A  VIRTUE  APPROACH  TO  PUBLIC  HEALTH  ETHICS     By     Karen  M.  Meagher                           A  DISSERTATION     Submitted  to   Michigan  State  University   in  partial  fulfillment  of  the  requirements   for  the  degree  of     DOCTOR  OF  PHILOSOPHY     Philosophy     2012           ABSTRACT     A  VIRTUE  APPROACH  TO  PUBLIC  HEALTH  ETHICS     By     Karen  M.  Meagher     While  the  virtues,  or  ideal  character  traits,  of  a  physician  are  well  established  as  a   cornerstone  of  medical  ethics,  the  focus  in  public  health  has  been  on  policy  and  practice,  not  on   professionalism.    In  this  dissertation  I  focus  on  the  contributions  that  a  virtue  ethics  approach   can  make  to  discourse  in  public  health  ethics.      The  central  points  of  my  dissertation  include  (1)   an  aretaic  concern  with  balancing  self-­‐  and  other-­‐concern  can  help  resist  oversimplifying  public   health  problems  in  terms  of  conflicts  between  group  interests  and  individual  rights  (2)  the   virtue  of  trustworthiness  suggests  trust  as  an  alternative  to  paternalistic  relationships  in  public   health  practice,  (3)  the  language  of  courage  and  its  associated  vices  is  sometimes  latent  in   public  health  risk  discourse,  and  (4)  the  notion  of  harmartia,  or  “missing  the  mark”  can  shed   light  on  current  debates  regarding  the  scope  of  public  health  as  a  discipline.    I  consider  it  to  be   an  advantage  of  virtue  ethics  that  it  connects  what  public  health  professionals  ought  to  do  with   what  kind  of  life  professionals  want  to  live,  or  who  they  want  public  health  professionals  to   become.    By  speaking  to  the  professional  identity  of  public  health  workers,  my  contribution  to   ethics  of  public  health  helps  to  address  the  concern  that  the  profession  currently  lacks  a   coherent  normative  foundation.      My  primary  aim  throughout  this  project  is  to  demonstrate   how  virtues  create  a  standard  of  excellence  that  professionals  can  aspire  to  attain.                                           ©Copyright  by   Karen  M.  Meagher   2012                 ACKNOWLEDGEMENTS   I  would  like  to  express  my  deep  gratitude  to  the  many  people  who  were  integral  to  my   completion  of  this  dissertation.    I  am  especially  grateful  to  Tom  Tomlinson  for  his  mentorship.     His  patience,  thoughtfulness,  and  sense  of  humor  were  indispensible  and  inspirational.    I  would   like  to  thank  the  other  members  of  my  committee,  Judy  Andre,  Paul  Thompson,  and  Scot  Yoder,   for  their  helpful  comments,  guidance,  and  collaborative  encouragement.    In  the  same  vein,  I   would  like  to  thank  the  faculty  of  the  Philosophy  Department,  especially  Debra  Nails  for   revealing  the  shadows  on  the  cave  wall  for  what  they  really  are,  Dan  Steele,  Fred  Gifford,  Jim   Nelson,  and  Hilde  Lindemann  for  their  influence  on  my  thoughts  over  the  years,  and  Marilyn   Frye  for  making  sense  of  my  world.    I  would  like  to  recognize  Lisa  Schwartzman  for  her   unparalleled  dedication  to  graduate  student  success,  and  for  the  helpful  advice  she  and  Sean   Valles’  provided  while  I  was  navigating  the  job  market.    I  would  particularly  like  to  thank  the   faculty  and  staff  of  Center  for  Ethics  and  Humanities  in  the  Life  Sciences,  and  members  of  the   Biomedical  Institutional  Review  Board  for  engaging  me  as  a  full  partner  in  their  interdisciplinary   efforts.     I  would  like  to  thank  those  who  first  started  me  in  philosophy,  Marianne  Janack  and   Robert  Simon,  paragons  of  the  high  standard  of  teaching  at  my  alma  mater,  Hamilton  College.     They  provided  my  first  glimpse  into  what  it  might  mean  to  excel  in  philosophy,  and  to  consider   a  future  as  a  college  professor.  I  endeavor  to  emulate  their  examples  of  good  teaching  for  the   benefit  of  my  own  students.  I  would  like  to  think  my  many  friends  and  fellow  graduate  students   for  their  conversation  over  the  years,  and  especially  their  ability  to  make  me  laugh.         iv           Lastly,  I  would  like  to  express  my  love  and  gratitude  to  my  parents,  Linda  and  Paul   Meagher,  for  their  unconditional  belief  in  me,  and  to  the  rest  of  my  large  and  gregarious  family,   including  my  brother  Peter  and  his  wife  Melinda,  the  Gerlachs,  and  Paul  and  Janis  Emmi  for   their  support  (often  in  the  form  of  food).    Finally  I  cannot  find  adequate  words  for  Jeremy,  my   partner  in  life,  for  his  unswerving  love.         v         TABLE  OF  CONTENTS       INTRODUCTION       CHAPTER  1     BALANCING  SELF-­‐  AND  OTHER-­‐CONCERN  IN  PUBLIC  HEALTH  PRACTICE     1.1  Civic  Friendship       1.1.1  Altruism  and  Selfishness       1.1.2  Civic  Friendship       1.1.3  Resemblance  to  virtue  friendship       1.1.4  How  can  other-­‐concern  also  be  in  my  interest?       1.1.5  Do  civic  friendships  exist  in  modern  societies?     1.2  Civic  Friendship  and  Public  Health       1.2.1  The  Synoptic  Perspective  of  Public  Health     1.2.2  Objections  to  the  Synoptic  Perspective       1.2.3  Imaginative  Engagement     1.2.4  Examples  in  public  health  practice     CHAPTER  2     PUBLICHEALTH  RELATIONSHIPS:  DEFERENCE,  RELIANCE,  AND  TRUST   PART  I           2.1  Public  Health  Paternalism     2.1.1  Kinds  of  Paternalism     2.1.2  Professional  Relationships  with  the  Public     2.2  Case  Study:  MMR  Vaccination     2.3  Deference         2.3.1  Deference  and  Reforming  Belief   2.3.2  Epistemic  vs.  Moral  and  Legal  Deference   2.3.3  Epistemic  vs.  Moral  and  Legal  Deference   PART  II           2.4  Reliance  and  Reliability     2.5  When  Reliance  is  not  enough     2.6  Interpersonal  Trust  and  Trustworthiness       2.6.1  The  Encapsulated-­‐Interest  Account     2.6.2  Affective  Accounts  of  Trust  and  Trustworthiness     2.7  Group  Trust,  Institutional  Trustworthiness     2.7.1  Social  Capital     2.7.2  Generalized  Trust     2.7.3  Trust,  Trustworthiness,  and  Institutions               vi   1   5   6   6     8   9     13   16   17   18   19   22 24   31   32   32   33 36   42   50   50   55   58   61   61   68   73   74   78     84   85   86   89             CHAPTER  3     COURAGE  IN  PUBLIC  HEALTH  RISK  COMMUNICATION  AND  MANAGEMENT     3.1  Risk         3.2  Public  Health  Courage     3.2.1  Professional  Courage  in  Public  Health  Practice     3.2.2  What  is  courage?     3.2.3  Courage  and  public  health  communication     3.2.4  Practical  excellence  and  courage  in  public  health  practice     3.3  Beyond  the  Doctrine  of  the  Mean     3.4  Types  of  Courage         3.4.1  Heroic  Courage       3.4.2  Courage-­‐Fortitude     3.4.3  Courage  and  Justice       3.5  Institutional  Courage     3.6  Courage  and  Prudence       CHAPTER  4     THE  BOUNDARY  PROBLEM  AND  THE  SCOPE  OF  PUBLIC  HEALTH     4.1  The  Boundary  Problem       4.2  Models  of  Public  Health       4.3  A  Virtue  Approach  to  the  Boundary  Problem     4.4  Toward  public  health  inquiry  into  the  nature  of  the  profession       4.4.1  Is  there  a  distinctive  ethics  of  public  health?     4.4.2  What  shared  assumptions  can  provide  starting  points?       4.4.3  What  are  the  rules  of  engagement?     4.4.4  What  are  the  desired  outcomes  of  discourse?     4.5  Professional  Flourishing       CONCLUSION           BIBLIOGRAPHY                 vii   98   99   105   106   108   110   113   115   123   123   125   129   134   137   144   144   146   164   174   174   176   178   179   180   184   189       INTRODUCTION     “Medicine  is  a  moral  community  because  it  is  at  heart  a  moral  enterprise  and  its   members  are  bound  together  by  a  common  moral  purpose.    If  this  is  so,  they  must  be  guided  by   some  shared  source  of  morality  –  some  fundamental  rules,  principles,  or  character  traits  that   1 will  define  a  moral  life…”      This  is  the  way  Pellegrino  and  Thomasma  begin  their  account  of  the   virtues  in  medicine.      Within  the  last  two  decades,  the  call  for  greater  attention  from   bioethicists  to  address  the  normative  foundations  of  public  health  has  grown  increasingly   louder,  with  some  of  the  voices  beginning  to  fill  in  such  accounts.      Public  health  has  been   traditionally  understood  as  deeply  rooted  in  utilitarianism,  but  Onora  O’neill’s  work   demonstrates  that  Kant  can  hold  his  ground  in  public  health  ethics  as  well.    My  purpose  here  is   to  establish  a  place  for  virtue  ethics  within  the  nascent  stages  of  this  discourse.     It  is  also  important  to  say  what  I  do  not  intend  to  offer  here,  which  is  a  comprehensive   account  of  the  virtues.    I  draw  primarily  on  Aristotelian  notions  of  virtue,  but  also  some  Stoic   and  Platonic  insights  to  supplement  this  account.    I  do  not,  however,  address  some  of  the   pressing  questions  in  ancient  philosophy,  including  whether  there  is  a  unity  of  the  virtues,  and   the  related  question  of  whether  the  virtues  are  a  form  of  knowledge.    And  while  my  approach  is   eudaimonistic,  I  do  not  offer  a  full-­‐fledged  account  of  the  flourishing  life  (eudaimonia).    Rather,   by  focusing  on  the  virtues  of  professionals,  the  task  at  hand  is  truncated.    But  it  is,  for  the  same   reason,  incomplete.      While  I  have  provided  some  insights  into  the  connections  between  virtues   and  professionalism,  there  are  many  different  approaches  to  virtue  theory.    Thus,  bioethicists                                                                                                                           1  Edmund  D.  Pellegrino  and  David  C.  Thomasma,  The  Virtues  in  Medical  Practice  (New  York:   Oxford  University  Press,  1993),  3.       1     interested  in  moral  theory  should  be  cognizant  of  the  potential  for  debates  in  ancient  circles  to   disagree  with  what  I  have  suggested  here,  both  in  matters  of  interpreting  Aristotle,  but  also  due   to  ongoing  debates  in  virtue  theory.    Meanwhile,  public  health  professionals  should  be  aware   that  such  conversations,  while  occurring  primarily  in  the  circles  of  philosophers  and  classicists,   may  nevertheless  have  implications  for  public  health  practice.    For  example,  whether  the   virtues  are  a  form  of  knowledge,  and  how  we  acquire  them  may  be  central  to  public  health   education  and  training.     2 The  suggestion  that  virtues  are  pertinent  to  public  health  practice  is  not  new.    But,  for   public  health  ethics,  they  are  not  necessarily  an  intuitive  place  to  start.    Given  the  focus  of   public  health  on  collective  ends  and  means,  the  agent-­‐centered  perspective  of  virtue  ethics  may   seem  ill  suited  to  the  nature  of  health  policy.    By  approaching  ethical  questions  from   perspective  of  the  agent,  a  virtue  ethics  approach  works  from  the  “inside  out.”3    Given  current   feelings  of  professional  angst,  however,  I  consider  it  to  be  an  advantage  of  virtue  ethics  that   connects  what  public  health  professionals  ought  to  do  with  what  kind  of  life  professionals  want   to  live,  or  who  they  want  public  health  professionals  to  become.    By  speaking  to  the   professional  identity  of  public  health  workers,  my  contribution  to  ethics  of  public  health  helps   to  address  the  concern  that  the  profession  currently  lacks  a  coherent  normative  foundation.    In   addition,  while  I  address  civic  friendship  and  civic  courage  in  Chapters  1  and  3  respectively,  my                                                                                                                           2  Douglas  L.  Weed  and  Robert  E.  McKeown,  "Epidemiology  and  Virtue  Ethics."  International   Journal  of  Epidemiology  27,  no.  3  (1998):  343-­‐8;  J.  Stuart  Horner,  “For  Debate:  The  Virtuous   Public  Health  Physician.”  Journal  of  Public  Health  Medicine  22,  no.  1  (2000):  48–53;  Wendy   Rogers,  “Virtue  Ethics  and  Public  Health:  A  Practice-­‐based  Analysis.”  Monash  Bioethics  Review   23,  no.  1  (2004):  10–21.”   3  John  McDowell,  “Virtue  and  Reason,”  in  Virtue  Ethics,  ed.  Roger  Crisp  and  Michael  Slote  (New   York:  Oxford  University  Press,  1997),  141-­‐62.       2     primary  aim  throughout  this  project  is  to  demonstrate  how  virtues  create  a  standard  of   excellence  that  professionals  can  aspire  to  attain.       My  approach  to  this  project  was  to  consider  how  the  resources  of  virtue  ethics  could  be   brought  to  bear  on  four  ethical  aspects  of  public  health  practice:  1)  How  to  resolve  conflicts   between  individual  rights  and  group  interests;  2)  Public  health  paternalism  and  its  justifications;   3)  Risk  communication  and  risk  management;  and  4)  The  boundary  problem,  or  how  to   determine  the  proper  scope  of  public  health.   In  Chapter  1,  I  argue  that  an  Aristotelian  view  of  civic  friendship  can  help  to  approach   problems  in  public  health  often  conceived  of  as  conflicts  between  the  individual  and  the   community.      I  critique  the  tendency  to  characterize  the  options  available  to  citizens  in  terms  of   a  spectrum  that  runs  from  self-­‐centered  disregard  for  others,  to  altruistic  sacrifice  on  behalf  of   others.    I  contend  that  public  health  professionals  will  play  a  role  in  fostering  civic  friendship,   which  involves  both  self-­‐  and  other-­‐  concern.   Chapter  2  is  divided  into  two  parts.    In  the  first  part,  I  consider  some  faulty  arguments   used  to  justify  public  health  paternalism,  and  critique  the  resultant  suggestion  that  the  proper   relationship  between  public  health  professionals  and  members  of  the  public  is  epistemic   deference,  and  that  the  main  responsibility  of  public  health  professionals  is  to  be  competent.     In  the  second  part  of  this  chapter,  I  defend  relationships  of  reliability  and  trust  –  and  the   corresponding  traits  of  reliability  and  trustworthiness,  of  which  only  trustworthiness  is  a  virtue.   In  Chapter  3  I  argue  that  the  virtue  conception  of  courage  and  its  associated  vices  can   contribute  to  greater  clarity  in  risk  discourse  while  professional  expression  of  the  virtue  itself   can  guide  appropriate  responses  to  fear  in  public  health  practice.    The  main  contention  in  this       3     chapter  is  that  cultivation  of  the  virtue  of  courage  will  help  to  place  attitudes  and  perspectives   regarding  fearsome  objects  at  the  center  of  discussions  of  and  reactions  to  public  health   hazards.    I  argue  that  the  virtue  of  courage  helps  to  initiate  a  discussion  as  to  what  kinds  of   attitudes  of  fear  we  might  consider  appropriate  and  inappropriate  in  response  to  public  health   hazards,  especially  in  public  health  professionals.       In  Chapter  4  I  examine  current  debates  over  the  boundary  problem,  or  what  counts  as   public  health  problem.    I  consider  different  candidate  features  of  public  health  that  are  often   proposed  to  mark  the  field  as  distinctive  from  any  other.    I  consider  the  merits  of  these   “models”  of  public  health,  but  also  their  limitations  and  especially  their  potential  to  lead  to   problematic  or  objectionable  forms  of  “publichealthification.”    I  provide  an  Aristotelian  account   of  hamartia,  or  missing  the  mark,  that  helps  to  capture  a  more  complex  picture  of  goal-­‐oriented   behavior  by  collectives,  not  merely  by  individuals.    I  then  consider  what  resources  a  virtue   account  can  muster  in  order  to  provide  guidance  for  how  inquiry  into  a  philosophy  (and  ethics)   of  public  health  may  proceed.         4     CHAPTER  1:  BALANCING  SELF-­‐  AND  OTHER-­‐CONCERN  IN  PUBLIC  HEALTH  PRACTICE     "…there's  no  question  of  heroism  in  all  this.  It's  a  matter  of  common  decency.  That's  an  idea   which  may  make  some  people  smile,  but  the  only  means  of  fighting  a  plague  is  –  common   4 decency."    -­‐Albert  Camus,  The  Plague     In  this  chapter,  I  argue  that  an  Aristotelian  view  of  civic  friendship  can  help  to  approach   problems  in  public  health  often  conceived  of  as  conflicts  between  the  individual  and  the   5 community.      While  such  problems  often  characterized  the  options  available  to  citizens  in   terms  of  self-­‐centered  disregard  for  others,  or  altruistic  sacrifice  on  behalf  of  others,  I  seek   other  options  available  for  cooperation  with  public  health  interventions.    In  Section  1  I  outline   the  ways  in  which  such  conflicts  are  often  conceptualized  in  public  health.    I  then  present  the   Aristotelian  conception  of  civic  friendship  as  illustrative  of  the  ways  in  which  self-­‐  and  other-­‐ concern,  as  found  within  the  aretaic  tradition,  complicate  the  picture  of  human  motivation  at   play  in  policy  conflicts.    I  then  consider  to  what  extent  civic  relationships  exist  in  modern   society.    In  Section  2  I  consider  the  notion  of  synoptic  perspective  to  articulate  the  way  in  which   Aristotle  envisioned  a  community,  and  its  pertinence  to  public  health  practice.    I  conclude  that   public  health  policy  will  sometimes  play  a  role  in  facilitating  members  of  the  public  to  take  on   the  synoptic  perspective.    I  expand  on  Childress  and  Bernheim’s  notion  of  imaginative   engagement,  which  I  conclude  plays  a  role  in  fostering  civic  friendship,  and  thus  one  way  for   public  health  professionals,  with  the  help  of  the  community,  to  balance  individual  and   communal  interests.                                                                                                                             4  Albert  Camus,  The  Plague,  trans.  Stuart  Gilbert  (Vintage  Books,  1972),  53.   5  Throughout,  I  rely  on  Aristotle,  Nicomachean  Ethics,  trans.  Christopher  Rowe,  ed.  Sarah   Broadie  (Oxford:  Oxford  University  Press,  2002).       5     1.1  Civic  Friendship     In  this  section  I  present  the  way  in  which  individual  and  group  conflicts  are  commonly   portrayed  in  public  health  ethics,  and  how  this  sets  up  two  contrasting  understandings  of  civic   attitudes  as  exclusively  self-­‐concerned,  or  entirely  other-­‐concerned.    I  then  consider  the  ways  in   which  an  Aristotelian  notion  of  civic  friendship  allows  for  a  more  complex  notion  of  civic   dispositions.     1.1.1  Altruism  and  Selfishness     Let  us  consider  the  classic  public  health  challenge  of  an  epidemic.    Throughout  the   chapter  I  will  consider  other  public  health  hazards,  but  the  possibility  that  quarantine  may  be   needed  is  often  relied  upon  to  illustrate  the  nature  of  conflicts  in  public  health  ethics.      In  the   context  of  an  epidemic,  public  health  professionals  must  consider  how  to  control  the  spread  of   the  disease  within  and  between  populations.    In  such  cases,  the  collective  goods  of  health  and   safety  are  at  stake.    Containment  methods,  however,  may  require  restrictions  on  the  actions  of   individuals,  including  travel  restrictions,  isolation  of  the  infected,  and  involuntary  quarantine  of   the  exposed.      In  determining  when  to  call  for  such  measures,  the  conflict  is  often  depicted  as  a   choice  between  individual  liberty  (sometimes  in  terms  of  rights)  and  collective  wellbeing.    For   public  health  ethics,  the  challenge  is  to  justify  limiting  the  actions  of  some  individuals  in  the   name  of  the  community  –  and  the  solutions  are  often  expressed  in  terms  of  “trade-­‐offs.”   The  value  of  civil  liberties  is  often  associated  with  political  liberalism,  in  its  diverse   forms.    A  valuing  of  individual  freedom  in  part  marks  a  desire  to  allow  individuals  to  pursue   diverse  conceptions  of  a  good  life,  i.e.,  to  pursue  preferences  and  interests  distinct  from  those       6     that  arise  due  to  membership  within  a  community.    Part  of  the  challenge  that  this  presents  for   public  health  is  the  ways  in  which  it  sets  up  a  dichotomous  depiction  of  the  behavior  of  citizens   during  an  epidemic.    Stalwart  defenders  of  civil  liberties  may  appear  not  as  advocates  for   human  rights,  but  as  self-­‐centered  and  indifferent  to  the  wellbeing  of  others.    