Balancing the Potential for Harm With Our Capacity for Good

In public health, we can find ourselves in positions where proportionality is of core importance. Public health often makes recommendations to policymakers that involve “asks” of the public. We propose actions that entail some restraint or sacrifice in exchange for less risk of harm. We saw this during the pandemic when public health played a role in the adoption of lockdowns, mask mandates, and vaccination requirements.

This recent history reflects a dynamic that has long characterized what we do. As long as public health has existed, it has at times placed checks on individual autonomy in the name of the greater good of supporting a healthier society. From quarantines during times of plague to mandatory treatment for diseases like tuberculosis to taxes on harmful products like sugar-sweetened beverages, public health has supported measures that place impositions on the public.

In some cases, such as the extended restrictions on movement of the COVID-19 moment, these impositions created their own challenges for health. This places public health, a field which exists to shape healthier populations, in the difficult position of sometimes proposing measures which create tradeoffs for health. In order to be effective in our core mission, we, at times, impose restrictions on populations which, if too tight, could cause undue harm, but, if too loose, could mean opening the door to greater harm. Proportionality helps us to strike this balance; to advocate for policies that suit the moment, imposing on the public no more than is necessary to support health.

It strikes me that proportionality in public health is fundamentally about the question: What is the potential for harm and what is the potential for good in a public health action? As we navigate this philosophical space, the following three principles can, I think, serve as useful guides, helping us to better engage with proportionality in this post-war moment.

Prioritizing proportionality

First, proportionality has to be central to public health. Throughout the history of public health, we have, at various points, chosen to embrace certain concepts as core to our field. For example, as we became more focused on crafting policies that shape health at the population level, we began to have more conversations about advancing these policies while respecting individual autonomy. As it became clear that social exclusion and historical injustice are foundational drivers of poor health, we embraced the pursuit of equity as a foundational focus. Now, in this post-COVID moment, public health has, in many ways, more power than ever before to shape policy and engage with the public debate to advance our favored solutions.

With this newfound power comes the responsibility to place proportionality at the center of public health thought and action. We should never find ourselves in the position of recommending an action that might cause more harm than it prevents. This means having a clear-eyed view of the potential harms of any step we are considering. We need to engage dispassionately with the data to see both the costs and benefits of a given action.

The pursuit of equity

Second, it is important that our focus on proportionality is informed, always, by our pursuit of equity. Just as public health is centrally concerned with ensuring that all have access to the resources and opportunities that support health, it has a responsibility to ensure that no groups bear undue burdens.

This means that our calculus when it comes to the harm our interventions may cause must account for the disproportionate burden of poor health experienced by certain marginalized groups. This can help us avoid taking actions that may worsen inequities even as they might benefit the overall population. It is not enough for a given measure to be worth the inconvenience or harm it may cause the population at large. We must also consider how it may affect groups whose health is poorer than the average, or for whom the burden of our intervention will be particularly heavy.

Understanding various perspectives

Third, it is important to remember that our conception of harm is shaped by what we value. Proportion depends on being able to weigh the risks and benefits of a given measure, but, as I have recently written, risk is not a value-neutral concept. It is influenced by our biases, by the individual and cultural lens through which we view the world. This has implications for how we determine whether a policy or action is truly proportional.

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Consider the example of alcohol consumption. It is, I think, fair to say that many in public health regard alcohol consumption as nothing more than a health hazard. For this reason, we may not regard efforts to ban or severely limit the sale of alcoholic beverages as anything less than an unalloyed good. We might therefore favor, of all possible actions to address the health harms of drinking alcohol, the strictest possible ban on the practice. But for many, consuming alcohol is a source of pleasure, and an activity tempered by moderation. This reality should change our understanding of proportion as we consider alcohol policy. Even if it does not change our position on alcohol, it should help us to think about how different populations have different definitions of harm and how it is important for public health to take these perspectives into account. And that should guide how we approach efforts to limit alcohol consumption, through changing what does give pleasure in the direction of more healthful pastimes, rather than simply imposing a ban heedless of how weighty it may feel for some.

I have been writing this set of essays in 2023 to the end of articulating a practical philosophy of health in what I have called a post-war period. This leads me to focusing on principles that allow us to maximize our capacity to support health while minimizing the harms our efforts may cause. Choosing to prioritize proportionality as central to our thinking can help us to do so. It can ensure we act, always, within the bounds of what is necessary to create better health for all, imposing on the public just as much as we need to, but never more than we must.

A version of this post also appears on Substack.