Friday, November 18, 2005

CHALLENGING DOGMA (Post #8): The Anti-Smoking Agenda Justifies Itself

One of the lessons that I have learned during the past 2 weeks (since I questioned the justification for policies in which employers refuse to hire smokers and for broad outdoor smoking bans) is that there are a considerable number of anti-smoking groups/advocates who are just not interested in discussing the justification for their tobacco control policies.

One of the responses I received to my posts questioning the justification for these two particular trends in anti-smoking policies was that there are more important things we need to do and discussion of these issues is a distraction to the important work that we should be doing. I also heard from one anti-smoking advocate who expressed a lack of interest in discussing the justification for these policies in the first place.

Apparently, there is a feeling that the agenda, being a well-intentioned one with a good end in mind, justifies itself.

It was interesting to me, because this wasn't the first response I received. The responses came in waves, and here's how I summarize them:

In the first wave, there was an attempt to dispute my suggestion that there is not adequate scientific evidence that outdoor smoking in open, non-enclosed places where people can freely move about is a substantial public health problem. I was referred to a study and told that I am not up to date on the facts.

While I had read that study, I re-read it, and still did not find evidence that outdoor smoking in most public places is a substantial public health problem.

When I pointed out that the evidence was unconvincing, that's when a slew of alternative possible justifications for outdoor smoking bans were suggested (the second wave) - everything from the need to control the litter on beaches to smoking being a nuisance to the desire to keep kids from seeing people smoke to smoking in public being a moral affront.

When I suggested that these justifications were not adequate, that's when the third wave of responses came in:
  • this discussion is a distraction that is taking us away from the important work we need to be doing; and
  • we are not interested in discussion that challenges the justification for what we are doing.
In other words, what I'm saying is that anti-smoking groups did not immediately express a lack of interest in discussing the issue. They were interested enough to point me to scientific data that they thought could convince me that secondhand smoke exposure outdoors is a substantial enough public health problem to justify broad outdoor smoking bans. But when I challenged whether that data actually demonstrated that the problem was a substantial one that was actually causing significant morbidity, they resorted to a second wave of arguments.

So there was some interest in the science behind the issue, but only an interest if the science supported the agenda. Once it became apparent that I wasn't going to buy the notion that the science supported the agenda, then the science no longer was critical. There were, after all, other reasons to support these policies.

After seeing that I wasn't convinced that these other reasons supported the agenda, that's when it became clear that a number of groups/advocates just aren't interested, when it really comes down to it, in the justification for what they are doing. They are doing it for a good cause, so it is by definition justified.

The Rest of the Story

I guess the thing I'd like to emphasize is that I view public health as a public service career. We are, first and foremost, public servants who are trying to advance the best interests of the public, focusing of course on the protection of the public's health. And to accomplish that end, we are promoting policy changes that are going to interfere with the way in which people live their lives. That's fine, but it means to me that we need to be able to adequately justify the need for intervention.

As public servants, I think we owe it to our constituents (the public) to be able to provide a solid justification for our interventions, especially those which intrude upon the freedoms and liberties of citizens.

And a solid justification, to me, implies that we need to be able not only to show that our proposed policies are going to benefit health, but that they are going to not harm the public, represent a just policy, and demonstrate respect for the autonomy of persons (specifically, that the benefits of the policy should outweigh any intrusion into individual autonomy).

In a recent article in Tobacco Control, Brion Fox of the University of Wisconsin Comprehensive Cancer Center beautifully articulated the ethical principles that tobacco control practitioners must consider in their work (see Fox BJ. Framing tobacco control efforts within an ethical context. Tobacco Control 2005; 14[Suppl II]:ii38-ii44).

The first principle, of course, is beneficence: "the duty to act for the benefit of others." Essentially, as Fox explains, this means "an effort to do good." This is clearly part of every tobacco control policy that is proposed. However, it is not the only ethical principle. The justification discussion does not end here. But it is at this point that I sense many anti-smoking groups feel that the discussion should end or that it simply does end.

As Fox points out, there are a number of other ethical principles that must also be considered.