In  contrast,  those   who  willingly  comply  with  public  health  efforts  appear  to  be  paragons  of  supererogation,   making  great  sacrifices  for  the  public  good.      Thus,  the  picture  we  get  of  civic  attitudes  in  public   health  emergencies  is  pure  self-­‐concern  and  pure  other-­‐concern.   The  false  dichotomy  I  have  articulated  results  from  an  understanding  of  morality  that   has  been  criticized  by  many  proponents  of  virtue.      Altruism  is  commonly  understood  as  a   willingness  to  place  the  interests  of  others  before  one’s  own.    The  notion  of  sacrifice  as   essential  to  moral  action  results  from  the  view  that  acting  for  one’s  self,  or  valuing  the   individual,  is  to  prioritize  satisfaction  of  desires.    In  contrast,  when  individuals  act  on  behalf  of   others,  they  act  out  of  a  sense  of  obligation,  contrary  to  their  desires.      This  picture  of  morality   has  been  resoundingly  criticized  by  Bernard  Williams  who  notes  that  such  a  notion  “makes   people  think  that,  without  its  very  special  [sense  of]  obligation,  there  is  only  inclination;  without   6 its  utter  voluntariness,  there  is  only  force…”  It  rules  out  the  possibility  that  being  moral  counts   amongst  my  interests,  because  a  moral  life  is  one  I  would  prefer  to  lead.     Public  health  ethicists  have  used  many  different  ways  to  rearticulate  what  can  be  done   about  such  conflicts  between  self  and  other,  including  compatibility  arguments  that  point  to                                                                                                                           6  Bernard  Williams,  Ethics  and  the  Limits  of  Philosophy  (Cambridge:  Harvard  University  Press,   1986),  196.       7     7 the  deep  connections  between  human  rights  and  wellbeing.    Others  have  suggested   “internalizing”  the  tension  to  illustrate  the  way  that  civil  liberties  contribute  to  communal   wellbeing,  or  by  articulating  the  ways  in  which  individuals  desire  both:  “We  are  all  torn   between  our  private  wills  and  our  civic  wills,  between  our  interests  as  isolated  individuals  or   consumers  and  our  moral  interests  and  commitments  as  members  of  a  community  of  shared   8 purpose  broader  than  ourselves.    This  is  the  symbiosis  of  the  public  and  the  private.”    In  one   way,  what  I  propose  here  is  a  continuation  of  this  work.    However,  even  amongst  such  work,   the  view  of  altruism  is  still  the  most  dominant  conception  of  moral  action.    I  hope  to  make   room  for  an  alternative  vision  of  civic  participation  that  does  not  equate  it  with  “a  society  of   9 total  commitment.”                                                                                                                                                                                                                                                                                                                                       1.1.2  Civic  Friendship   For  the  ancients,  “Philia  is  other-­‐concern  restricted  to  those  people  to  whom  one  has  a   certain  kind  of  commitment.    The  commitment  can  be  deep,  as  with  friendships  based  on  good   character,  or  shallow,  as  in  utility  friendships;  it  can  be  continuing  or  transitory.    It  can  be  based   10 on  mature  choice…or  can  arise  from  an  unchosen  relationship.”    Schwarzenbach  notes  that   the  notion  that  the  positing  of  a  “friendly  feeling”  that  binds  citizens  together  is  often   considered  a  rather  parochial  thought  in  modern  political  philosophy.    But  the  connections  put                                                                                                                           7  Jonathan  M.  Mann,  “Medicine  and  Public  Health,  Ethics  and  Human  Rights.”  The  Hastings   Center  Report  27,  no.  3  (1997):  6–13.   8  Bruce  Jennings,  “Public  Health  and  Civic  Republicanism,”  in  Ethics,  Prevention,  and  Public   Health,  ed.  Angus  Dawson  and  Marcel  Verweij  (Oxford:  Oxford  University  Press,  2007),  55.   9  Ibid.,  55.   10  Julia  Annas,  The  Morality  of  Happiness  (Oxford:  Oxford  University  Press,  1995),  250.       8     forth  can  be  distinguished  from  interpretations  that  depict  such  relationships  as  merely   superficial  ties,  or  its  contrary,  a  utopian  fantasy:    “a  society  animated  by  civic  friendship  is  an   ideal;  it  is  not  satisfied  if  each  citizen  likes  some  citizen  (which  is  far  too  minimal)  nor  can  every   citizen  like  every  other  personally  (which  is  impossible).    Rather,  such  liking  and  doing  works  via   public  standards  of  behavior,  standards  which  ultimately  do  rest  on  the  goodwill  and  friendly   11 dispositions  of  its  individual  citizens.”     However,  it  would  be  a  mistake  to  identify  civic  friendship  merely  with  goodwill,  a  kind   of  general  well-­‐wishing  or  beneficent  view  of  others,  or  even  purely  emotive  feelings  of   affection.      While  such  attitudes  do  exist,  Aristotle  distinguishes  goodwill  from  friendship  by   pointing  out  that  general  goodwill  extends  to  strangers,  or  springs  up  suddenly  –  and  therefore   can  dissipate  just  as  quickly.  (NE  9.5  1166b30-­‐1167a3)    Rather,  he  observes  that  goodwill  is  the   starting  point  of  friendship.    And  the  true  mark  of  friendship  is  not  feelings  or  sympathy  that   might  develop,  but  rather  that  such  interest  in  benefitting  others  is  motivating;  it  moves  friends   to  action,  to  do  something  that  furthers  the  interests  of  others,  or  even  to  combine  their  efforts   together  –  to  unite  to  achieve  shared  ends  or  mutual  benefit  (NE  9.5  1167a10).         1.1.3  Resemblance  to  virtue  friendship   Aristotle’s  view  of  other-­‐concern  is  admittedly  paradoxical  –  he  claims  that  our  caring   for  others  is  a  development  from  self-­‐concern.  (NE  9.8)    Thus,  the  odd  conclusion  is  that  we   care  for  others  because  we  care  for  ourselves.    Aristotle’s  view  of  other-­‐concern  reflects  the   element  of  formal  egoism  present  in  his  philosophy:  to  love  one’s  self  is  to  desire  to  live  the                                                                                                                           11  Sibyl  A.  Schwarzenbach,  “On  Civic  Friendship.”  Ethics  107,  no.  1  (1996):  109.       9     most  excellent  life  available  to  one,  and  sometimes  this  also  means  making  sacrifices  which  are,   on  balance,  what  one  desires  the  most.    This  is  counterintuitive  in  part  because  the  notion  of  a   beneficial  sacrifice  sounds  incoherent.      What  is  less  controversial,  and  perhaps  a  feature  of  all   human  life,  is  the  reality  that  it  is  sometimes  preferable  to  sacrifice  some  desires  in  order  to   fulfill  others.    The  virtue  ethicist  merely  adds  that  the  desire  to  live  a  moral  life  is  the  motivating   force  behind  a  virtuous  agent’s  decisions.   Formal  egoism  should  be  contrasted  to  substantive  egoism.    Unlike  relationships   developed  just  for  the  benefits  of  association,  prestige,  or  other  self-­‐serving  ends,  virtue-­‐friends   are  not  motivated  by  the  self-­‐centered  benefits  of  friendship.    Rather,  virtuous  friendship   involves  true  concern  for  the  wellbeing  of  another  –  but  nevertheless,  acting  in  such  a  way  can   further  the  happiness  of  an  agent,  precisely  because  caring  for  another  often  entails  that  two   friends’  happiness  is  tied  to  that  of  the  other.    Just  like  close  friendships  and  family,  virtue   entails  that  the  flourishing  of  others  can  be  (and  may  even  need  to  be)  part  and  parcel  of  the   agent’s  flourishing.    This  may  be,  in  part,  because  it  is  hard  to  imagine  a  solitary  life  being  the   very  best  of  lives.    But,  for  Aristotle,  the  reverse  is  true  as  well.    True  friends  care  about  our  own   wellbeing,  and  as  a  result  help  us  to  achieve  happiness  –  they  help  us  to  attain  what  we  cannot   on  our  own.         Thus,  the  first  reason  that  civic  friendship  resembles  the  best  kinds  of  friendship  is  that   it  is  tied  to  our  nature.    The  good  life  for  humans  is  a  social  one  –  characterized  by  the  goods  of   experience  that  only  companionship  can  provide.    In  addition,  Aristotle’s  view  is  that  some   good  activities  are  not  available  to  us  unless  we  engage  in  civic  forms  of  activities  –  which  help   us  not  only  to  construct  a  good  life,  but  also  a  good  society.    And  the  two  are  also  not  easily       10     extricated.    It  is  also  worth  considering  whether  a  flourishing  life  is  possible  outside  of  the   context  of  a  good  community.    This  is  a  point  that  I  come  back  to  throughout  this  project,   returning  to  it  in  both  Chapters  2  and  3;  virtues  arise  out  of  shared  sets  of  practices,  and  social   institutions  and  communities  are  what  create  and  sustain  such  practices.    For  the  purpose  of   this  discussion,  I  am  interested  in  the  ways  in  which  public  health  professionals  engage  in   activities  that  are  constitutive  of  a  moral  community.   Julia  Annas  describes  the  Aristotelian  insight  that  other-­‐concern  involves  a  recognition   that  “a  friend  is  another  self.”    Thus,  just  as  we  care  about  our  own-­‐wellbeing,  we  can  extend   this  capacity  for  concern  to  others.    We  might  do  this  because  we  realize  that  our  happiness  is   tied  up  in  that  of  others’,  but  another  benefit  of  friendship  is  that  it  provides  with  insight  into   ourselves.    We  are  often  able  to  identify  the  character  strengths  and  weaknesses  of  others,  and   as  a  result  gain  insight  into  our  own  proclivities  for  vice  and  virtue.    In  addition,  the  intimacy   12 that  friendship  provides  also  helps  us  to  articulate  our  desires,  or  shape  new  ones.     Friendship,  then,  is  central  to  learning  who  we  are,  and  who  we  want  to  be.   The  second  reason  that  civic  friendship  resembles  virtue  friendship  is  that  it  also  lends   us  similar  insights.    The  communities  that  we  inhabit  and  identify  with  inform  of  us  who  we  are.     Ancestors  provide  us  with  ideals  to  emulate,  and  also  examples  of  mistakes  to  avoid.     Contemporary  communities  help  to  form  our  desires,  for  the  good  and  for  the  bad.    When  we   enter  new  communities,  they  provide  similar  opportunities  for  us  to  learn  about  ourselves,  and   what  kind  of  lives  we  wish  to  lead  both  as  individuals,  but  also  as  members  of  such  groups.     Thus  civic  friendship  is  greatly  important  to  shaping  the  possibilities  for  my  individual  life  to  be                                                                                                                           12  Annas,  "The  Morality  of  Happiness,"  254.       11     the  very  best,  but  also  in  forming  an  understanding  of  what  it  means  to  be  part  of  a  community.     I  will  argue  in  the  remainder  of  the  chapter  that  this  aspect  of  civilian  life  is  central  to  the  work   that  public  health  professionals  do.   What  are  the  limits  of  civic  friendship?  Aristotle  did  not  believe  that  other-­‐concern   extended  to  everyone;  in  his  society,  perhaps  he  failed  to  see  how  all  of  humanity  might  be  able   to  consider  themselves  part  of  one  community.    But  Julia  Annas  explains  that  this  view  of  the   limits  of  other-­‐concern  was  not  unanimous  amongst  the  ancients.    In  contrast,  the  Stoics   claimed  that,  in  fact,  other-­‐concern  does  extend  to  the  far  reaches  of  the  world.13    In  today’s   globalized  world,  the  occurrence  of  pandemics  illustrates  the  need  for  an  ethics  of  public  health   that  can  accommodate  such  connections  with  strangers  on  the  other  side  of  the  world.    If  an   Aristotelian  virtue  ethics  is  to  be  modified  to  fill  this  “gap,”  then  other-­‐concern  must  be   14 extended  to  any  whom  share  the  kind  of  connection  Aristotle  had  in  mind.     Civic  friendship  is  both  based  on  and  is  found  in  “a  good  that  is  common  not  just  in  the   sense  that  each  severally  gets  some  part  of  a  sum  total  of  distributable  benefit,  but  in  the   strong  sense  that  it  is  achieved  in  or  belongs  to  the  common  activity  that  is  the  single  life  they   15 all  jointly  live  by  merging  their  lives  with  one  another’s.”                                                                                                                                       13 Ibid.,  251.   14  Ibid.,  253.   15  Cooper,  John,  “Political  Animals  and  Civic  Friendships,”  in  Aristotle’s  Politics,  ed.  Kraut  and   Skultety  (Rowman  &  Littlefield,  2005),  79-­‐80.       12     1.1.4  How  can  other-­‐concern  also  be  in  my  interest?   I  would  like  to  return  again  to  the  notion  that  friendship  simultaneously  involves  self-­‐   and  other-­‐concern.      Such  a  possibility  will  need  to  be  examined  for  civic  virtue  more   particularly  because  it  seems  incoherent  to  say  that  making  a  sacrifice  is  in  my  interest.     According  to  Aristotle,  the  individual  who  dies  for  a  greater  cause  knows  the  value  of  her  own   life  and  wellbeing:  “for  to  such  a  person,  most  of  all,  is  living  worthwhile,  and  this  person  will   knowingly  be  depriving  himself  of  goods  of  the  greatest  kind.”    (NE  III.7  1117b10-­‐13).    I  revisit   the  importance  of  this  in  the  context  of  courage  in  Chapter  3,  but  for  now  I  wish  to  establish   that  for  Aristotle,  when  other-­‐concern  entails  that  an  agent  put  others’  interests  ahead  of  her   own,  she  feels  this  as  a  sacrifice.    Nevertheless,  virtuous  agents  will  only  do  this  voluntarily  if   they  are  simultaneously  striving  for  something  they  deem  more  valuable,  or  fine.    When  the   happiness  of  others  is  truly  tied  to  our  own,  it  sometimes  hurts  more  to  watch  our  friends   suffer  than  to  sacrifice  something  of  our  own  to  save  them  pain.    Again,  Annas  provides  us  with   a  simple  example  in  the  context  of  friendship:     the   self-­‐sacrificing   agent   is   also   getting   for   herself   what   matters.     Her   motives   will   thus   be   mixed.     She   sacrifices   her   money,   say,   so   that   her   friends   can   get   more  money.    She  does  this  for  her  friends’  sake,  because  this  is  a  fine  thing  to   do  (and  not  for  any  ulterior  motive,  such  as  showing  off  or  feeling  virtuous).    But   she  also  ‘assigns  the  greater  good  to  herself,’  for  in  doing  a  virtuous  action  she  is   doing   what   matters   to   her   more   than   gaining   money,   and   so   gaining   what   she   16 regards  as  her  good.     The  plausibility  of  this  example  illustrates  that  the  view  of  self-­‐  and  other-­‐concern  and  their   compatibility  is  certainly  possible  in  everyday  life.    We  commonly  put  ourselves  out  to   accommodate  those  we  care  about,  and  while  certainly  we  may  be  irritated  sometimes,  there                                                                                                                           16  Annas,  "The  Morality  of  Happiness,"  259.       13     are  other  times  when  we  think  such  actions  are  part  of  what  it  means  to  be,  and  to  have,  good   friends.    And  so  while  we  acknowledge  the  sacrifice  as  a  loss,  we  often  downgrade  its   significance  given  that  the  action  also  helped  someone  we  care  about.    Nevertheless,  there  is  a   real  question  of  how  deep  of  a  cost  we  are  willing  to  make  for  our  fellow  citizens,  and  whether   we  feel  a  strong  enough  connection  to  write  off  the  costs  required  by  public  health   participation.   The   possibility   for   self-­‐   and   other-­‐concern   to   be   expressed   simultaneously   is   significant  in  public  health  because  it  shatters  the  two  opposing  options  of  altruistic  or   self-­‐centered   action.     I   argue   this   opens   up   more   options   for   public   health   professionals   to   depict   different   motivations   for   engaging   in   public   health   interventions   that   also   impose  burdens.    On  this  view,  cooperation  in  public  health  interventions  does  not  need   to   be   selfless   –   citizens   do   not   need   to   view   public   health   activities   as   inherently   implying  that  some  individuals  will  be  sacrificed  for  the  greater  good,  i.e.,  will  be  made   into   public   health   martyrs.     When   public   health   cooperation   requires   small   sacrifices   on   the  part  of  citizens,  they  might  think  of  small  things,  like  proper  disposal  of  household   hazardous  wastes,  in  terms  of  “doing  one’s  part”  or  helping  the  community.    But  when   large   sacrifices   are   made   –   as   in   the   case   of   quarantine   –   we   need   an   account   that   explains  why,  on  balance,  this  is  also  in  the  agents’  own  interest.   Philippa   Foot   provides   a   different   picture   of   aretaic   sacrifice,   and   a   correspondingly   alternate   interpretation   that   is   helpful   for   understanding   large   sacrifices.    She  is  especially  concerned  the  kind  of  hits  to  an  agents’  interests  that  seems   hard  to  characterize  as,  nevertheless,  a  benefit  to  the  agent  “on  balance.”      She  offers  us       14     a  different  example  of  men  who  were  imprisoned  and  sentenced  to  death  for  opposing   the  Nazis.    In  their  letters  to  loved  ones,  the  men  seem  to  express  a  sense  of  regret  for   what  might  have  been,  but  not  their  resistance.  “So  one  may  very  naturally  say  that  they   knowingly  sacrificed  their  happiness  in  making  their  choice.    And  yet  this  does  not  seem   to  be  the  only  thing  we  could  say.    One  may  think  that  there  was  a  sense  in  which  the   Letter   Writers   did,   but   also   a   sense   in   which   they   did   not,   sacrifice   their   happiness   in   refusing  to  go  along  with  the  Nazis.” 17    On  this  alternative  view,  the  sacrifice  made  does   not  (pace  Socrates)  give  the  men  the  very  best  of  lives.    Rather,  the  very  best  of  lives  –   ones  lived  with  families  and  friends  in  a  way  consistent  with  justice  and  honor  –  were   simply   not   an   option.     But   under   the   circumstances,   such   an   option   was   tragically   unavailable.    The  sacrifice  on  this  view  does  not,  on  balance,  bring  the  agent  closer  to   the  very  best  life;  it  is  simply  the  only  better  option  of  two  terrible  alternatives.      Thus,   we  are  able  to  say  it  is  the  very  best  life  for  her,  given  the  circumstances.   I   contend   that   this   second   view   will   also   be   necessary   for   public   health   professionals  to  make  room  for.    If  and  when  great  sacrifices  must  be  made,  one  might   consider   that   options   for   all   involved   are   tragic.     In   the   case   of   a   serious   epidemic,   quarantine   may   be   a   terrible   method   that   provides   the   only   possibility   for   lessening   the   severity   of   the   unfolding   communal   tragedy.     In   imposing   serious   sacrifices   on   others,   however,  employing  quarantine  also  imposes  tragic  costs  on  individuals.                                                                                                                             17  Philippa  Foot,  Natural  Goodness  (Oxford:  Oxford  University  Press,  2003),  95  original   emphasis.       15     1.1.5  Do  civic  friendships  exist  in  modern  societies?     What  evidence  is  there  that  modern  citizens  employ  shared  norms  for  behavior  qua   citizens?  One  might  look  at  national  narratives  cultures  share  invoking  such  norms.    The  stories   we  tell  –  our  local,  regional,  and  national  narratives  (even  if  not  based  in  fact)  are  expressions   of  and  mechanisms  for  reinforcing  such  expectations.      That  such  narratives  work  to  draw   contrasts  to  non-­‐citizens  marks  the  difference  Aristotle  had  in  mind  –  the  notion  that  citizens   conceive  of  their  relationships  to  each  other  as  different  from  their  relationships  to  citizens  of   another  country.  