Philosophy of public health and public policy: an interview with James Wilson

James Wilson is Professor of Philosophy at University College London and Co-Director of the Center for Health Human Sciences at UCL. He has served on National Health Service advisory groups on data collection and access, and serves on the steering group of the National Data Guardian. James is interviewed here by Peter Momtchiloff, philosophy editor at OUP.

“Public health” is now a familiar phrase in our daily lives. Do you think that philosophy took a little time to tame public health? I note that the newspaper Public Health Ethics was only founded in 2008.

Philosophy, along with bioethics, has been decidedly late in approaching public health. The leading political philosophers of the previous generation, such as John Rawls, now often seem simply naïve or uninformed when discussing health. Usually they don’t deal with the social determinants of health literature at all. Some topics such as the imposition of risk, which are fundamental to works on the philosophy of public health, have only become mainstream in philosophy in the last 15 years.

How do philosophical questions related to public health differ from typical questions in medical ethics? Is it particularly a question of going beyond ethics?

Work in medical ethics and bioethics has often been highly individualistic, focusing on issues such as the doctor-patient relationship and informed consent in medical research. Public health focuses attention on what societies as a whole are doing to protect the health of populations. Public health ethics compels us to think about the design of institutions, but it is essential to remember that those who are helped or abandoned by institutions are individuals. We need to integrate ethics and politics, rather than going beyond ethics.

“Long-term, trustworthy communication builds high levels of public trust and citizens are likely to adhere to government directives.”

You have worked on government health care advisory groups. Have you come up with any general ideas on how government can better communicate with citizens about public health?

The practice of public health far more often aims to influence the behavior of citizens through information and persuasion than through direct coercion. How governments communicate makes a significant difference to outcomes. Long-term, trustworthy communication builds high levels of public trust, and citizens are then much more likely to adhere to government directives. This requires honesty, integrity and consistency from government ministers. It is much easier to lose trust than to regain it.

Do you think the “boost” or other non-transparent methods of public health management have a valuable role to play?

The nudge alone is unlikely to change the dial on the structural causes of health inequalities, so it would be a dereliction of public health policy duty to deploy only nudges. Nudges can nevertheless be useful. Some public health nudges can be cost-effective and obviously beneficial, such as soundtracks that provide tactile feedback to an inattentive driver drifting out of line. What matters most is how publicly defensible the rationale for the boost is and whether a boost is the best solution to the public health problem at hand.

How has the impact of COVID-19 affected your writing of the book?

The full manuscript was already at OUP when COVID-19 hit. I argue that philosophers cannot do philosophy well unless they engage in complex real-world cases, and so COVID-19 has provided a powerful test for the adequacy of the book’s analysis . In the first wave, I was able to use the book’s ethical framework to provide urgent ethical advice on resource allocation and data ethics to a range of public institutions. After that, I spent a few months trying to figure out what needed to change in my arguments. It became clear that the pandemic had, if at all, justified the complex systems approach that I had championed in the book. This focuses on how change and momentum are continually occurring at all levels relevant to public health, and why we should expect change to be mediated and shaped in real time by structural injustice.

“Just as the pandemic has supercharged public health, it has supercharged public health protest.”

Do you think COVID-19 will have made it easier or more difficult for governments to promote public health?

COVID-19 has given us precedents of governments doing extraordinary things to protect public health. Three years ago, no one would have expected that our governments would criminalize everyday activities like visiting parents, or that most people would agree that this was a fair way to spread the burden of harm reduction.

Once you’ve shown that radical action is politically possible, that opens the door to more forceful action on climate change, or air quality, or health inequalities. But just as the pandemic has supercharged public health, it has supercharged public health protest. We have seen the rise of anti-vax movements and the transformation of mask wearing into a “culture war” issue in many countries. So while COVID-19 sets a precedent and anchor for public health advocates, it also provides a rallying point for public health opponents.

Given the current political volatility, it is too early to tell which framework will prevail. One thing philosophers can do to help is articulate the case for public health in a way that is accessible even to those who mistrust the state, as my book attempts to do.

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