastructure: Mul- Evidence from U.S. Cities,” American Eco- Based Medicine: Evidence from Internal
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Roberto (Oxford: Oxford University Press, Value.” thor: How Pharmaceutical Marketing Is
2015), 299-341. 31. F. J. Zimmerman, “Using Marketing Embraced within Medicine’s Scholarly Lit-
21. Kahneman, Thinking, Fast and Slow. Muscle to Sell Fat: The Rise of Obesity in erature,” Hastings Center Report 46, no. 4
22. W. James, “Habit,” chapter 4 in Prin- the Modern Economy,” Annual Review of (2016): 31-37.
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Vanderbilt Prize in Biomedical Science Ad- zana, “Physicians and the Pharmaceutical Situation: An Introduction to the Situ-
dress, 2008, Nashville, TN. Industry: Is a Gift Ever Just a Gift?,” Jour- ational Character, Critical Realism, Power
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27. Zimmerman, “From Choice Archi- Autonomy,” 43. Hanson and Yosifon, “The
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28. National Association of City Trans- ing Upstream: The Political Economy of Ill- 44. Ibid., 229.
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