As  John  Cooper  observes  in  a  rather  prescient  statement  in  2005:     The   typical   American   when   she   hears,   say,   about   the   attitudes   of   Wall   street   brokers   and   commercial   bankers   have   apparently   quite   routinely   been   holding   about   privileged   information   that   comes   their   way   in   their   professional   work,   about  sleaziness  in  government  circles,  feels  injured  in  ways  she  certainly  does   18 not  feel  in  hearing  similar  things  said  about  people  in  high  places  abroad.     Bernheim  and  Childress,  however,  note  that  invocations  of  national  civic  identity  is  complicated   in  the  United  States:  “they  [citizens]  have  conflicting,  often  incoherent,  civic  ideals  that   fluctuate  between  egalitarian  and  inegalitarian  and  liberal  and  nonconsensual  orientations,   with  strong  populist  and  pragmatic  sentiments  predominating  at  different  times.    Share  myths   both  shed  light  on  the  American  civic  identity  and  operate  to  shape  that  identity...they  can   persuade  people  with  different  philosophies,  beliefs,  and  loyalties  that  they  share  a  civic   19 identity.”    While  civic  identity  is  not  the  same  as  civic  friendship,  Bernheim  and  Childress   reveal  that  civic  identity  is  another  starting  point  for  civic  friendship.    Like  goodwill,  it  sows  the   seeds  for  engaging  in  collective  action  on  behalf  of  one’s  community.                                                                                                                           18  Cooper,  “Political  Animals,”  73.   19  James  F.  Childress  and  Ruth  Gaare  Bernheim,  “Beyond  the  Liberal  and  Communitarian   Impasse:  A  Framework  and  Vision  for  Public  Health,”  Florida  Law  Review  55,  no.  5  (2003):  1213.       16     One  objection  to  this  view  would  be  that  modern  societies  are  entirely  too  diverse  to   assert  that  all  citizens  do  in  fact  have,  or  ought  to  have,  such  relationships.    Either  the  content   of  such  mutual  concern  will  falsely  presume  a  unity  of  purpose  or  identity,  or  it  will  postulate   such  “thin”  commitments  (be  just,  be  civil),  as  to  be  meaningless.      This  critique  draws  our   attention  to  the  key  feature  of  civic  friendship,  which  is  a  bond  that  is  strong  enough  to  move   one  to  action.    But  such  actions  span  a  broad  array,  including  mere  civility,  all  the  way  to  dying   for  one’s  country.    Civic  friendship  is  not  just  a  feeling,  it  is  an  activity:  “there  are  all  those   activities  which  we  perform  for  strangers  (from  giving  the  correct  time  to  fighting  for  their   liberties)  as  well  as  those  institutions  through  which  we  respect  others,  grant  them  their  rights,   help  them  in  troubled  times,  and  so  forth.    The  critical  point  is  that  to  persist  in  seeing  others  in   20 this  “friendly”  way  requires  training,  repetition,  and  above  all,  public  reinforcement.”    Thus,   the  role  of  public  health  professionals  will  be  this  educative  one,  and  is  the  topic  of  the  next   section.     1.2  Civic  Friendship  and  Public  Health     In  this  section  I  summarize  an  Aristotelian  notion  of  synoptic  perspective  and  examine   the  ways  in  which  it  is  involved  in  public  health  work,  as  well  as  some  possible  objections  to  this   viewpoint.    I  then  consider  the  ways  in  which  public  health  professionals  employ  strategies  of   imaginative  engagement  to  reinforce  and  create  civic  friendships.    Lastly,  I  consider  some   illustrative  examples  in  contemporary  public  health  practice.                                                                                                                             20  Schwarzenbach,  "On  Civic  Friendship,"  121.       17     1.2.1  The  Synoptic  Perspective  of  Public  Health   In  this  section,  I  will  be  drawing  on  David  Janssens’  articulation  of  an  Aristotelian   “synoptic  perspective,”  or  the  vision  of  a  community  or  group  from  an  outside  vantage  point.     Janssen  develops  this  account  from  Aristotle’s  employment  of  the  term  eusunoptos,  which   translates  roughly  as  the  feature  of  being  able  to  be  “easily  taken  in  at  a  glance.”    Synoptic   perspective  denotes  the  picture  of  a  group,  community,  or  citizenry  that  one  grasps  from  a   21 vantage  point  removed,  or  at  some  degree  of  distance  from  the  group  itself.    In  context,   synoptic  perspective  conjures  up  a  human  parallel  to  the  common  idiom  that  it  is  often  difficult   to  see  the  forest  for  the  trees;  i.e.,  to  view  oneself  as  a  member  of  a  group,  one  first  has  to  have   a  vision  or  understanding  of  the  group  as  a  whole,  as  well  as  one’s  place  within  it.    According  to   Janssens,  such  envisioning  requires  a  creative  process  of  social  construction  by  which  one   comes  to  see  oneself  as  having  a  story  within  or  as  part  of  a  community:   Political  unity  is  intimately  connected  with  memory  and  narrative:  for  a  political   community  to  view  itself  and  act  on  itself  as  a  whole,  easy  to  be  taken  in  with  a   glance,   it   must   be   able   to   see   and   remember   itself   as   involved   in   a   plot,   a   common  history.    However,  both  are  never  simply  historical  facts,  but  poetic  and   22 rhetorical  constructs…       I  contend  that  this  view  is  also  central  to  public  health  practice,  where  public  health   professionals  are  able  to  see  what  members  of  populations  have  in  common  with  respect  to   health.    The  unique  nature  of  population  data,  however,  means  that  new  potential   communities  are  revealed  by  newfound  public  health  commonalities.    Epidemiologists  may   discover  a  higher  death  rate  for  commuters  during  peak  hours,  or  a  higher  incidence  of  a                                                                                                                           21  David  Janssens,  “Easily,  At  a  Glance:  Aristotle’s  Political  Optics,”  The  Review  of  Politics  72,   no.  3  (2010):  393.   22  Ibid.,  404.       18     disease  for  women  ages  25-­‐35  in  the  San  Francisco  area.    By  revealing  that  such  populations   have  something  in  common,  population  health  data  sets  the  stage  for  public  health   interventions  to  create  new,  or  build  upon  existing,  civic  friendships.    If,  in  educating  the  public   about  new  health  statistics,  citizens  form  new  identities  or  affiliations,  then  they  may  move  to   act  in  concert  with  others  in  the  group  on  their  own,  thereby  creating  new  civic  friendships.    But   by  proposing  participation  in  public  health  interventions  (e.g.,  community  walks  to  reduce   obesity,  arthritis  support  groups  at  the  local  community  center),  public  health  professionals   also  cultivate  civic  friendships.         1.2.2  Objections  to  the  Synoptic  Perspective     One  objection  to  the  synoptic  perspective  is  that  it  may  mislead  public  health   professionals  to  assume  that  population  health  data  implies  that  such  groups  already  have   reason  to  act.    Importantly,  the  synoptic  perspective  does  not  assume  that  a  community’s   coherence  is  already  formed,  or  that  it  can  or  ought  to  be  achieved  in  a  monolithic  fashion.     Rather  than  viewing  individuals  and  communities  as  purely  static  relationships  that  exist  prior   to  political  leadership,  this  view  accommodates  the  dynamic  process  of  constructing  public   forms  of  identity;  “the  citizen  community...is  neither  entirely  pre-­‐given  nor  entirely  produced:   23 rather,  it  remains  suspended  between  these  two  poles,  and  cannot  be  reduced  to  either.”   This  view  harmonizes  with  that  of  Childress  and  Bernheim  on  imaginative  engagement,  which   24 envisions  policy  as  derived  from  both  citizens  and  public  health  officials.  However,  in                                                                                                                           23  Ibid.,  329.   24Childress  and  Bernheim,  “Beyond  the  Liberal  and  Communitarian  Impasse,”  1191.         19     attempting  to  make  civic  beliefs  explicit  and  community  values  intelligible,  public  health   professionals  will  need  to  be  wary  of  various  pitfalls  that  result  from  misinterpreting  what  the   synoptic  perspective  entails.     First,  because  population  data  alone  does  not  establish  shared  interests,  a  public  health   synoptic  perspective  should  not  be  interpreted  to  entail  group  homogeneity.  As  Schwarzenbach   warns,  “political  friendship  between  citizens  today  can  no  longer  refer  to  a  state  where  all   25 citizens  share  the  same  “thick”  values.”  The  perspective  of  eusunoptos  captures  a  delicate   balance  by  which  agents  see  themselves  as  part  of  a  group  from  the  outside,  while   simultaneously  recognizing  their  particular  and  actual  membership  within  the  group  from  the   inside:   while   it   is   true   that   the   object   will   not   be   seen   as   a   meaningful   whole   if   the   viewpoint  is  too  close,  the  object  will  not  be  seen  as  a  meaningful  whole  if  the   viewpoint  is  too  far  away.    In  the  latter  case,  the  heterogeneity  of  the  parts  can   no   longer   be   recognized,   so   that   the   whole   cannot   be   defined   as   this   or   that   particular   whole,   in   this   case,   friends   or   enemies.     Thus   it   would   seem   that   eusunoptos   involves   a   process   of   negotiating   the   proximity   of   a   practical   26 perspective  and  the  distance  of  a  theoretical  perspective.       Thus,  public  health  statistical  indices  call  upon  us  to  abstract  away  from  our  particular  life  and   see  ourselves  as  part  of  a  whole,  whose  members  we  previously  may  not  have  recognized  as  a   collective.    But  to  act  upon  such  knowledge  in  civic  friendship,  we  must  come  back  to  the   particular,  and  act  in  community  with  others.      But,  the  warnings  against  homogenization   should  not  be  underemphasized;  public  health  professionals  will  need  to  be  prepared  for  civic   identities,  and  therefore  civic  friendships,  to  come  into  conflict.      This  may  be  internal  to  public                                                                                                                           25  Schwarzenbach,  “On  Civic  Friendship,”  114.   26  Janssens,  “Easily,  At  a  Glance,”  394.       20     health  –  I  may  have  many  disparate  potential  communities  to  identify  with  given  population   health  information,  and  I  cannot  possibly  act  on  all  them,  merely  as  a  matter  of  expediency.       But  external  to  the  possible  civic  friendships  I  can  form  based  in  collective  efforts  to  achieve   healthier  societies,  there  are  also  entirely  different  civic  friendships  that  may  conflict  –  either   substantively,  or  again,  as  a  matter  of  expediency.        Thus  public  health  professionals  must  be   careful  not  to  assume  that  engaging  a  community  will  always  lead  to  citizens  prioritizing  that   community  over  others  to  which  they  feel  much  stronger  ties.    Rather,  imaginative  engagement   (which  I  address  in  the  next  section)  begins  with  the  view  that  plurality,  complexity,  and  even   27 contradictory  features  will  characterize  civic  identity.  When  such  professional  expectations   demand  that  citizens  act  on  one  particular  civic  bond  –  without  justifying  its  priority  over   competing  forms  of  other-­‐concern  –  public  health  professionals  impose  rather  than  express   28 community.   Second,  in  tapping  into  existing  “thicker”  community  narratives  that  build  solidarity,   group  identity,  and  a  shared  vision  of  the  good,  public  health  professionals  risk  endorsing   problematic  aspects  of  such  identities.    The  narratives  that  characterize  American  national   29 identity  are  disparate  and  conflicting,  even  incoherent.      Such  narratives  also  often  achieve   unification  at  the  expense  of  creating  an  out-­‐group;  in  defining  who  we  are  as  a  group  we   necessarily  also  identify  who  we  are  not.    Thus,  if  public  health  professionals  engage  in  a   practice  of  eliciting  communal  forms  of  shared  identity,  they  will  bear  some  responsibility  for   the  result,  including  any  exclusionary  and  oppressive  aspects  of  such  visions.    It  will  be  a                                                                                                                           27  Childress  and  Bernheim,  “Beyond  the  Liberal  and  Communitarian  Impasse,”  1213.   28  Ibid.,  1208.   29  Ibid.,  1213.       21     challenge  for  public  health  professionals  to  create  the  space  for  individuals  and  communities   within  a  population  to  express  multiple  and  even  conflicting  notions  of  who  they  are.   However,  one  important  implication  that  arises  from  the  synoptic  perspective  is  that   other-­‐concern  can  arise  from  relationships  we  do  not  choose  to  have;  i.e.,  we  can  feel   compelled  to  act  in  concert  with  others  because  we  are  connected  in  ways  we  did  not  choose   to  be  connected.      The  impetus  to  act  does  not  derive  from  the  fact  that  I  have  something  in   common  with  others,  but  that  in  finding  out  about  such  interests  (or  such  a  group),  these  new   connections  moves  me  to  act  for  our  mutual  benefit.    For  public  health  practice,  an   understanding  of  other-­‐concern  explains  why  it  is  that  we  may  have  an  interest  in  population   health  indices  –  they  reveal  to  us  relationships  to  others  that  we  did  not  know  about.    They   illustrate  to  us  the  ways  in  which  our  health  is  intricately  connected  to  the  health  of  others,  and   how  we  may  be  able  to  achieve  a  better  life  by  acting  in  concert.         1.2.3  Imaginative  Engagement   With  Childress  and  Bernheim  I  contend  that  a  process  of  “imaginative  engagement”  may   be  central  to  public  health  efforts  to  navigate  the  polarity  of  communitarian  and  liberal   characterizations  of  relationships  between  groups  and  individuals.    The  process  of  imaginative   engagement  uses  “personal  narratives,  stories  from  history  or  literature,  or  revelations  of   personal  uncertainties  and  vulnerabilities” 30  to  depict  different  ways  in  which  citizens  can  act   together,  and  respond  collectively.    In  public  health  for  example,  Jacob  Heller  considers  the   potency  of  stories  about  the  development  of  the  polio  vaccine,  which  at  the  time  of  its  advent                                                                                                                           30  Childress  and  Bernheim,  “Beyond  the  Liberal  and  Communitarian  Impasse,”  1215.       22     coincided  with  a  national  confidence  in  science  and  technology.    Thus,  such  narratives  were  a   reflection  of  contemporary  public  understandings  of  American  ingenuity  and  potential  –  public   health  vaccination  success  represented  the  society  citizens  wanted  to  live  in.      Today,  such   stories  still  have  power  when  used  in  public  health  because  they  invoke  the  possibility  of  similar   success  and  safety  in  the  future,  and  a  kind  of  return  to  a  golden  time  in  American  public  health   31 history.    Such  stories  remind  Americans  of  the  collective  benefits  of  public  health,  and  create   civic  ties  that  generate  corresponding  collective  behaviors,  such  as  willingness  to  be  vaccinated.       The  authors’  use  of  narrative  strikes  a  chord  with  the  Aristotelian  view  of  the  polis  as”   easily  taken  in  at  a  glance,”  and  the  actions  that  follow  from  imagination  can  be  said  to  be  an   imitation  of  this  possibility,  a  reproduction  and  discovery  of  a  shared  vision  for  a  community.       At  the  heart  of  this  process  lies  a  recognition  –  a  glimpse  of  oneself  in  relation  to  the  whole:   “Political  action,  both  by  the  individual  citizen  and  by  the  community  as  a  whole,  may  be  said  to   be  an  imitation  in  order  to  learn  and  figure  out  what  each  thing  is,  in  this  case  by  anticipating   what  it  is  to  be  a  citizen  or  a  community:  “That’s  us!”  In  this  imitation  and  anticipation,  we   stage  and  look  at  ourselves  as  a  whole  that  is  eusunoptos,  so  that  we  are  able  to  act  as  though   32 we  actually  were  what  we  cast  ourselves  to  be.”     Imaginative  engagement  also  illustrates  the  relationship  between  civil  service  and  civic   friendship:      “the  state  plays  a  critical  role  in  regulating  our  awareness  of  the  facts  of  other   citizens’  lives  (through  education,  etc.)  as  well  as  in  stipulating  what  are  to  be  our  minimal   responsibilities  toward  them.    The  ideal  of  civic  friendship  is  alive  and  well  in  a  society  which                                                                                                                           31  Jacob  Heller,  The  Vaccine  Narrative  (Nashville:  Vanderbilt  University  Press,  2008),  6–7.     Heller’s  analysis  is  also  concerned  with  the  downside  of  narratives.   32  Janssens,  “Easily,  At  a  Glance,”  406.       23     33 respects  and  fosters  public  service.”    To  claim  that  imaginative  engagement  is  part  of  public   health  work  is  to  claim  that  the  substantive  meaning  of  civic  ties  are  created  by  both  the  public   and  civil  servants;  it  is  to  articulate  a  place  and  role  for  public  health  professionals  in  helping   create  a  public  understanding  of  the  relationships  that  “frame  the  meaning  of  all  public  health   34 actions.”       1.2.4  Examples  in  public  health  practice   What  kind  of  support  for  public  health  does  civic  friendship  entail?    Civic  friendship   includes  both  an  attitude  toward  others  and  a  willingness  to  act  on  their  behalf.    Thus,  to  be  a   civic  friend  one  must  be  concerned  about  other  community  members’  wellbeing,  and  also   willing  to  assist  in  time  of  need,  or  to  achieve  shared  ends:  “such  help  can  range  anywhere  from   (most  minimally)  my  not  begrudging  my  tax  dollars…to  my  actively  supporting  such  programs   35 and  even  willingly  performing  direct  public  service.”   Let  us  examine  one  case  in  public  health  practice  that  illustrates  the  pertinence  of   imaginative  engagement,  and  civic  friendship.    Considering  the  cost  of  life  that  resulted  from   traffic  accidents  prior  to  the  passage  of  seat  belt  laws,  Jean  Forster  articulates  that  while  the   potential  risk  of  accident  for  each  individual  is  low,  the  annual  mortality  rate  has  costs  for  all  of   society  given  the  magnitude  of  lives  lost.    While  it  is  possible  to  express  such  loss  in  economic   terms,  it  is  also  possible  to  consider  the  ways  in  which  so  much  loss  of  life  will  affect  the   interdependent  and  reciprocal  relationships  characteristic  of  a  society.    On  this  view,  “coercive                                                                                                                           33  Schwarzenbach,  “On  Civic  Friendship,”  110.   34  Childress  and  Bernheim,  “Beyond  the  Liberal  and  Communitarian  Impasse,”  1209.   35  Schwarzenbach,  “On  Civic  Friendship,”  109–110.           24     measures  provide  opportunities  for  expression  of  our  concern  for  the  well-­‐being  of  the  whole   36 community.”    In  such  a  case,  citizens  support  (in  the  many  nuanced  ways  outlined  above)  the   cost  of  sacrificing  some  freedom  (not  wearing  a  seatbelt)  for  the  sake  of  the  safety  of  the   community  as  a  whole,  or  with  the  idea  in  mind  that  such  support  may  save  the  life  of  a   particular  community  member  I  care  about  because  she  is  a  member  of  my  community.    And   we  imagine  that  such  a  citizen  might  express  her  willingness  to  sacrifice  as  does  the  friend  who   lends  another  friend  money  –  as  being  well  worth  the  sting,  or  even  not  much  of  a  sting  at  all.       According  to  this  author,  an  individual  will  never  know  if  she  has  benefitted  individually  from   the  seat  belt  law  because  it  saved  her  life,  but  she  can  nevertheless  appreciate  living  in  a   society  that  experiences  less  loss  of  human  life  as  a  result.   But  how,  then,  does  this  help  us  resolve  the  more  pressing  case  of  quarantine,  when   what  is  required  a  citizen  is  much  more  significant  sacrifice?    Can  civic  friendship  be  strong   enough  to  motivate  such  actions?    