One is the principle of non-maleficence: "the duty to do no harm." As Fox points out, "inattentiveness to negative consequences is ethically risky and could allow the community to be characterised as unconcerned. For example, the negative consequences of increased tobacco taxation on low income populations should be thoughtfully considered so as not to appear that the community is insensitive to the needs of this population."

I would argue that the principle of non-maleficence also needs to be considered in the issue of firing or not hiring smokers. Such a policy would have a severe negative impact on the ability of smokers to find employment and therefore to make a living and support themselves and their families. To simply toss this concern aside is, as Fox suggests, "ethically risky."

Just yesterday, I suggested that the principle of non-maleficence was violated by the Georgia workplace smoking law, which actually harms restaurant workers who are forced to work under the extremely dangerous conditions of smoke-filled smoking rooms.

Another principle that Fox outlines is that of justice: "the duty to act with fairness." For example, Fox points out that "as the tobacco control community advocates for increased taxes, the possible regressivity of these taxes should be clearly considered and efforts made to limit any impact that could increase disparities."

I would argue that this principle applies importantly to the consideration of discriminatory workplace policies. Is it fair to smokers to make employment decisions based on their membership in a particular group or category, rather than on the basis of their individual qualifications for a particular job?

Perhaps the most overlooked principle is that of respect for autonomy: "the right to be free from controlling influences." Fox emphasizes that the autonomy of smokers must be considered: "the tobacco control community should show that it respects the autonomy of all individuals, including smokers, by demonstrating how its programmes are consistent with this principle."

Here is where Fox has elegantly made the primary argument that I am trying to make. It isn't enough for a proposed anti-smoking policy to be benificent - that is, to be intended to promote health. It also has to respect individual autonomy. And to respect autonomy, tobacco control practitioners must demonstrate "how its programmes are consistent with this principle."

In other words, the burden of proof is on us. Our policies are not self-justifying. We must specifically show how they take into account the ethical principle of autonomy, we must demonstrate that the benefits of the policy outweigh any intrusion into individual autonomy. That is precisely what I mean when I talk of the need to adequately justify our policies.

It is not enough to say that outdoor smoking should be banned because it is a nuisance or because it causes a huge litter problem or because it leads kids to smoke, or even because it is a health hazard. We must demonstrate that the degree of the problem is substantial enough to justify the degree of intrusion into individual autonomy that the proposed policy represents.

With the case of outdoor smoking bans, I find the intrusion to be substantial, so I feel that the degree of the problem must also be substantial. And this is why the absence of scientific evidence that the problem is a major one from a public health perspective is so important to me.

It's not that I don't think banning smoking everywhere in public has some benefit or is intended to protect health. It's that banning smoking everywhere in public intrudes upon personal autonomy and it's not clear to me that the benefit in terms of protecting health outweighs the degree of the intrusion. That's the issue that I've been trying to bring to the forefront, apparently unsuccessfully.

Perhaps my frustration with the response to my recent posts is that many anti-smoking advocates and groups tend to speak only in the language of beneficence. If it is intended to improve health, then it is automatically justified.

But as Fox insighfully points out, this is just one of a number of ethical principles that must be considered. A proposed policy must also not do harm, must be fair, and must respect the autonomy of persons, and that includes smokers.

What I am trying to do is to make sure that, in our role as public servants, we are being true to our responsibility to consider all of these ethical principles: non-maleficence, justice, and respect for autonomy (Fox also includes transparency and truthfulness, which I address repeatedly in many of my posts about the tobacco control movement), and not just beneficence.

The rest of the story is that the anti-smoking agenda does not justify itself. It is our duty, our obligation, our public responsibility to demonstrate that our proposed policies are justified. And to do this, we must not simply show that a policy is beneficent; we must also show that it will not cause undue harm, that it is fair, and that it respects autonomy (that the health benefits outweight the degree of intrusion into individual autonomy). We must also be forthright (transparent) and honest in all of our efforts to promote these policies.

To me, this is what would make the difference between being simply an anti-smoking movement and truly being a public health movement that is dedicated to the reduction of tobacco-related suffering.

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