I  suggest  that  another  case  helps  to  shed  some  light  on  the   matter:    Marcel  Verwiej  presents  the  case  of  immunizing  residents  of  a  nursing  home,  and   whether  there  are  valid  reasons  to  support  a  tacit  consent  policy.  37      He  is  motivated  by  a   concern  that  some  justifications  presume  that  vaccination  is  clearly  in  the  interests  of  residents   or  groups.  The  problem  with  this  assumption,  argues  Verweij,  is  that  while  all  members  have  an   interest  in  avoiding  illness,  some  also  have  an  interest  in  getting  sick  –  pneumonia  that  results                                                                                                                           36  Jean  L.  Forster,  “A  Communitarian  Ethical  Model  for  Public  Health  Interventions:  An   Alternative  to  Individual  Behavior  Change  Strategies,”  Journal  of  Public  Health  Policy  3,  no.  2   (1982):  159.   37  Marcel  Verweij,  “Individual  and  Collective  Considerations  in  Public  Health:  Influenza   Vaccination  in  Nursing  Homes,”  Bioethics  15,  no.  5–6  (2001):  536–546.  Original  emphasis.    In   doing  so,  Verweij  can  be  seen  as  claiming  that  residents  of  nursing  homes  are  not  civic  friends.       25     from  the  flu  may,  on  the  view  of  some  residents,  offer  a  less  painful  death  than  they  may  face   otherwise.    Verweij  believes  that  arguments  from  individual  benefit,  harm  to  others,  herd   immunity,  and  to  protect  the  most  vulnerable  all  fail.    I  do  not  review  these  arguments  here,   but  it  is  interesting  that  he  rejects  the  argument  to  protect  the  vulnerable  because  it  presumes   a  “thick”  sense  of  community  amongst  residents.  When  considering  the  strength  of  the   arguments  for  a  common  interest  in  herd  immunity,  Verwiej  notes  that  it  conflicts  with  an   interest  to  not  protect  against  the  flu;  “it  is  an  open  question  as  to  how  these  interests  are  to   38 be  weighed,  or,  in  other  words,  what  the  net  interest  is  of  these  residents.”    Thus,  we  have   arrived  at  group-­‐individual  conflict,  albeit  internalized  in  Jennings’  sense  (see  Section  1.1).      In   contrast,  Verweij  argues  that  reasons  for  tacit  consent  are  valid  when  an  epidemic  threatens  to   undermine  the  daily  life  of  the  nursing  home  residents,  thereby  jeopardizing,  amongst  other   goods,  quality  of  care  and  a  social  life.      The  detriment  to  the  residents  then  is  a  threat  to  the   collective  health  and  very  existence  of  the  community,  without  which  individuals  also  lose  their   chance  to  pursue  individual  interests  as  well.    Verweij  argues  that  in  such  a  case,  tacit  consent  is   valid  because  an  interest  in  one’s  social  life  tips  the  balance  in  determining  what  might  be  in  a   particular  resident’s  net  interest.   The  notion  I  wish  to  extract  from  Verweij’s  analysis  is  that  of  damage  to  the  community   as  tipping  the  scales  as  two  what  is  in  someone’s  net  interest,  and  contrast  this  to  the  notion  of   a  person’s  interest  all  things  considered.    The  notion  of  net  interest  implies  a  calculus,  in  which   someone’s  interests  are  tallied  up.    This  seems  to  be  what  Verweij  has  in  mind,  for  he   characterizes  the  losses  to  residents  in  terms  of  benefits  that  accrue  to  the  individual.    Thus  we                                                                                                                           38  Ibid.,  544.       26     can  imagine  that  public  health  professionals  could  make  the  case  that  quarantine  is,  on  balance,   actually  in  an  individual’s  best  interest  –  just  as  Verweij  thinks  he  can  make  this  case  for  tacit   consent  for  vaccination.    On  the  advent  of,  or  in  the  midst  of,  a  truly  serious  epidemic,  the   losses  accrued  by  widespread  morbidity  and  mortality  may  be  so  devastating  for  the  individual   as  to  outweigh  the  loss  of  liberty  (and  other  goods)  that  result  from  quarantine.    When  such  a   case  is  persuasive  to  members  of  the  public,  civic  friendship  is  obsolete.   The  difficulty  with  the  net  interest  view  is  that  it  tends  to  leave  out  some  reasons  why   something  may  be  in  my  interest.    Net  interest  accounts  include  a  broad  picture  of  what   contributes  to  my  wellbeing,  from  the  physical  benefits  of  health,  to  the  social  benefits  that   result  from  being  part  of  a  community.    There  is  also  the  possibility  something  can  be  beneficial   in  a  way  that  cannot  be  extricated  from  membership  in  a  group:  in  such  cases,  I  view  a  course   of  action  as  benefiting  me  because  it  benefits  us.        Missing  from  this  picture  is  the  possibility   other’s  wellbeing  can  count  toward  my  own  interests  –  i.e.,  because  I  see  others’  wellbeing  as   intrinsically  valuable.    I  may  do  so  for  any  number  of  reasons  –  from  an  impartial  perspective,  or   as  a  matter  of  justice,  or  out  of  affection.    Such  valuing  gives  me  a  reason  for  action,  one  that   contributes  to  my  happiness  in  a  way  that  needs  to  be  included  in  the  considerations  for  what  I   ought  to  do  all  things  considered.   This  additional  consideration  reveals  why  some  individuals  may  be  supportive  (and   therefore  cooperative)  with  quarantine  efforts  even  when  the  argument  for  net  interests   cannot  be  made.    This  is  especially  the  case  in  the  advent  of  epidemics,  when  the  nature  of  a   pathogen  is  not  entirely  understood.    Under  such  circumstances  public  health  professionals   may  have  an  incomplete  understanding  of  a  pathogen’s  virulence  and  modes  of  transmission.           27     In  such  cases,  the  net  interests  argument  will  be  hard  to  make  because  it  is  not  clear  what   consequences  will  follow  from  compliance  or  refusal  to  comply.  An  appeal  to  civic  friendship  at   this  time  may  be  what  can  tip  the  scales.    For  those  who  value  the  wellbeing  of  others,  it  may   be  the  possibility  of  harming  others  unnecessarily  that  motivates  public  health  cooperation.      It   is  worth  noting  that  the  degree  of  uncertainty  with  respect  to  the  epidemiological  realities  of   the  situation  will  also  affect  the  agent’s  evaluation  of  the  decision  to  resist  quarantine.    If  there   is  scant  evidence  that  exposing  others  will  indeed  lead  to  disease,  or  not  enough  evidence  to   establish  that  the  disease  in  question  significantly  affects  wellbeing,  then  it  is  in  turn  difficult  to   make  the  case  that  the  agent  is  unjust,  uncompassionate,  or  uncivil  in  refusing  to  comply.    It  is   my  contention,  however,  that  an  appeal  to  civic  friendship  can  motivate  support  of  public   health  by  providing  an  additional  reason  for  action  left  out  of  the  appeal  to  net  interests.         Nevertheless,  we  might  have  reservations  as  to  whether  it  makes  sense  to  call  our  civic-­‐ minded  quarantined  individual  made  happy  by  her  decision.    Happiness,  for  Aristotle,  consists   in  activity,  or  the  exercise  of  virtue.    Thus,  it  would  seem  that  by  acting  virtuously  out  of   concern  for  others,  the  civic-­‐minded  agent  ought  to  be  happy.    However,  quarantine  deprives   individuals  of  a  great  deal  of  what  makes  for  a  good  life,  and  Aristotle’s  view  is  not  so   insensitive  to  the  loss  of  external  goods  –  especially  the  loss  of  many  or  all  of  these,  and  over   long  periods.    (NE  1.10  1101a10)    Thus,  the  degree  to  which  quarantine  will  affect  our   assessment  of  whether  an  agent  leads  a  flourishing  life  will  depend  very  much  on  the  degree  of   duration  of  deprivation.    Furthermore,  periods  of  inactivity  also  prevent  individuals  from   exercising  the  virtues  that  she  has  committed  to,  making  her  more  like  an  excellent  person  who   is  asleep.  (NE  1.6  1095b35)    Thus,  I  argue  that  quarantine  has  the  potential  to  resemble  the       28     situation  of  Foot’s  Letter  Writers.    In  their  case,  impending  death  absolutely  closed  off  the   possibility  of  the  very  best  of  lives.    In  the  case  of  our  quarantined  and  virtuous  agent,  however,   her  life  may  still  turn  out  to  be  a  good  one,  and  made  better  by  having  acted  to  support  others.     Nevertheless,  the  period  during  which  she  is  confined  is  not  representative  of  the  very  best  kind   of  living,  and  as  a  result  we  can  still  say  that  had  quarantine  been  avoidable  (she  could  have   lived  a  life,  in  society,  without  the  possibility  of  causing  harm),  she  would  have  been  happier.   I  contend  that  this  analysis  sheds  new  light  on  calls  for  reciprocity  in  public  health   practices,  such  as  quarantine.    Such  practices  include  monetary  compensation,  or  requiring   employers  to  either  pay  or  refrain  from  laying-­‐off  workers  in  the  midst  of  a  public  health   emergency.      Such  efforts  are  usually  justified  on  the  grounds  that  they  help  to  ease  the   burdens  imposed  on  those  who  are  (voluntarily  or  involuntarily)  sacrificing  freedom  for  the   sake  of  others,  and  in  terms  of  justice  to  be  sure  that  the  burdens  of  a  policy  that  helps  many   are  not  exclusively  born  by  a  few.      But  on  the  civic  friendship  view,  such  policies  are  also  ways   of  enabling  individuals  to  re-­‐evaluate  the  balance  of  different  forms  of  other-­‐concern.    For,  if   valuing  others  motivates  behavior,  then  part  of  the  problem  of  quarantine  is  that  we  do  not   only  have  moral  commitments  to  other  citizens.      A  mother  may  not  feel  she  should  limit  her   movements  if  she  does  not  know  who  will  care  for  her  child.      Similarly,  if  compliance  results  in   the  loss  of  one’s  source  of  income,  then  the  reasons  for  resisting  quarantine  are  not  necessarily   self-­‐directed,  but  other-­‐directed.    Thus,  reciprocal  public  health  measures  can  also  be  ways  of   enabling  agents  to  resolve  such  conflicts  in  moral  commitments.    The  claim  is  not  that  such   public  measures  will  make  each  and  every  citizen  more  beneficent.    Rather,  such  measures  can       29     be  ways  of  allowing  civic  friendships  to  have  greater  moral  salience  –  perhaps  enough  to  tip  the   balance  –  when  an  agent  is  considering  what  she  ought  to  do  all  things  considered.   In  conclusion,  when  reasons  for  action  are  conceived  of  as  lying  along  a  continuum   between  self-­‐interest  and  group-­‐interest,  there  is  a  temptation  to  view  behavior  in  terms  of  the   extremes  of  selfishness  and  altruism.    This  picture  depicts  moral  behavior  as  going  against  one’s   desires.    If,  however,  we  except  that  “the  line  between  self-­‐concern  and  other-­‐concern  in  no   way  corresponds  to  a  line  between  desire  and  obligation,”  then  we  make  room  for  the   possibility  for  civic  friendship  to  motivate  support  for  public  health  measures  in  a  way  that  does   39 not  entail  altruism.    With  this  in  mind,  public  health  professionals  can  use  a  process  of   imaginative  engagement  to  educate  citizens  about  matters  involving  their  health,  and  frame   public  responses  to  such  information  in  terms  of  communal  support.  I  do  not  believe  such   possible  methods  will  obviate  the  need  for  coercive  measures,  but  they  do  provide  an   40 alternative,  enabling  public  health  professionals  to  utilize  persuasion  rather  than  force.    As   Williams  puts  it,  the  purpose  of  such  engagement  is  “not  to  control  the  enemies  of  the   community  or  its  shirkers  but,  by  giving  reason  to  people  already  disposed  to  hear  it,  to  help  in   41 continually  creating  a  community  held  together  by  that  same  disposition.”                                                                                                                             39  Williams,  "Ethics  and  the  Limits  of  Philosophy,"  50.   40  George  J.  Annas,  “Bioterrorism,  Public  Health,  And  Human  Rights,”  Health  Affairs  21,  no.  6   (2002):  94–97.    Public  health  coercion  and  persuasion  are  not  mutually  exclusive  alternatives  –   the  public  can  be  persuaded  the  coercion  is  necessary.   41  Williams,  "Ethics  and  the  Limits  of  Philosophy,"  27.       30     CHAPTER  2:  PUBLIC  HEALTH  RELATIONSHIPS:  DEFERENCE,  RELIANCE,  AND  TRUST     In  their  important  work  on  the  virtues  and  medicine,  Thomasma  and  Pellegrino  argued   that  the  virtues  fall  out  of  the  structure  of  medical  practice,  which  includes  the  “central   distinguishing  feature  of  medical  activity,  that  is,  the  healing  relationship  between  one  who  is  ill   42 and  one  who  professes  to  help  and  heal.”    From  this  relationship,  the  authors  argue,  the   feature  of  trust  is  ineradicable,  and  it  follow  that  it  is  essential  for  the  good  physician   corresponding  virtue  of  fidelity  to  trust,  or  trustworthiness.    Trust,  then,  is  put  forward  as  a   crucial  relationship  between  doctors  and  their  patients,  and  it  related  character  trait,   trustworthiness,  as  an  ideal  for  physicians.       In  this  chapter,  I  examine  the  question  of  whether  the  same  ideals  hold  in  public  health   practice.    Given  the  often  impersonal  nature  of  the  relationship  between  public  health   professionals  and  members  of  the  public,  we  might  imagine  that  the  nature  of  the  relationship   is  so  different  as  to  entail  different  virtues  –  or  perhaps  no  virtues  at  all.        To  consider  the  place   of  trust,  and  the  need  for  trustworthiness,  in  public  health,  I  divide  this  chapter  into  two  parts.     In  the  first,  I  consider  the  alternative  kinds  of  relationships  that  might  hold  in  public  health   practice.    I  begin  in  Section  1  with  a  consideration  of  paternalistic  attitudes,  which  I  contend  can   mistakenly  imply  that  the  proper  public  response  to  public  health  professionals  is  epistemic   deference,  and  that  the  main  responsibility  of  public  health  professionals  is  to  be  competent.     In  Section  2,  I  contend  that  public  health  professional  expectations  for  deference  outside  of   paternalistic  relationships,  as  exemplified  by  a  case  of  vaccination  skepticism.  I  argue  that  such                                                                                                                           42  Pellegrino  and  Thomasma,  "Virtues  in  Medical  Practice.”       31     expectations  are  problematic  by  further  articulating  what  it  means  to  defer,  by  examining   Phillip  Pettit’s  analysis  of  epistemic  deference  in  Section  3.       After  pointing  out  the  flaws  with  uncritical  expectations  for  epistemic  deference  in   public  health,  I  turn  to  a  positive  account  of  public  health  relationships  in  Part  II.    I  argue  in   Sections  4  and  5,  that  a  virtue  approach  pushes  us  to  consider  reliance  and  the  related  species   of  reliance,  trust.    The  corresponding  attributes  that  provide  the  basis  for  such  relationships  –   reliability  and  trustworthiness  –  are  thereby  suggested  as  essential  to  public  health  practice,   and  public  health  professionalism.  Included  in  Section  5  is  also  a  defense  of  an  affective  account   of  trust  over  a  cognitive  approach.    In  Section  6,  I  contend  that  a  virtue  approach  to  public   health  relationships  also  requires  that  we  reexamine  dominant  conceptions  of  trust  and  the   virtue  of  trustworthiness  to  account  for  the  possibility  of  trust  in  groups  and  virtuous   institutions.     PART  I   2.1  Public  Health  Paternalism     In  this  section,  I  first  distinguish  between  medical  paternalism  and  one  form  of  public   health  paternalism.    I  identify  some  of  the  attitudes  and  beliefs  that  lie  behind  problematic   defenses  of  paternalism  in  public  health,  especially  those  that  lead  professionals  to  conceive  of   public  health  expertise  solely  in  terms  of  better  factual  understanding.    While  paternalism   might  be  defensible  under  other  justifications,  these  mistaken  defenses  of  public  health   paternalism  translate  into  an  expectation  for  public  deference  to  expert  authority,  implying       32     that  the  primary  feature  for  professionals  to  focus  their  efforts  on  is  building  professional   competency.           2.1.1  Kinds  of  Paternalism   Public  health  interventions  are  often  justified  on  the  grounds  that  failing  to  act  brings   harms  to  others.    Such  preventive  efforts  are  not  paternalistic  because  they  are  consistent  with   Mill’s  harm  principle  that  “the  only  purpose  for  which  power  can  be  rightfully  exercised  over   any  member  of  a  civilized  community,  against  his  will,  is  to  prevent  harm  to  others.”43  In   contrast,  there  are  times  when  public  health  policies  are  offered  up  as  beneficial  to  all  or  even   of  benefit  to  those  who  fail  to  view  the  intervention  in  question  as  furthering  their  interests.    I   will  not  engage  here  in  a  consideration  of  which  approach  is  more  justified  for  public  health   purposes.    Rather,  I  wish  to  consider  the  history  of  paternalism  in  bioethics  and  some   implications  it  has  for  public  health  paternalism.   Paternalism  is  broadly  defined  as  actions  that  limit  the  choices  or  actions  of  an   individual  on  the  basis  that  such  limits  are  his  or  her  own  interest.    In  medical  paternalism,   limits  on  choice  are  sometimes  broadly  construed,  including  the  withholding  of  information  or   provision  of  misinformation,  which  is  also  argued  to  be  in  the  individual’s  best  interest.    Two   distinct  forms  of  paternalism  are  often  distinguished.    In  weak  paternalism,  the  decision-­‐making   capacity  of  an  agent  is  considered  compromised,  thereby  requiring  intervention  on  her  behalf.                                                                                                                             43  John  Stuart  Mill,  "On  Liberty"  in  On  Liberty  and  Other  Essays,  ed.  John  Gray  (Cambridge:   Oxford  University  Press,  1998);  Ross  E.  G.  Upshur,  “Principles  for  the  Justification  of  Public   Health  Intervention,”  Canadian  Journal  of  Public  Health  93,  no.  2  (2002):  101–3.       33     In  strong  paternalism,  agents  are  considered  competent,  and  yet  intervention  is  still  performed,   justified  on  the  grounds  that  it  benefits  the  agent.     In  public  health,  paternalism  is  sometimes  invoked  in  a  slightly  different  way.    According   to  Dan  Beauchamp,  public  health  is  concerned  with  the  ways  in  which  health  and  safety  are   public  goods.    Thus,  individual  freedom  may  be  restricted  on  the  grounds  that  this  is  in  the   interest  of  the  common  good.    Beauchamp  does  not  mean  to  invoke  the  harm  principle  when   articulating  this  vision  of  public  health  paternalism  –  for  he  wishes  to  distinguish  this  kind  of   public  health  justification  from  that  which  identifies  possible  or  actual  harms  to  specific   44 individuals.    On  this  view,  public  health  professionals  are  focused  on  limiting  societal   practices,  not  individual  behavior.  “This  distinction  between  practices  and  behavior  should  help   us  see  the  difference  between  public  health  paternalism  aimed  at  the  group  and  the  “personal   45 paternalism”  of  the  doctor-­‐patient,  lawyer-­‐client  relationship.  The  crux  of  Beauchamp’s   argument  is  not  that  limits  are  being  placed  on  individual  autonomy,  but  rather  on  everyone’s   autonomy,  because  of  the  effects  of  certain  choices  on  a  general  level  of  population  health.    It   is  not  my  intent  consider  all  defenses  of  this  view  of  public  health  paternalism.       The  kind  of  paternalism  Beauchamp  has  in  mind  is  sometimes  invoked,  as  when  public   health  professionals  characterize  policy  outcomes  in  terms  of  a  public  good  whose  benefits  are   best  attributed  to  an  entire  community.    Health  can  be  a  public  good  in  part  because  public   health  benefits  are  sometimes  indivisible,  or  “cannot  be  broken  down  or  divided  up  into                                                                                                                           44  Dan  E.  Beauchamp,  “Community:  The  Neglected  Tradition  of  Public  Health,”  The  Hastings   Center  Report  15,  no.  6  (1985):  28–36.   45  Ibid.,  34.       34     46 individual  or  private  goods  to  be  distributed  amongst  the  members  of  a  group  or  population.”   This  perspective  contrasts  with  the  aggregate  view  of  public  health,  where  the  policy  offers   additive  protection  because  each  individual  saved  will  benefit  from  compliance.  On  the   collective  view,  policies  like  helmet  laws  provide  a  public  good  by  reducing  mortality  rates   throughout  society.    Even  though  some  citizens  might  never  individually  benefit  from  such  a   policy,  so  the  argument  goes,  it  is  best  for  all  members  to  live  in  safer  and  healthier   47 communities.    On  the  public  good  view,  the  benefit  is  social,  and  the  benefit  might  be   articulated  as  a  boon  to  all  members  of  a  group  since  the  society  or  community  is  designed  to   be  safer  for  the  targeted  subpopulation.   And  yet,  it  is  not  clear  that  the  collective  form  of  paternalism  is  all  public  health   professionals  have  in  mind  when  they  articulate  justifications  for  public  health  limits  on  choice.     Bayer  and  Moreno,  while  taking  into  account  Beauchamp’s  views,  also  consider  the  possibility   of  ‘personal’  paternalism  in  public  health.    According  to  these  authors,  “[t]he  goal  of  justifiable   paternalism  is  to  protect  the  individual  from  the  consequences  of  actions  that  he  or  she  would   48 not  choose  to  engage  in  were  the  capacity  for  free  choice  truly  present.”    In  public  health   contexts,  such  paternalism  is  justified  by  reaching  the  high  evidentiary  standards  required  to   establish  that  individual  behaviors  do  not  result  from  free  choices.    And  while  behaviors  like   alcoholism  and  smoking  may  exhibit  impaired  decision-­‐making  capacity  that  result  from  the                                                                                                                           46  Angus  Dawson  "Herd  Protection  as  a  Public  Good:  Vaccination  and  our  Obligations  to   Others,"  in  Ethics,  Prevention,  and  Public  Health,  ed.  Angus  Dawson  and  Marcel  Verweij   (Oxford:  Oxford  University  Press,  2007),  164.   47  Beauchamp,  “Community,”  35.   48  Ronald  Bayer  and  Jonathan  D.  Moreno,  “Health  Promotion:  Ethical  and  Social  Dilemmas  of   Government  Policy,”  Health  Affairs  5,  no.  2  (1986):  72  –85.       35     addictive  properties  of  the  products,  it  is  not  clear  that  these  meet  the  high  bar  set  by  fierce   advocates  of  autonomy.  Thus,  Bayer  and  Moreno  conclude  that  if  public  health  professionals   are  to  successfully  argue  for  a  form  of  paternalism  in  public  health,  it  will  need  to  be  weak   paternalism,  and  only  in  those  cases  with  strong  indications  for  compromised  decision-­‐making   49 capacity.   A  reluctance  to  endorse  paternalism  in  public  health  is  in  part  a  reflection  of  critiques  of   medical  paternalism,  and  defenses  of  the  importance  of  individual  autonomy  in  matters  of   health.    In  the  next  section  I  shall  consider  what  kind  of  relationships  paternalistic  attitudes  set   up,  why  these  were  found  to  undesirable  in  clinical  medicine,  and  whether  the  same   conclusions  apply  in  public  health.     2.1.2  Professional  Relationships  with  the  Public     Paternalism  in  all  its  forms  assumes  a  dependency  in  which  one  party,  it  is  asserted,   needs  another  to  intervene  on  her  behalf.    When  viewed  in  this  light,  it  is  clear  why  paternalism   is  often  interpreted  as  presumptuous.    Individuals  or  groups  may  reject  the  notion  of   dependency  as  even  pertaining  to  the  situation  at  hand  (e.g.,  “I  am  perfectly  capable  of  making   up  my  own  mind,”)  or  may  assert  that  there  are  better  ways  to  handle  current  needs  for   depending  on  others  than  restricting  individual  choice  or  freedom  of  action  (e.g.,  capacity-­‐ building).     In  this  section,  I  argue  that  flawed  paternalistic  reasoning  results  in  a  characterization  of   the  ideal  public  health  professional  as  merely  competent.    The  flaws  I  present  are  (1)  the  failure                                                                                                                           49  Ibid.       36     to  acknowledge  the  element  of  evaluative  judgment  necessary  to  paternalism  and  (2)  a   conflation  of  public  health  as  a  public  good  and  public  health  as  the  public  good.    I  contend  that   the  resultant  picture  of  professionalism  is  inadequate  because  it  is  devoid  of  any  notion  of   excellence;  both  bad  and  good  public  health  professionals  can  be  competent.    I  conclude  that   the  ideal  of  public  health  expert  competency  helps  set  the  conditions  for  identifying  the  proper   public  response  to  expertise:  deference.     There  is  no  doubt  that  epidemiological  data  and  professional  experience  gained  from   public  health  interventions  can  lend  professionals  insight  into  what  has  an  effect  on  human   health,  as  well  as  what  may  create  obstacles  to  human  understanding  of  various  benefits  and   harms.  However,  it  is  important  for  public  health  professionals  to  recognize  two  important   limits  on  the  nature  of  professional  expertise.       The  first  confusion  can  result  from  an  overly  inflated  understanding  of  public  health  or   epidemiological  knowledge.      Due  to  the  epidemiological  basis  of  public  health  knowledge,   public  health  professionals  can  mistakenly  believe  that  health  policy  recommendations  are   matters  of  objective  or  scientific  fact,  rather  than  normatively  laden  decisions  involving  value   judgments  about  how  we  ought  to  live.    I  will  address  this  normativity  more  specifically  with   respect  to  conceptions  of  risk  in  Chapter  3.    Here,  I  wish  to  draw  attention  to  the  possibility  that   paternalism  is  in  part  grounded  on  the  claim  that  experts  have  a  kind  of  insight  unavailable  to   non-­‐experts.    When  this  knowledge  is  identified  as  purely  empirical  or  objective,  public  health   professionals  may  be  failing  to  recognize  the  normative  dimensions  of  public  health  insight.       To  illustrate  the  case  with  which  it  can  occur,  I  will  adapt  an  argument  against  medical   paternalism.    Allen  Buchanan  outlines  a  common  argument  in  favor  of  medical  paternalism:       37     1. The  physician’s  duty  –  to  which  he  is  bound  by  the  Oath  of  Hippocrates  –  is  to   prevent  or  at  least  minimize  harm  to  his  patient.   2. Giving  the  patient  information  X  will  do  great  harm  to  him.   3. (Therefore)  It  is  permissible  for  the  physician  to  withhold  information  X  from   50 the  patient.   While  Buchanan  finds  many  faults  with  the  argument,  I  wish  to  focus  here  on  his  observation  of   a  missing  premise  which  he  identifies  as  2’:  giving  information  X  will  do  the  patient  greater   harm  on  balance  than  withholding  of  the  information  will.    Buchanan  claims  that  this  missing   premise  reveals  the  central  feature  of  paternalistic  reasoning  to  be  a  “comparative  judgment”   between  two  possible  sets  of  actions  and  their  outcomes.     Let  us  construct  the  parallel  argument  necessary  for  public  health  paternalism.    We  will   need  to  modify  it  if  it  is  to  accommodate  the  more  positive  formula51  Beauchamp  envisions:   A. The  public  health  professional’s  duty  is  to  establish  and  sustain  public  health   in  its  form  as  a  public  good.   B. Allowing  certain  practices,  such  as  X’s  freedom  to  Y,  will  do  significant   damage  to  public  health,  and  thereby  the  public  good.   C. (Therefore)  It  is  permissible  for  the  public  health  professional  to  restrict  the   freedom  of  X  to  Y.                                                                                                                           50  Allen  Buchanan,  “Medical  Paternalism,”  Philosophy  &  Public  Affairs  7,  no.  4  (1978):  377.   51  If  left  in  the  preventive  form  to  forestall  harm  to  others,  the  argument  is  not  paternalistic   but  merely  an  invocation  of  the  harm  principle.    Thanks  to  Tom  Tomlinson  for  this  point.       38     In  this  parallel  argument,  the  missing  “comparative  judgment”  premise  is  B’:  Allowing  certain   practices,  such  as  X’s  freedom  to  Y,  will  do  significantly  more  damage  to  the  public  good  than   limiting  such  freedoms  either  in  a  restricted  or  general  fashion.     The  significance  of  (B’)  is  that  (B)  without  modification  falls  entirely  within  the  realm  of   public  health  technical  expertise.    The  only  burden  of  proof  that  falls  upon  the  public  health   professional  when  making  a  case  for  (B)  is  to  demonstrate  a  real  or  potential  detriment  to  the   public’s  health.    Without  the  explicit  acknowledgment  of  comparative  judgment  it  would  seem   that  determination  of  what  is  in  the  public’s  interest  is  a  matter  of  fact  –  of  assessing  what   improves  and  harms  the  public’s  overall  level  of  safety  from  injury  and  provides  relief  from  the   harms  of  disease  and  premature  death.      Thus,  public  health  expertise  is  identified  as   competency  –  the  knowledge  and  skills  necessary  to  identify  and  forestall  detriments  to  the   public’s  health.    By  ignoring  the  role  of  moral  judgment  required  to  execute  the  evaluative   judgments  of  (B’),  the  corresponding  notion  of  the  ideal  public  health  professionals  is  devoid  of   any  qualifications  that  would  ground  such  judgment.   The  second,  but  related  confusion,  can  occur  because  in  the  midst  of  epidemiological   methodologies  and  analyses,  it  is  possible  to  equate  knowledge  of  public  health  with   knowledge  of  human  wellbeing.  This  is  especially  the  case  in  public  health,  where  broad   definitions  of  health  and  pervasive  determinants  of  public  health  seem  to  imply  that  every   aspect  of  life  can  fall  under  the  domain  of  public  health.    For  example,  the  World  Health   Organization’s  definition  of  health  has  been  widely  criticized  precisely  because  it  fails  to       39     52 differentiate  a  healthy  life  from  more  general  human  wellbeing.    In  Chapter  4,  I  address  the   ethical  dimensions  of  such  broad  definitions  in  more  detail.    For  the  moment  I  merely  wish  to   draw  attention  to  the  potential  for  a  failure  to  recognize  the  distinction  between  health  as  a   public  good  and  the  public  good.      While  health  is  arguably  a  constituent  of  or  means  to  achieve   many  formulations  of  a  good  life,  even  a  broad  understanding  of  health  and  its  determinants   ought  not  to  encompass  all  the  aspects  of  wellbeing.    Given  the  ease  with  which  one  can   conflate  health  and  wellbeing,  one  possible  mistake  in  public  health  constitutes  a  failure  to   recognize  the  limits  of  public  health  insight  into  the  public  good.   This  kind  of  slip  is  especially  relevant  as  it  can  provide  another  faulty  foundation  for   paternalistic  reasoning.    In  public  health,  such  a  mistake  is  the  equivalent  to  those  made  by   many  in  curative  medical  practice  when  paternalism  was  the  norm;  many  clinicians  assumed   that  clinical  expertise  was  sufficient  for  making  decisions  in  a  health  care  context,  failing  to  see   that  such  decisions  had  bearing  on  all  aspects  of  human  wellbeing,  not  just  those  relating  to   health.      Thus,  while  a  physician  might  argue  that  surgery  is  in  a  patient’s  interest  with  respect   to  maximizing  her  health,  it  does  not  follow  that  surgery  is  in  her  interests  all  things  considered.     As  many  have  argued,  different  patients  may  value  quality  of  life  vs.  quantity  of  life  differently,   illustrating  how  other  aspects  of  human  wellbeing  may  be  weighted  differently  by  different   individuals.    The  parallel  in  public  health  is  that  different  communities  might  strike  different   trade-­‐offs  between  social  values.                                                                                                                           52  Rodolfo  Saracci,  “The  World  Health  Organisation  Needs  to  Reconsider  Its  Definition  of   Health,”  British  Medical  Journal  314,  no.  7091  (1997):  1409–1410;  Johannes  Bircher,  “Towards  a   Dynamic  Definition  of  Health  and  Disease,”  Medicine,  Health  Care,  and  Philosophy  8,  no.  3   (2005):  335–41.       40     For  public  health  practice,  my  claim  here  is  that  public  health  paternalism  is  sometimes   rooted  in  a  similar  mistake  –  in  a  belief  that  public  health  understanding  is  sufficient  to  provide   guidance  in  what  is  deemed  to  be  a  public  health  context.    This  problem  is  reinforced  by  the   failure  to  see  comparative  judgment  as  an  inherently  normative  endeavor,  but  it  is  also  a   distinct  concern.    Here,  I  am  concerned  with  the  possibility  that  public  health  professionals  will   view  the  public  health  as  the  only  constituent  of  the  overall  public  good.    In  doing  so,   professionals  fail  to  articulate  the  relationship  of  the  public’s  health  to  the  overall  public  good,   and  why  it  is  worth  sacrificing  some  liberties  to  sustain  it.       In  this  section,  I  have  argued  that  both  mistaken  foundations  for  public  health   paternalism  that  I  have  described  here  present  a  picture  of  the  public  health  professional  as   ideally  competent.    By  failing  to  see  public  health  as  an  endeavor  that  requires  articulating  the   public’s  health  as  one  of  many  public  goods  to  choose  between,  or  as  part  of  an  overall  notion   of  the  public  good  all  things  considered,  flawed  paternalism  constructs  a  correspondingly  false   picture  of  public  health  professionalism.    The  bar  for  ideal  public  health  professionals  is  set   surprisingly  low  –  at  mere  competency.    The  problem  with  this  view  is  that  it  fails  to  distinguish   between  good  and  bad  public  health  professionals  –  a  person  can  be  competent  but   nevertheless  exercise  their  expert  knowledge  and  skills  toward  good  or  bad  ends.    By   illegitimately  erasing  value  judgments  from  the  work  of  public  health,  the  resultant  ideal  for   public  health  professionalism  is  a  flat  picture  of  the  public  health  professional,  one  who  lacks   any  criteria  for  exercising  proper  moral  judgment.   The  ideal  of  competency  also  sets  up  expectations  for  public  responses  to  public  health   professionals.    If  what  is  (mistakenly)  required  to  justify  public  health  paternalism  is  public       41     health  technical  expertise,  members  of  the  public  must  be  prepared  to  defer  to  the  judgment  of   those  experts  inside  the  context  of  public  health.    By  constructing  an  account  of  public  health   devoid  of  normativity,  public  health  professionals  set  the  stage  for  public  relationships  that   center  around  who  is  more  qualified  to  make  expert  assessments.    If  public  health  policy  is   solely  a  matter  of  empirical  knowledge  and  epidemiological  skill,  then  public  health  policy  will   be  entirely  a  matter  for  professionals  to  determine.    Because  public  health  professionals  have   greater  knowledge,  so  the  argument  goes,  the  public  must  defer  to  this  superior  knowledge.    In   the  next  section  I  consider  a  case  study  that  illustrates  this  picture  of  public  health  and   expertise  in  action.     2.2  Case  Study:  MMR  Vaccination   In  this  section  I  present  the  arguments  of  Tom  Sorell  in  the  context  of  the  vaccination-­‐ autism  debates  as  an  example  of  the  call  for  public  deference  to  public  health  expertise.      Sorell   does  contend  that  his  arguments  justify  strong  public  health  paternalism,  but  also  seems  to   advocate  for  a  different  form  of  public  health  policy  when  he  contends  that  his  arguments   establish  that  the  public  has  a  moral  duty  to  defer  to  public  health  expertise,  and  thereby   follow  public  health  professional  recommendations  voluntarily:    “where  the  coercive  policy  is   backed  by  a  clear  medical  consensus,  appropriately  reconsidered  in  the  light  of  claims  of   doubters,  there  is  sometimes  a  moral  obligation  on  the  part  of  the  public  to  defer  to       42     53 experts.”    Thus,  it  is  possible  to  conceive  of  Sorell  as  advancing  the  view  that  the  relationship   of  deference  entails  both  acquiescence  to  mandatory  vaccination  and  also  voluntary   participation  in  vaccination  programs.    The  kind  of  deference  Sorell  has  in  mind  is  epistemic   deference;  he  expects  parents  to  understand  that  public  health  professionals  will  have  greater   knowledge  in  areas  of  epidemiology,  including  vaccination,  and  thinks  that  the  weight  of   professional  opinion  ought  to  convince  parents  that  vaccination  is  safe,  and  indeed,  the  right   thing  to  do  for  one’s  child.  Despite  not  characterizing  his  argument  as  disagreements  about  the   proper  relationship  between  citizens  and  public  health  professionals,  I  argue  that  a  virtue  ethics   approach  pushes  us  to  consider  his  arguments  in  this  light  by  calling  our  attention  to  the  ways   in  which  policy  recommendations  are  tied  to  conceptions  of  appropriate  relationships  in  public   health.         The  source  of  the  controversy  began  in  1998,  as  a  result  from  an  article  published  (and   since  retracted)  by  Andrew  Wakefield  and  colleagues  in  the  Lancet.    In  this  paper  and  a   subsequent  press  conference,  researchers  put  forth  the  possibility  of  a  causal  link  between  a   vaccine  for  measles,  mumps,  and  rubella  (MMR),  bowel  disease,  and  autism.    The  subsequent   public  demand  for  investigation  and  scientific  criticism  of  the  research  was  complicated  by  a   lack  of  a  scientific  process  for  handling  suspected  misconduct  in  research,  as  well  as  the  media   furor  that  followed.  54  In  this  section  I  examine  one  argument  that  calls  for  public  deference  to   experts  with  respect  to  vaccine  safety.    And  while  I  use  the  MMR  case  for  illustration,  for  the                                                                                                                           53  Tom  Sorell,  “Parental  Choice  and  Expert  Knowledge  in  the  Debate  About  MMR  and  Autism,”   in  Ethics,  Prevention,  and  Public  Health,  ed.  Angus  Dawson  and  Marcel  Verweij  (Oxford:  Oxford   University  Press,  2007),  95.   54  Richard  Horton,  “The  Lessons  of  MMR,”  The  Lancet  363,  no.  9411  (2004):  747–9.       43     remainder  of  this  chapter  I  treat  skepticism  of  public  health  efforts  more  broadly.    The  lessons   of  the  MMR  debate  can  at  the  very  least  be  applied  to  other  instances  of  vaccination   skepticism,  including  Nigerian  boycotts  of  the  polio  vaccination  campaign  in  2003,  or  objections   to  the  human  papilloma  virus  (HPV)  more  recently  in  the  United  States.    In  this  section,  I  argue   that  the  MMR  case  illustrates  a  common  thread  with  the  paternalistic  rationales  outlined  in   Section  1.1,  even  when  not  explicit  defenses  of  public  health  paternalism.    I  contend  that  this   analysis  leads  us  to  question  examine  the  justification  for  expectations  of  deference.     There  are  several  different  reasons  that  members  of  the  public  might  object  to   vaccination.    The  first,  which  seems  to  be  the  one  most  commonly  attributed  to  those  who   question  vaccination,  is  a  belief  that  they  are  unsafe.    This  belief  may  result  from  knowledge  of   the  controversial  studies.    It  may  also  come  from  ignorance  of  the  studies  that  demonstrate   vaccine  safety,  misleading  rumors,  or  any  number  of  faulty  forms  of  inference.    It  may  also  be   supported  independently  by  a  second  view  that  public  health  professionals  have  a  vested   interest  in  not  disclosing  harms  that  accompany  vaccination.    Vaccines,  after  all,  are  the   hallmark  of  public  health.    Both  reputations  and  livelihoods  may  be  staked  on  continuation  of   vaccines  as  standard  public  health  policy.    A  third  reason  to  resist  vaccination  might  be  based   on  a  kind  of  free-­‐rider  mentality,  understanding  that  the  statistics  entail  that  some  adverse   events  do  result  from  vaccination  (even  if  not  autism),  and  thus  one  can  hedge  one’s  bets  by   simply  relying  on  herd  immunity.    Lastly,  a  fourth  group  may  not  consider  themselves  as  either   for  or  against  vaccines,  but  are  just  not  sure  what  to  do.    This  rather  ambivalent  group  may   have  some  of  the  information,  and  want  assurances  both  as  to  the  safety  of  vaccinations,  but   also  as  the  underlying  justification  for  compliance  –  whether  expressed  in  moral  or  legal  terms.         44     This  list  is  not  meant  to  be  exhaustive,  but  merely  a  collection  of  the  kind  of  reasons  at  play.    It   is  often  the  case  that  some  of  them  are  extraordinarily  well  articulated,  while  other  may  be   implicit  in  the  attitudes  expressed  by  those  engaging  in  the  debate.   In  the  previous  section  I  argued  that  in  some  faulty  forms  of  paternalistic  reasoning  it  is   possible  to  mistakenly  view  the  problem  as  merely  a  factual  one.    This  type  of  reasoning  leads   public  health  professionals  to  characterize  the  need  for  vaccine  compliance  as  an  entirely   empirical  matter  –  the  problem  is  that  the  public  either  fails  to  (or  even  refuses  to)  understand   the  facts.    Sorell’s  characterization  illustrates  this  thought  process:  “In  the  MMR  case,  I  want  to   argue,  parental  opinion  is  no  more  relevant  than  public  opinion  in  general,  since  what  matters   55 is  the  actual  effects  of  the  MMR  vaccine.”    In  this  instance,  Sorell  understands  “the  public   good”  to  be  a  matter  of  fact,  and  fails  to  see  it  as  a  normative  concept,  about  which  non-­‐ 56 professionals  may  have  insight  and  understanding.    Thus,  by  failing  to  see  public  health   assessment  as  including  a  comparative  judgment,  Sorell  views  the  main  task  of  public  health  as   demonstrating  the  harms  of  non-­‐vaccination  to  human  health.    If  he  were  to  adopt  the  view   57 that  public  health  professionals  help  to  inform  public  decisions  about  whether  coercion  or   voluntary  policy  is  better  for  the  public  good,  he  might  begin  to  see  that  public  health  technical   expertise  is  not  the  only  consideration  required  to  form  a  judgment.   Sorell’s  flawed  paternalistic  arguments  nevertheless  have  some  merit,  in  that  they   would  be  a  good  reason  to  support  greater  educational  interventions  that  accompany                                                                                                                           55  Sorell,  “Parental  Choice  and  Autism,”  97.   56  Ibid.,  95.   57  Ibid.,  106.    Sorell  speaks  of  a  “duty  to  defer  to  experts,”  which  I  will  address  shortly,  but  he   also  seems  to  think  that  the  same  arguments  –  once  provided  to  individuals  in  question  –  also   justify  coercive  measures  to  vaccinate  children.         45     vaccination.      Sorell  envisions  a  different  model  for  managing  public  health  expertise  –  one  akin   to  the  educational  system.      Much  like  parents  often  depend  on  professionals  to  help  educate   their  children,  Sorell  contends  they  must  also  call  on  public  health  professionals  to  help  them   make  decisions  regarding  their  child’s  wellbeing.  To  help  him  make  this  case,  he  contends  that   deep  concern  for  a  particular  individual’s  wellbeing  does  not  necessarily  translate  into  a  better   understanding  of  what  constitutes  her  interests  and  how  to  fulfill  them:  “...actively  helping   one’s  children  is  only  going  to  be  successful  within  the  limits  of  one’s  competence.    If  you  are   lousy  at  maths,  then  no  matter  how  conscientiously  you  try  to  help  your  children  with  the   58 maths  homework,  it  is  not  going  to  do  them  any  mathematical  good.”      Sorell  envisions  that   while  parents  may  have  some  insight  into  what  benefits  or  harms  their  children,  only  public   health  competency  can  ground  conclusions  about  vaccination  safety.    Sorell  envisions  a   “division  of  labor”  in  which  parents  consult  the  experts  in  matters  outside  their  own  knowledge   base.   Sorell’s  points  are  well  taken;  we  have  good  reason  to  believe  that  sometimes  those   closest  to  us  may  misunderstand  or  miscalculate  our  own  interests  –  partiality  can  familiarize   one  with  another’s  concerns,  but  it  can  also  create  blinders  to  open  alternatives.    But  while   there  are  certainly  drawbacks  to  partiality,  there  are  also  excellent  reasons  to  believe  that   parents  do  have  intimate  understanding  of  their  children’s  needs,  especially  their  particular   preferences,  desires,  and  needs  that  differentiate  them  from  other  children.    Once  one  has   gathered  the  empirical  data,  it  may  be  that  other  considerations,  including  normative  ones,  are   also  necessary  to  determine  not  what  is  the  case,  but  what  one  ought  to  do.    Thus,  expert                                                                                                                           58  Ibid.,  100.       46     consultation  may  be  necessary  in  child  rearing,  but  it  is  hardly  sufficient.    Sorell  is  right  to   conclude  that  partiality  is  not  a  definitive  source  of  insight  into  a  child’s  wellbeing  (or  all   children’s  wellbeing),  but  neither  is  public  health  knowledge.   Sorell’s  education  solution  may  indeed  provide  some  peace  of  mind  to  parents,   especially  to  those  who  are  merely  uncertain  about  why  there  is  a  controversy  in  the  first  place,   and  merely  wish  to  know  where  the  scientific  consensus  lies.    However,  this  is  unlikely  to   convince  any  who  have  moral  objections  to,  or  even  concerns  with,  vaccination  policy.       Technical  expertise  alone  does  not  give  skeptics  a  reason  to  believe  that  the  source  of   information  has  no  conflict  of  interest.  By  articulating  a  concern  for  the  public  good  over   attention  paid  to  individual  good,  without  acknowledging  the  value-­‐laden  nature  of  this   perspective,  public  health  professionals  may  be  reinforcing  a  public  perception  that   professionals  are  willing  to  accept  costs  to  the  few  for  the  sake  of  the  many.       For  example,  a  parent  might  also  question  whether  a  public  policy  designed  for  many   ought  to  be  implemented  in  the  same  way  for  every  member  of  society.    A  parent  might  be   concerned  that  what  is  good  for  the  average  child  is  not  necessarily  good  for  his  or  her   particular  child  and  may  seek  not  only  factual  reassurance,  but  a  normative  justification  for   uniform  public  policy,  especially  one  with  an  acknowledged  incidence  of  adverse  events.    Such   questions  regarding  vaccination  policy  are  intelligent  questions  with  both  scientific  and   normative  aspects.    They  express  a  wish  to  understand  the  justifications  for  policies  designed   for  all  people,  which  as  a  result  may  inherently  lack  flexibility.  It  is  not  surprising  then,  that  part   of  the  backlash  against  vaccinations  sparked  requests  for  alterations  in  the  timing  of  childhood       47     vaccinations.    The  public  questioned  not  only  whether  vaccines  were  safe,  but  also  what   59 justifies  uniformity  in  public  policy  implementation.     To  express  this  concern  in  Beauchamp’s  terms,  such  groups  argue  that  this  practice  does   not,  on  balance,  further  the  public  good.    From  this  perspective,  their  comparative  judgment   comes  out  differently,  on  balance.    This  difference  is  often  articulated  as  the  conflict  between   individuals  and  groups,  but  as  I  argued  in  Chapter  1,  we  can  view  it  as  an  internal  social  conflict   (i.e.,  parents  generally  care  both  about  societal  options  and  lower  levels  of  disease)  regarding   how  to  balance  societal  freedom  of  choice  with  the  public’s  health.      It  may  also  be  an  argument   from  justice  regarding  how  to  balance  maximizing  general  utility  with  the  harms  this  may  entail   for  a  minority.  This  difference  in  balancing  values  may  actually  be  exacerbated  by  focusing  on   expertise,  which  draws  divisions  between  professionals  and  the  public.    Rather  than  viewing  the   policy  as  a  mutual  endeavor  collectively  devised  by  citizens  (or  their  representatives)  and   professionals,  vaccination  policy  becomes  viewed  as  something  professionals  do  to  the  public,   not  with  the  public.    In  the  end,  what  may  reasonably  justify  resistance  to  mandatory   vaccination  is  twofold:  (1)  an  absence  of  an  articulated  underlying  justification  for  the   comparative  judgment  made  by  public  health  professionals  (why  the  public  good,  in  this  case,  is   furthered  by  compulsory  vaccination  over  freedom  of  choice)  and  (2)  the  feeling  that  the  public   has  not  been  adequately  included  in  the  conversation  that  generates  social  policy.                                                                                                                           59  It  is  likely  Sorell  would  claim  again  that  this  argument  is  based  on  mistaken  views  of  the   harms  of  vaccination  –  but  it  need  not  be.    It  is  reasonable  for  a  parent  who  has  a  child  with  a   history  of  adverse  reactions  to  vaccination  to  question  how  to  handle  future  vaccination,  and  to   expect  that  the  recommendations  for  her  child  (or  children)  be  different  from  the   recommendations  for  families  with  no  such  history.    That  public  health  professionals  do  not   believe  that  an  alternate  vaccination  schedule  offers  any  such  benefit  is  not  a  reason  to   conclude  that  no  alteration  in  policy  implementation  is  reasonable.       48     To  express  this  concern  in  Beauchamp’s  terms,  such  groups  argue  that  this  practice  does   not,  on  balance,  further  the  public  good.    From  this  perspective,  their  comparative  judgment   comes  out  differently,  on  balance.    This  difference  is  often  articulated  as  the  conflict  between   individuals  and  groups,  but  as  I  argued  in  Chapter  1,  we  can  view  it  as  an  internal  social  conflict   (i.e.,  parents  generally  care  both  about  societal  options  and  lower  levels  of  disease)  regarding   how  to  balance  societal  freedom  of  choice  with  the  public’s  health.      It  may  also  be  an  argument   from  justice  –  regarding  how  to  balance  maximizing  general  utility  with  the  harms  this  may   entail  for  a  minority.  This  difference  in  balancing  values  may  actually  be  exacerbated  by   focusing  on  expertise,  which  draws  divisions  between  professionals  and  the  public.    Rather  than   viewing  the  policy  as  a  mutual  endeavor  collectively  devised  by  citizens  (or  their   representatives)  and  professionals,  vaccination  policy  becomes  viewed  as  something   professionals  do  to  the  public,  not  with  the  public.    In  the  end,  what  may  reasonably  justify   resistance  to  mandatory  vaccination  is  twofold:  (1)  an  absence  of  an  articulated  underlying   justification  for  the  comparative  judgment  made  by  public  health  professionals  (why  the  public   60 good,  in  this  case,  is  furthered  by  compulsory  vaccination  over  freedom  of  choice)  –  and  (2)   the  feeling  that  the  public  has  not  been  adequately  included  in  the  conversation  that  generates   social  policy.   How  then  should  public  health  professionals  consider  the  merits  of  Sorell’s  arguments?     While  he  may  be  incorrect  to  characterize  public  health  policy  solely  in  empirical  terms,  it  is                                                                                                                           60  It  is  also  possible  to  read  Sorell’s  arguments  as  merely  advocating  for  morally  obligatory   public  health  adherence,  in  which  case  they  are  not  paternalistic,  although  they  exhibit  many  of   the  same  features.         49     worth  considering  when  it  is  reasonable  to  expect  deference  within  public  health  relationships.     In  the  next  section,  I  turn  to  a  more  in-­‐depth  consideration  of  the  notion  of  deference.     2.3  Deference     When  public  health  professionals  expect  deference  to  their  expertise,  this  provides  one   candidate  relationship  that  might  structure  public  health  interactions.    In  this  section  I  consider   Philip  Pettit’s  account  of  when  it  is  more  or  less  reasonable  to  expect  epistemic  deference.    In   the  course  of  this  analysis,  I  argue  that  (1)  marginalization  of  public  health  skepticism  can   backfire.    In  addition,  when  a  more  reflective  understanding  of  deference  is  articulated,  it   becomes  clear  that  (2)  epistemic  deference  to  public  health  expertise  may  be  epistemically   arduous  and  (3)  appeals  to  expert  authority  may  actually  demand  deference  to  moral  or  legal   authority.    I  conclude  that  this  analysis  illustrates  why  the  source  of  public  health  information  is   as  important  to  the  public  as  its  veracity.    This,  in  turn,  sets  the  stage  for  the  second  half  of  the   chapter,  and  a  turn  toward  virtue  as  an  alternate  guide  for  public  health  professionals.     2.3.1  Deference  and  Reforming  Belief   Philip  Pettit’s  analysis  of  epistemic  deference  to  majority  testimony  helps  to  fill  in  what   61 it  might  mean  to  have  reason  to  defer.    Pettit  offers  us  the  instance  of  a  car  accident,  in   which  you  believe  you  saw  a  car  run  a  red  light  and  cause  the  subsequent  crash.    However,  a   large  number  of  other  witnesses  swear  that  the  light  was  green.    Pettit  claims  that  in  such  an                                                                                                                           61  Philip  Pettit,  “When  to  Defer  to  Majority  Testimony  –  and  When  Not,”  Analysis  66,  no.  3   (2006):  179  –187.       50     instance,  we  can  offer  good  reasons  to  believe  that  you  ought  to  defer  to  the  opinion  of  other   witnesses  –  namely,  the  unreliability  of  perceptions  and  how  quickly  the  accident  occurred.     When  Sorell  characterizes  vaccination  skepticism  as  a  matter  of  fact,  it  is  reasonable  to  expect  a   similar  process  of  revision  in  this  public  health  context.    A  parent,  having  heard  of  the  Wakefield   paper,  questions  whether  vaccination  is  the  right  course  of  action  for  her  child.    Sorell  believes   that,  on  the  basis  of  expert  consensus,  a  parent  ought  to  be  willing  to  override  her  initial   misgivings,  and  revise  her  belief  in  line  with  expert  opinion.   However,  our  expectations  for  when  it  is  appropriate  to  revise  belief  based  on  the   testimony  of  others  may  sometimes  differ  in  matters  of  scientific  expertise,  or  once  moral   convictions  are  involved.  Pettit  offers  us  the  examples  of  a  staunch  believer  in  intelligent   design,  confronted  by  a  large  number  of  defenders  of  evolution;  and  in  turn,  a  person  who   believes  that  abortion  is  morally  wrong,  but  faced  with  a  majority  who  believe  the  contrary.   The   difference   between   the   first   case   and   the   other   two   is   that   the  belief  under  pressure  in  that  case  is  not  deeply  embedded  in   your  Quinean  web  of  belief,  whereas  the  beliefs  in  the  other  cases   are.   You   can   come   to   think   that   the   car   went   through   on   the   green  without  revising  any  of  your  other  beliefs…But  you  cannot   come   to   think   that   intelligent   design   is   false,   or   that   abortion   is   not   grievously   wrong,   without   a   range   of   adjustments   in   other   62   matters  of  belief.     This   does   not   mean   that   the   person   in   question   is   justified   in   maintaining   a   belief   in   intelligent   design   or   the   immorality   of   abortion   –   the   deeply   embedded   network   of   beliefs   that   support   this   view   may   indeed   suffer   from   significant   falsities   and/or   invalidities.     Pettit’s   conclusion  is  that  deference  in  such  cases  is  unreasonable  to  expect,  and  even  unwarranted,  for                                                                                                                           62  Ibid.,  181.       51     the  depth  of  a  conviction  has  bearing  on  whether  we  think  belief  ought  to  be  swayed  by  others.     A   tendency   to   bend   wherever   the   wind   of   majority   opinion   blows,   especially   in   matters   of   63 conscience,   reflects   a   kind   of   “epistemic   timidity   or   servility.”     Thus,   while   it   may   be   a   relatively   trivial   matter   to   revise   one’s   opinion   of   what   one   saw   in   a   rushed   and   hurried   moment,  it  is  not  nearly  such  a  simple  matter  to  revise  a  complex  of  beliefs,  or  a  deeply  rooted   moral  conviction.       Pettit’s  analysis,  however,  also  assumes  several  preconditions  of  the  disagreement  that   do  not  hold  in  the  MMR-­‐vaccination  case.    Pettit’s  view  assumes  that  the  parties  in  question  are   64 intelligent,   informed,   and   impartial.   But   for   those   that   question   or   defend   vaccine   safety   and   efficacy,  the   sources   of  information  on  vaccines  may   be   dubious  to  begin  with.     Whether  the   parties   in   question   are   equally   informed   is   part   of   what   is   at   stake.     In   addition,   the   impartiality   of   public   health   professionals   may   be   particularly   in   question,   for   professional   reputations   may   hinge   on   the   status   of   vaccine   safety,   or   there   may   be   a   perception   that   careers   may   be   staked   on  a  high  degree  of  public  participation  in  vaccination  campaigns.    As  I  argued  in  Section  2.2,   parents  may  view  this  as  a  potential  conflict  of  interest.  Similarly,  professionals  may  believe,  for   example,  that  a  citizen’s  unbending  and  general  distrust  of  all  government  authorities  creates  a   bias   that   prevents   her   from   weighing   expert   opinions   appropriately.     Thus,   the   factual   disagreement  of  the  MMR  case  is  set  within  a  wider  set  of  beliefs  and  attitudes,  including  views   about  the  government,  and  perhaps  even  the  structures  and  nature  of  society.    Challenging  this   system  of  beliefs,  especially  when  it  can  be  characterized  as  a  coherent  world-­‐view,  requires  far                                                                                                                           63  Ibid.   64  Ibid.,  186.       52     more   revision   than   public   health   professionals   can   expect   to   occur   overnight,   or   simply   by   pointing  to  studies  and  statistics.     Health   professionals   and   the   media   paint   vaccine   skeptics   as   ignorant,   dogmatic,   irrational,  and  extreme.    Such  depiction  may  be  strategic  in  an  attempt  to  contain  and  control   public  doubt.    I  argue  that  such  a  tack  is  counterproductive  insofar  as  it  sets  up  an  undesirable   relationship   between   citizens   and   public   health   professionals.     Even   if   such   a   depiction   were   accurate,  one  might  reasonably  wonder  how  effective  ridicule,  scorn,  and  condescension  are  at   inspiring  greater  confidence.  The  call  for  public  deference  itself  often  extends  this  patronizing   attitude   to   anyone   associated   with   vaccination   skepticism   –   even   those   for   whom   epistemic   revision   may   be   a   reasonable   expectation.   While   there   may   be   staunch   opponents   to   vaccination   who   lie   beyond   the   reach   of   reason   or   patience,   we   have   little   reason   to   believe   that  this  is  true  of  all  who  question  vaccine  safety,  and  even  less  reason  to  characterize  such   concern   as   a   “forgivable”   transgression   when   it   constitutes   a   simple   request   for   greater   65 accountability  on  the  part  of  public  health  professionals.    The  public  outcry  and  popular  press   magnification   of   the   MMR   controversy   exposed   large   numbers   of   people   to   skepticism   about   vaccine  safety,  and  even  referenced  significant  historical  lapses  of  public  health  and  vaccination   dependability,  such  as  the  Guillian-­‐Barré  cases  caused  by  swine  flu  vaccination  in  1976.    In  this   context,   one   might   find   it   unsurprising   that   parents   now   expect,   at   the   least,   more   information   from   clinicians   regarding   the   safety   of   vaccinations.     It   is   reasonable,   in   such   a   context,   to   assume   that   these   less   convinced,   or   merely   concerned,   parents   are   more   akin   to   Pettit’s                                                                                                                           65  Sorell,  “Parental  Choice  and  Autism,”  101.       53     witness   who   can   reasonably   expected   to   revise   her   opinion   of   what   she   saw,   or   at   least   her   degree  of  certainty  that  she  saw  it.    Such  parents  are,  self-­‐admittedly,  already  on  the  fence.       However,  there  are  also  a  moral  elements  to  the  vaccination  and  car  accident  cases  that   reveals  why  deference  in  our  mistaken  witness’s  case  is  not  only  a  lesser  epistemic  challenge,   but  also  less  likely  to  earn  the  pejorative  label  of  “servility.”    For,  in  the  case  of  the  accident,  the   stubborn   witness   who   refuses   to   revise   her   beliefs   subjects   the   driver   in   question   to   the   possibility   of   liability,   a   heavy   conscience,   and   public   attribution   of   recklessness.     To   do   so   despite   evidence   that   such   condemnation   is   unwarranted   is   not   only   epistemic   folly,   but   also   potential   cruelty.     Thus,   our   car   accident   witness   has   a   moral   reason   to   take   into   account   other   witness’   statements   –   to   fail   to   do   so   may   indicate   a   moral   failure   on   her   part   to   have   an   appropriate  self-­‐awareness  of  her  own  fallibility.    In  contrast,  while  the  epistemic  state  of  our   on-­‐the-­‐fence   parent   parallels   that   of   the   witness   (she   does   not   necessarily   know   which   evidence   to   believe),   her   moral   state   does   not.     On   the   contrary,   she   has   moral   reason   to   be   more   cautious   regarding   belief   revision   given   her   role   as   a   parent   and   her   concerns   for   the   safety   of   her   child   –   for   her   to   incautiously   defer   (even   to   expert   consensus)   can   more   reasonably  merit  the  label  of  epistemic  subservience.   It  has  been  my  intention  throughout  this  chapter  to  question  what  kind  of  relationship   we   desire   between   public   health   professionals   and   members   of   the   public.     I   hope   to   have   demonstrated   that   insofar   as   public   health   professionals   expect   epistemic   deference,   we   might   wonder   whether   there   are   better   ways   to   understand   what   it   is   that   inspires   confidence   in   public   health.     Epistemic   revision   can   be   inspired   by   acquiescence   to   the   weight   of   others’   views,  but  also  by  justifications  provided  in  a  clear  and  accessible  way;  parents  can  choose  to       54     vaccinate   based   on   (1)   professional   opinion,   or   (2)   by   coming   to   understand   the   explicit   rationale  that  lies  behind  such  professional  judgments.    As  Larson  and  Heymann  observe,  this   second   alternative   method   of   handling   public   skepticism   acknowledges   that   the   epistemic   burden   of   proof   lies   on   those   with   expertise:   “New   social   media   and   the   emergence   of   a   postdeferential  society  are  challenging  traditional  trusted  sources  of  information…rather  than   becoming   defensive   in   the   face   of   an   increasingly   questioning   public,   the   medical   and   public   health   communities   must   recognize   the   importance   of   changing   the   conversation   with   individual  patients  and  the  public  and  the  importance  of  being  open  to  hearing  real  concerns   66 that  will  affect  the  acceptance  or  rejection  of  health  services.”  I  claim  that,  in  cases  like  the   MMR   debate,   the   public   is   not   unreasonable   to   prefer   such   comprehensive   arguments   in   order   to  avoid  the  self-­‐ascription  of  epistemic  timidity  which  is  now  associated  with  a  bygone  era.         2.3.2  Epistemic  vs.  Moral  and  Legal  Deference   When  beliefs  are  also  connected  to  values,  the  question  is  not  only  one  of  revision  of  a   complex  of  cognitive  commitments.    It  is  also  a  question  of  redefining  who  one  is,  and  what   67 Bernard  Williams  calls  one’s  ground  projects.    In  virtue  terms,  the  question  of  what  we  ought   to  do  with  respect  to  vaccination  is  revealed  as  related  to  the  wider  question  of  who  we  ought   to  be.    In  such  cases,  where  a  deep  set  of  integrated  and  interdependent  beliefs  and   commitments  prevent  someone  from  recognizing  what  is  in  their  own  interests,  what  is  needed                                                                                                                           66  Heidi  J.  Larson  and  David  L.  Heymann,  “Public  Health  Response  to  Influenza  A(H1N1)  as  an   Opportunity  to  Build  Public  Trust,”  JAMA:  The  Journal  of  the  American  Medical  Association  303,   no.  3  (2010):  272.   67  Bernard  Williams,  Moral  Luck  (Cambridge:  Cambridge  University  Press,  1982),  13.       55     68 is  “a  substantive  account  of  how  people  may  fail  to  recognize  their  real  interests.”    Such  an   account  may  either  justify  weak  paternalism  because  it  establishes  why  some  people  aren’t   capable  of  making  the  best  decisions,  or  else  it  may  also  suggest  other  avenues  that  build   autonomy,  thereby  allowing  individuals  to  make  informed  decisions.      In  the  absence  of  such  an   account,  the  only  alternative  open  to  public  health  professionals  may  be  to  abandon  the  call  for   deference  and  turn  to  other  forms  of  relationships  with  the  public.    It  is  these  other  candidate   relationships  that  I  consider  for  the  remainder  of  this  chapter.         I  contend  here  that  structuring  public  health  relationships  in  terms  of  obstacles  to   knowledge  only  captures  part  of  the  story;  since  ignorance  is  the  proposed  problem,  expertise   appears  to  the  be  the  obvious  solution.    Sorell  believes  that  the  conflict  hinges  on   epistemological  premises,  and  as  such  makes  a  case  that  parents  ought  to  defer  to  the   epistemic  authority  of  public  health  professionals.    He  is  not  so  unreasonable  as  to  assume  that   public  concern  does  not  require  a  response,  but  his  interpretation  of  taking  such  concerns   69 seriously  is  again  scientific  –  the  beliefs  in  question  need  to  be  “confirmed  or  refuted.”      If  the   objections  to  vaccination  are  not  solely  matters  of  factual  belief,  then  the  resources   professionals  bring  to  bear  must  acknowledge  the  human  and  moral  elements  of  public  health   policy  in  their  proffered  justifications.    If  they  are  asking  for  public  beneficence,  then  this  ought   to  be  clear,  if  they  are  demanding  public  compliance,  than  this  ought  to  be  morally  or  legally   justified.    By  making  the  normative  demands  of  public  health  policy  explicit,  it  becomes   apparent  that  the  argument  in  question  does  not  request  only  deference  to  epistemic                                                                                                                           68  Bernard  Williams,  "Ethics  and  the  Limits  of  Philosophy,"  43.   69  Sorell,  “Parental  Choice  and  Autism,”  100.       56     authority,  but  a  call  for  deference  to  moral  or  public  authority.    And  the  question  remains   whether  public  health  professionals  can  justify  claims  to,  and  exercise  of,  this  kind  of  authority.     It  is  worth  considering  whether  public  health  professionals  ever  expect  these  other  forms  of   deference,  including  moral  or  legal  deference,  thereby  suggesting  other  candidate  relationships   for  public  health.   In  the  absence  of  an  account  of  what  has  obscured  self-­‐knowledge,  public  health   professional  contentions  that  individuals  should  nevertheless  comply  with  vaccination   campaigns  is  not  merely  to  demand  what  Pettit’s  analysis  reveals  is  a  kind  of  whole-­‐sale   epistemic  deference,  but  is  also  to  expect  moral  deference.    It  is  to  ask  some  citizens  to   abandon  their  own  moral  commitments,  reconsider  their  identities,  and  shift  perspectives  on   the  grounds  of  greater  authority  in  such  matters.    In  other  words,  to  claim  that  citizens  ought  to   give  public  health  consensus  more  weight  in  their  deliberations,  professionals  may  be  claiming   that  public  health  professionals  have  greater  moral  authority  to  judge  what  is  best  for  a   population,  or  a  member  of  that  population.    But  it  is  precisely  this  moral  authority  that   vaccination  skeptics  do  not  recognize,  and  which  merely  “factual”  public  health  arguments  fail   to  justify.    If  arguments  in  favor  of  adherence  in  public  health  policy  invoke  public  or  moral   authority,  they  ought  to  do  so  more  explicitly  and  distinguish  these  claims  from  empirical   arguments.    When  compliance  is  expected,  It  is  not  clear  whether  what  is  sought  is  moral  or   legal  deference.             57     2.3.3  A  Mutual  Desire  for  Respect   Sorell’s  analysis  of  the  MMR-­‐vaccine  debate  illustrates  how  expectations  of  deference   can  cause  differing  parties  to  speak  past  one  another.    While  professionals  feel  slighted  when   individuals  disregard  their  professional  opinion,  members  of  the  public  feel  silenced  and   frustrated  when  they  perceive  that  the  priority  of  professional  opinion  downgrades  the  voices   of  citizens  in  public  policy-­‐making.    Thus,  Sorell’s  determination  that  the  MMR-­‐Autism  debate  is   merely  a  question  of  fact  implies  that  it  cannot  also  be  a  matter  of  respect:  “The  issue  is   precisely  not  one  of  respect…It  is  to  do  with  the  state  of  the  evidence  of  MMR  and  the  risks  of   70 having  a  different  scheme  of  vaccination.”    In  this  section,  I  argue  that  the  call  for  deference   to  public  health  expertise  is  also  a  demand  for  respect.  My  analysis  establishes  that  developing   norms  for  relationships  between  public  health  professionals  and  citizens  are  at  the  heart  of   public  health  skepticism.   Objections  to  public  health  paternalism  bring  to  light  the  possibility  that  public  health   attitudes  to  members  of  the  public  can  reflect  a  lack  of  respect.    Some  objections  to   paternalism  are  concerned  that  lack  of  respect  stems  from  faulty  premises  involving  the   decision-­‐making  capacity  of  others.    In  characterizing  vaccination  as  a  matter  of  scientific  fact   alone,  Sorell  demonstrates  how  public  health  claims  to  superior  knowledge  of  how  to  achieve   and  what  constitutes  a  flourishing  life  may  reflect  a  failure  to  understand  the  pertinence  of   non-­‐expert  communal  and  individual  insights  into  the  public  good.    Importantly,  concerns  for   disrespect  are  not  limited  to  those  on  the  receiving  end  of  public  health  interventions.     Resistance  to  public  health  efforts  and  skepticism  of  public  health  claims  can  leave  public  health                                                                                                                           70  Ibid.,  98,  original  emphasis.       58     professionals  feeling  as  if  their  knowledge,  skills,  and  hard  work  on  behalf  of  others  are  not   properly  recognized.71      Such  offense  is  more  likely  to  occur  when  public  health  resistance  is   interpreted  as  purely  factual  disagreement;  if  members  of  the  public  feel  free  to  disregard   public  health  opinion,  this  seems  to  entail  a  devaluation  of  epidemiological  expertise.      Thus,   some  public  health  calls  for  deference  are  partially  motivated  by  a  desire  for  greater  public   respect  for  public  health  expertise.    It  is  certainly  the  case  that  there  is  a  paucity  of  public   awareness  regarding  the  role  of  public  health  in  everyday  lives,  as  well  as  a  long  history  of   relegating  public  health  professionals  lower  social  status  than  other  health  professionals.       But  this  concern  for  respect  goes  awry  by  framing  the  debate  in  terms  of  who  has  more   knowledge  of  public  health  empirical  matters.    Such  umbrage  is  often  expressed  in  terms  of  a   usurpation  of  power,  e.g.,  “When  a  pressure  group  or  individual  parents  decide  that  single   vaccinations  would  do  just  as  well  as  the  triple  vaccine,  however,  they  are  precisely  taking  over   72 the  doctoring  role  from  the  doctors.”    By  capitalizing  on  professional  feelings  of  societal   neglect  for  the  importance  of  public  health,  Sorell’s  analysis  depicts  vaccination  skeptics  as   ignorant,  ungrateful,  and  overstepping  their  bounds,  thereby  masking  any  legitimacy  to  their   concerns.    An  uncritical  call  for  deference  rationalizes  the  reaction  of  professionals  to  dig  in   their  heels,  and  defend  a  high  valuation  of  public  health  without  offering  adequate  defense  for   such  priority.                                                                                                                                 71  Georges  Benjamin,  “Message  from  the  Executive  Director:  Refusing  to  Be  Invisible,”  Annual   Report  of  the  American  Public  Health  Association  (2011),  accessed  September  4,  2012,   http://www.apha.org/NR/rdonlyres/77372C3C-­‐82DA-­‐43F7-­‐A152-­‐ 1CE6583F2E5B/0/AnnReport2011_final.pdf.   72  Sorell,  “Parental  Choice  and  Autism,”  100.       59     Respect,  its  absence  (lack  of  respect),  and  its  contrary  (disrespect)  are  notoriously  vague   terms.    This  is,  in  part,  because  their  normative  force  is  called  upon  in  such  a  wide  array  of   contexts,  from  mere  breeches  of  etiquette  to  the  most  egregious  of  injustices.    I  suggest  here   that  it  is  possible  to  view  unjustified  paternalism  as  a  misguided  demand  for  either  (or  both)   epistemic  or  moral  deference.    One  might  interpret  the  content  or  attitudes  associated  with  the   paternalism  identified  here  as  expressing  disrespect  for  non-­‐expert  forms  of  knowledge.    At  the   very  least,  the  refusal  to  view  members  of  the  public  as  having  something  to  contribute  to  the   73 application  of  public  health  policy  is  a  form  of  unjustified  “epistemic  exclusion.”  In  other   words,  “the  public  health  community  must  recognize  that  the  realm  of  rumors  and  perceptions   may  include  clues  about  reasons  for  concern,”  i.e.,  even  if  misinformed,  or  poorly  articulated,   74 public  skepticism  may  be  grounded  in  reasonable  calls  for  public  health  justification.    What   Sorell  fails  to  note  is  his  how  expectations  of  epistemic  deference  not  only  provide  a  solution  to   disagreements  about  the  facts,  but  also  a  remedy  to  the  injury  felt  by  professionals  when   others  question  their  professionalism.    Contrary  to  Sorell’s  assertion,  debates  about  public   health  policy  often  are  tied  to  respect  –  for  both  members  of  the  public  and  professionals  alike.     In  this  first  part  of  the  chapter,  I  have  argued  that  some  defenses  of  public  health   paternalism  are  flawed.    They  result  in  a  picture  of  public  health  policy  and  public  health   expertise  that  fails  to  incorporate  the  normative  dimensions  of  public  health  practice  and  public                                                                                                                           73  Nancy  Daukas,  “Epistemic  Trust  and  Social  Location,”  Episteme  3,  no.  1–2  (2006):  109–124.     Daukas  is  primarily  concerned  with  those  whose  assertions  are  not  taken  seriously  due  to  social   problems  such  as  sexism  and  racism,  whereas  I  am  using  the  term  more  broadly  to  include  all   those  who  are  not  deemed  to  have  the  authority  to  express  worthy  opinions  in  a  certain   context.   74  Larson  and  Heymann,  “Opportunity  to  Build  Public  Trust,”  271.       60     health  professionalism.    The  acknowledgement  that  a  hidden  demand  for  respect  is  built  into   the  call  for  deference  reveals  that  there  is  more  to  be  said  about  public  health  relationships   with  communities.    In  this  first  half  of  the  chapter  I  have  demonstrated  the  inadequacy  of  an   account  of  public  health  professionals  that  fails  to  pay  attention  to  the  virtues.    In  the  second   half  of  Chapter  2,  I  present  a  positive  account  of  public  health  professionals  in  which  I  defend   the  virtue  of  trustworthiness  as  the  foundation  for  public  health  relationships  of  trust.     PART  II     In  this  second  part  of  the  chapter  I  defend  an  account  of  public  health  relationships  of   trust,  and  the  corollary  virtue  of  trustworthiness.    To  do  so  I:  (1)  consider  and  reject  the   possibility  that  reliance  and  reliability  might  suffice;  (2)  articulate  why  trust  and  trustworthiness   are  an  ineradicable  part  of  public  health  practice;  (3)  support  affective  conceptions  of  trust  and   trustworthiness  over  the  most  dominant  cognitive  alternative  and;  (4)  present  some   preliminary  considerations  for  the  implications  of  this  analysis  for  trust  in  institutions  and  the   possibilities  of  virtuous  institutions.     2.4  Reliance  and  Reliability     One  reason  to  revise  beliefs,  or  to  reconsider  others,  is  the  confidence  one  places  in  the   sources  of  information  provided.    Sorrel  is  right  –  belief  in  matters  of  public  health  is  partly   about  competency;  if  public  confidence  in  professional  competency  falters,  the  veracity  of  such   experts  come  into  question.    Of  equal  importance  are  professionals’  motives  that  inform  why   they  will  tell  the  truth,  or  hide  it.    In  matters  of  public  health,  generating  public  confidence  in       61     public  health  information  will  in  part  hinge  upon  shoring  up  public  attitudes  regarding  the   sources  behind  that  information.      In  matters  of  public  health,  there  are  often  calls  for  instilling,   building,  and  inspiring  greater  public  trust.    A  virtue  ethics  of  public  health  calls  us  to  examine   the  assumption  that  a  trusting  relationship  is  an  ideal  that  ought  to  structure  public  health-­‐ community  interactions,  as  well  as  what  constitutes  such  a  relationship.    The  call  for  improving   public  trust  is  often  unexamined,  and  while  determinants  of  trust  have  been  identified,  greater   attention  to  conceptual  and  causal  understandings  of  trust  can  help  to  establish  a  firmer   foundation  for  building  trust,  as  well  as  why  it  is  desirable.    In  this  section,  I  will  argue  that  trust   in  public  health  offers  us  a  striking  alternative  to  the  picture  of  epistemic  deference  alone.     However,  trust  must  considered  side  by  side  with  relationships  of  reliance.     Both  empirical  evidence  and  some  formal  features  of  public  health  support  greater   attention  to  relationships  of  trust.    For  example,  Whetten  et  al.  indicate  that  socioeconomic   status,  but  not  race,  was  most  correlated  with  lower  levels  of  trust  in  government  and  in  health   care  providers.    In  addition,  the  study  revealed  that  greater  trust  among  HIV-­‐positive  patients   correlated  to  an  increased  number  of  clinic  visits,  but  the  general  paucity  of  research  on  trust   and  health  services  utilization  often  results  in  a  lack  of  clarity  about  causal  mechanisms;   researchers  were  unable  to  conclude  whether  lack  of  care  causes  a  corresponding  lack  of  trust,   75 or  the  reverse  –  lack  of  trust  meant  fewer  patients  seeking  continued  care.    Elsewhere,   distrust  of  international  vaccination  efforts  to  eradicate  polio  led  to  disastrous  results  which   some  have  argued  could  have  been  avoided  by  paying  more  attention  to  building  community                                                                                                                           75  Kathryn  Whetten  et  al.,  “Exploring  Lack  of  Trust  in  Care  Providers  and  the  Government  as  a   Barrier  to  Health  Service  Use,”  American  Journal  of  Public  Health  96,  no.  4  (2006):  716–21.       62     76 relationships  in  order  to  cultivate  trust.    There  are  also  conceptual  reasons  to  think  that   public  health  efforts  and  trust  are  linked.    Part  of  what  differentiates  public  health  from   medicine  is  that  it  is  public  in  the  sense  that  it  requires  “a  specific  sort  of  practice,  intervention,   77 or  public  policy  that  is  aiming  at  population  health  through  collective  means.”    In  addition,   78 trust  has  long  been  viewed  as  an  essential  or  integral  component  of  collective  efforts.    If   cooperation  and  trust  are  so  linked,  then  public  health  professionals  would  do  well  to  establish   trust  in  part  due  to  its  instrumental  value  in  furthering  collective  efforts.   Prior  to  endorsing  trust  as  an  ideal  relationship  within  public  health  practice,  we  must   first  consider  what  differentiates  trust  from  the  related  notion  of  reliance,  as  well  as  why  one   might  be  preferable  to  the  other.    Trust  is  generally  understood  to  be  a  species  of  the  larger   category  of  relationships  known  as  reliance.    Reliance  is  a  kind  of  dependence  on  the   consistency  or  regularity  of  behavior,  or  any  sequence  of  events.    While  people  and  their   behaviors  can  be  reliable  –  exhibit  a  kind  of  regularity  and  consistency  –  so  can  inanimate   objects.    The  classic  philosophical  example  to  distinguish  trust  from  reliance  draws  upon  the   behavior  of  famous  moral  philosopher,  Immanuel  Kant,  whose  punctuality  was  well  known.     “Kant’s  neighbors  who  counted  on  his  regular  habits  as  a  clock  for  their  own  less  automatically   regular  ones  might  be  disappointed  with  him  if  he  slept  in  one  day,  but  not  let  down  by  him,  let                                                                                                                           76  Larson  and  Heymann,  “Opportunity  to  Build  Public  Trust.”   77  Marcel  Verweij  and  Angus  Dawson,  "The  Meaning  of  'Public'  in  'Public  Health,'"  in  Ethics,   Prevention,  and  Public  Health,  ed.  Angus  Dawson  and  Marcel  Verweij  (Oxford:  Oxford  University   Press),  2007,  25.   78  Diego  Gambetta,  ed.  Trust:  Making  and  Breaking  Cooperative  Relations  (Blackwell   Publishing,  1990).  Cf.    Karen  S.  Cook,  Russell  Hardin,  and  Margaret  Levi,  eds.,  Cooperation   Without  Trust?  (New  York:  Russell  Sage  Foundation  Series,  2007).       63     79 alone  had  their  trust  betrayed.”    Our  use  of  language  blurs  these  conceptual  distinctions  –   thus,  we  say  that  we  “trust”  that  the  sun  will  rise  tomorrow.    To  get  to  the  crux  of  what  trust  is,   conceptualizations  aim  to  be  more  precise  than  the  common  conflation  of  the  two  terms.    In   contrast  to  mere  reliance,  the  relationship  of  trust  is  thought  to  rest  upon  a  particular  kind  of   regularity,  i.e.,  the  regularity  of  human  intentions.    Thus,  Kant’s  neighbors  can  rely  on  his   timeliness,  but  only  trust  him  if  he  is  aware  of  their  dependence.    If  they  ground  their  clock-­‐ setting  not  on  his  regularity  of  behavior,  but  on  his  concern  for  their  dependence  on  him,  then   this  can  be  said  to  be  trust.    In  other  words,  while  trains  and  watches  can  prove  unreliable,   whether  people  prove  to  be  worthy  or  unworthy  of  trust  turns  upon  the  content  of  their   intentions  and  how  these  motivate  responsive  behavior.      Only  people  can  be  motivated  by  the   dependence  of  others,  and  use  this  concern  as  an  impetus  for  regular  and  dependable  action.   Thus,  common  ground  in  theorizing  on  trust  finds  agreement  on  this  distinction  between  mere   reliance  and  trust,  as  well  as  the  view  that  trust  is  best  understood  as  a  three  part  relationship   in  which  agent  A  trusts  agent  B  with  some  object(ive),  X.    Theorists  greatly  disagree,  however,   on  which  intentions  are  the  most  important  in  providing  the  foundation  for  trust,  i.e.,  what   might  move  an  individual  to  find  the  dependence  of  another  motivating?       The  relationships  of  reliance  and  trust  imply  corresponding  attributes  of  public  health   professionals  that  provide  the  foundation  for  such  relationships.  If  reliance  and  trust  are   essential  relationships  for  public  health  practice,  then  it  will  be  necessary  for  public  health   professionals  to  build  reliability  and  cultivate  trustworthiness.    Another  example  can  help  to   illustrate  the  difference  between  these  two  traits:                                                                                                                           79  Annette  Baier,  “Trust  and  Antitrust,”  Ethics  96,  no.  2  (1986):  235.       64     Suppose   I   am   driving   into   a   city   that   I   do   not   know   and   I   wish   to   get   to   the   town   center.    I  see  a  bus  and,  knowing  the  pattern  on  which  bus  routes  are  generally   organized,  I  decide  to  rely  on  the  bus  driver  to  lead  me  to  the  center.    This  is  a   straightforward   case   of   active   reliance…But   the   reliance   that   his   example   illustrates   assumes   a   more   specific   and   interesting   form   if   it   becomes   interactive   as  well  as  active.  Suppose  that  I  worry  about  what  the  bus  driver  will  think  about   a  car  that  stops  every  time  the  bus  stops  and  that  follows  the  bus  faithfully  on  its   route.  This  may  lead  me  to  get  out  at  a  bus  stop  and  let  the  driver  know  that  I   am  relying  on  him  to  lead  me  to  the  center…I  may  expect  that  the  driver  will  be   positively   moved   by   seeing   that   I   have   made   myself   vulnerable   and   will   be   80 motivated  all  the  more  strongly  to  do  that  which  am  relying  on  them  to  do…     Much  like  our  consideration  of  the  punctuality  of  Kant,  in  the  first  case  the  bus  driver  exhibits   reliability  if  she  sticks  to  her  route.    In  the  second  case,  she  exhibits  trustworthiness  if  she  does   indeed  have  the  motivations  attributed  to  her.  Of  the  two,  only  trustworthiness  is  a  virtue.     Reliability  is  an  attribute,  and  it  may  indeed  require  appropriate  attitudes  (e.g.,  an  appreciation   for  precision,  and  commitment  to  consistency).    But  a  person  can  be  reliably  cruel  as  well  as   kind,  or  unwittingly  reliable  by  just  being  a  creature  of  habit.    Reliability,  on  its  own,  is  not  a   laudable  trait  until  we  assess  the  ends  it  achieves.   What  may  give  us  pause  in  placing  trust  at  the  center  of  public  health  are  the  realities  of   public  health  practice,  in  which  the  public  may  be  unaware  of  what  is  being  done,  purportedly   on  their  behalf.    Just  as  common  as  overt  cooperation,  the  public  may  have  little  to  no   knowledge  of  the  systems  in  place  that  work  to  protect  and  improve  health.    From  the  presence   of  iodine  in  salt,  to  the  infrastructure  in  place  to  ensure  a  potable  water  supply,  public  health   measures  save  lives  or  prevent  illness  in  ways  that  are  statistically  measureable,  but  not   necessarily  personally  apparent.    Prevention  often  results  in  invisible  successes.    We  may  be                                                                                                                           80  Philip  Pettit,  “The  Cunning  of  Trust,”  Philosophy  and  Public  Affairs  24,  no.  3  (1995):  204–5.       65     able  to  quantify  how  many  did  not  die,  or  how  many  did  not  fall  ill,  but  we  might  not  be  able  to   point  to  who  or  when  with  any  precision.    The  invisibility  of  public  health  successes  make  it   seem  less  likely  that  trust  is  at  the  heart  of  the  relationship  between  public  health  professionals   and  the  public.    Rather,  many  people  drink  from  the  tap  without  thinking,  and  go  on  about  their   lives  without  marveling  at  food  enrichment.    They  are  either  unconcerned  or  unaware  of  the   presence  of  health  policy  in  their  everyday  lives  precisely  because  success  is  so  common  as  to   become  a  background  condition.    In  such  instances,  public  response  to  the  presence  and  action   of  public  health  interventions  looks  more  like  reliance  on  consistent  processes  and  constant   practices  than  trust  in  the  motives  of  others.       Such  examples  also  illustrate  how  public  attitudes  span  a  range  of  actions  that  can  be   characterized  as  reliance,  trust,  both,  or  neither.    Individuals  who  question  the  safety  of  public   drinking  water,  for  example,  may  be  questioning  the  reliability  of  the  water  safety  system  itself.     Perhaps  its  age,  or  the  presence  of  newer  compounds  not  designed  to  be  picked  up  by  older   filters,  raise  a  concern  that  current  filtration  is  insufficient.    In  such  a  case,  the  concern  can  be   understood  as  resting  on  a  belief  that  present  water  safety  lacks  effectiveness;  the  consistency   and  regularity  of  the  system  in  achieving  the  ends  it  was  designed  to  meet  cannot  be  relied   upon.    In  contrast,  however,  there  are  some  who  question  the  motives  of  those  who  ensure  the   safety  of  the  nation’s  drinking  water.    While  publicly  justified  on  the  grounds  of  benefits  to   dental  health,  there  are  some  who  still  claim  that  water  fluoridation  aims  at  a  form  of   81 governmental  mind  control,  a  claim  tracing  back  to  anti-­‐communist  sentiments.    Such                                                                                                                           81  Jason  M.  Armfield,  “When  Public  Action  Undermines  Public  Health:  a  Critical  Examination  of   Antifluoridationist  Literature,”  Australia  and  New  Zealand  Health  Policy  4,  no.  1  (2007):  25.       66     individuals  do  not  only  find  the  water  safety  system  unreliable,  their  trust  in  the  professionals   behind  the  system  has  faltered.  Distrust  in  public  health,  whether  well-­‐founded  or  not,  rests  on   a  perception  that  the  vulnerability  of  the  public  is  no  longer  a  motivating  force  for  such   professionals.    The  example  also  helps  to  illustrate  both  reliance  and  trust  in  public  health  can   falter  –  for  example  a  citizen  who  feels  that  current  water  filtration  systems  are  inadequate  and   that  regulatory  oversight  has  been  corrupted  by  conflicts  of  interest.    In  such  an  instance,   citizens  may  feel  that  public  health  cannot  be  relied  upon  and  cannot  be  trusted.   For  those  implementing  public  health  policy  and  interventions,  it  may  be  the  case  that   establishing  reliability  is  sufficient  for  obtaining  the  majority  of  public  cooperation.    That  this   more  minimal  requirement  can  be  so  successful  is  at  the  root  of  a  great  deal  of  public  health   professional  frustration;  reliability  often  goes  unrecognized,  and  unappreciated,  precisely   because  a  high  degree  of  it  can  coincide  with  obliviousness  to  the  efforts  of  those  who  ensure   consistency.    Reliability,  at  its  best  and  most  enduring,  can  be  taken  for  granted.    But  as  much   as  we  might  think  improved  awareness  and  appreciation  for  public  health  may  be  necessary   and  desirable  in  order  to  sustain  public  health  investment,  for  a  great  deal  of  public  health   interventions  reliability  may  be  a  desirable  relationship  to  maintain  in  public  health  matters.  A   great  deal  of  prevention  results  in  reliance  on  healthy  lives  that  are  often  only  comprehensible   as  benefits  in  contrast  to  what  could  have  been  otherwise.    Without  a  counterfactual   perspective,  a  healthy  life  is  not  experienced  as  the  absence  of  an  illness,  disability,  or  death.     And,  indeed,  while  we  might  desire  for  the  sake  of  public  health  maintenance  that  citizens  be   more  aware  of  the  importance  of  public  health  efforts,  a  relationship  of  reliance  on  public   health  is  not  only  an  accurate  depiction  of  current  states  of  affairs  between  professionals  and       67     members  of  the  public,  it  may  be  a  relationship  to  strive  for,  despite  such  potential  drawbacks.     Since  one  can  also  rely  on  consistency  that  one  fully  understands  as  being  hard-­‐fought  for  and   requiring  maintenance,  it  is  only  the  case  that  reliance  and  blindness  to  public  health  are   contingently  connected.    Trust,  as  I  will  argue,  requires  a  great  deal  more  effort  on  the  part  of   public  health  professionals  to  establish  and  on  the  part  of  citizens  to  extend.    Thus,  before   claiming  that  public  health  professionals  ought  to  aim  to  increase  public  trust,  one  might   wonder  whether  all  that  is  needed  is  to  foster  public  reliance.     2.5  When  reliance  is  not  enough    In  her  recent  work,  Onora  O’neil  notes  three  important  reasons  why  trust  is  an  essential   part  of  public  policy,  even  if  difficult  to  attain.  Relationships  of  trust  cannot  be  replaced  by   policy  and  regulation  alone  for  three  reasons:    first,  ethical  principles  underdetermine  behavior;   second,  accountability  procedures  may  ensure  reliability  of  behavior,  but  not  trustworthiness,   and  third,  such  procedures  cannot  eliminate  trust,  but  rather  shift  the  object  of  trust  from   82 some  agents  to  those  in  charge  of  ensuring  and  monitoring  compliance.    In  what  follows,  I   expand  on  each  of  these  points  in  the  context  of  public  health  professionalism.     First,  principles,  like  many  normative  commitments,  are  general  and  require   interpretation  and  implementation  into  practicable  courses  of  action.    Even  if  a  commitment  to   83 a  principle  of  trustworthiness  demands  that  one  reject  deception  and  coercion,  putting  such   principles  into  practice  requires  discernment  and  experience.        Because  it  is  often  not  possible                                                                                                                           82  Onora  O’Neill,  Autonomy  and  Trust  in  Bioethics  (Cambridge:  Cambridge  University  Press,   2002).,  Chapter  6.   83  Ibid.       68     to  delimit  the  scope  and  priorities  that  accompany  a  particular  professional’s  set  of  obligations,   the  general  principles  that  require  and  proscribe  action  cannot  be  explicit  enough  to  eradicate   the  elements  of  personal  judgment  required  in  professional  fields.    As  a  result,  professional   discretion  is  an  ineliminable  part  of  public  health.    As  Annette  Baier  observed,  “the  more   extensive  the  discretionary  powers  of  the  trusted,  the  less  clear-­‐cut  will  be  the  answer  to  the   84 question  of  when  trust  is  disappointed.”    In  other  words,  the  more  discretion  citizens  give  to   public  health  professionals  to  pursue  the  public  good,  the  more  they  expose  themselves  to   disappointment  and  betrayal.      This  does  not  mean  that  general  ethical  principles  do  not  have   their  place,  or  that  regulation  cannot  help  ensure  a  greater  consistency  of  professional  conduct.     But,  in  matters  of  professional  policy  implementation,  there  are  limits  on  the  practicability  of   policies.    In  the  end,  good  judgment  mediated  by  excellence  of  character  will  be  an  essential   part  of  effective  professional  practice.       The  second  reason  trust  may  be  needed  in  public  health  is  that  reliability  may  simply  be   insufficient  reassurance  when  certain  kinds  of  confidence  in  public  health  falter.    It  is  easy  to   confuse  professional  compliance  with  policy  recommendations  with  trustworthiness.    When   incorrectly  implemented,  regulations  are  rightly  seen  as  impediments  to  achieving  professional   aims,  and  may  even  undermine  professional  standards  of  right  conduct.    For  example,   regulations  protecting  patient  confidentiality  can  be  interpreted  too  rigidly,  blocking  legitimate   85 attempts  by  epidemiologists  to  gather  health  information  that  serves  the  public  good.     Alternatively,  incentives  lined  up  to  provide  additional  motivation  for  right  conduct  can  end  up                                                                                                                           84  Baier,  “Trust  and  Antitrust,”  238.   85  Amy  Iversen  et  al.,  “Consent,  Confidentiality,  and  the  Data  Protection  Act,”  British  Medical   Journal  332,  no.  7534  (2006):  165  –9.       69     motivating  counterproductive  adversarial  behavior.  Finally,  regulatory  oversight  schemes  can   ensure  that  professionals  desire  to  comply  in  order  to  achieve  promotion  or  avoid  censure.     Such  motives,  however,  do  not  guarantee  that  professionals  will  be  moved  by  the  vulnerability   of  the  public’s  dependence  on  the  profession  –  the  key  feature  of  trust.    Regulatory  oversight  at   its  best  requires  that  professionals  behave  with  regularity.    But  because  public  health  requires   greater  flexibility,  there  will  be  times  when  the  public  will  need  to  depend  upon  the  properly   exercised  discretion  of  professionals.    This  explains  the  extension  of  public  wariness  to  not   merely  the  functioning  or  consistency  of  public  health  behaviors,  but  to  the  intensions  that   motivate  professionals  themselves.       Lastly,  the  third  reason  that  regulatory  processes  often  fail  to  advance  public   cooperation  is  that,  as  much  as  reliability  can  complement  trustworthiness,  it  cannot  replace  it.     Rather,  procedures  that  ensure  compliance  and  openness  merely  shift  the  locus  of  trust  to  the   auditors  and  regulators  in  charge  of  the  system.    “Standard  political  processes  of  reform,   regulation  and  scrutiny  cannot  provide  a  remedy  to  the  loss  of  trust  because  they  too  are   86 mistrusted.”    This  is  often  the  case  because  regulation,  even  when  effective,  can  increase   complexity  and  obscurity.    Paradoxically,  the  very  regulatory  mechanism  put  into  place  to   improve  accountability  and  transparency  may  simultaneously  increase  public  perceptions  that   policies  are  precisely  the  opposite.  The  conclusion  that  we  are  regrettably  forced  to   acknowledge  is  that  systems  that  enforce  compliance,  even  when  not  overly  burdensome  and   directed  to  ensure  right  conduct,  offer  no  guarantee  to  cultivate  public  confidence.    In  addition,   having  such  systems  in  place  can  signal  to  the  public  that  the  professionals  in  question  need                                                                                                                           86  O’Neill,  "Autonomy  and  Trust  in  Bioethics,"  138.  Original  emphasis.       70     such  oversight  precisely  because  they  (or  a  significant  majority  among  them)  cannot  be  trusted.   In  the  worst  of  cases,  regulatory  oversight  can  unintentionally  result  in  replacing  the  standard   of  conduct  associated  with  trustworthiness,  genuine  concern  for  human  wellbeing,  and   87 professional  responsibility  with  the  lower  bars  of  compliance  and  adherence.         Reliance,  like  deference,  is  one  possible  response  to  public  health  practices.    At  times,   however,  the  public  requires  knowledge  and  evidence  of  the  intentions  of  those  who  lie  behind   the  policies.  The  limits  to  ensuring  reliability  outlined  here  reveal  that  trust  is  sometimes   necessary  to  public  health  practice.  This  does  not  mean  that  oversight  and  resulting  reliability   are  not  important  –  merely  that  they  are  sometimes  insufficient.      Establishing  that  there  are   conditions  under  which  trust  will  be  required  in  public  health  gives  some  backing  to  the  calls  to   establish  such  relationships.    In  the  next  section,  I  turn  to  conceptual  and  empirical  work  done   on  trust  to  further  illuminate  what  it  might  mean  to  heed  such  calls.   One  might  object  at  this  point  that  mere  reliance  on  public  health  measures  is   impossible  –  there  appears  to  always  be  underlying  assumptions  regarding,  at  the  very  least,   benign  motives  on  the  part  of  public  health  professionals.    The  answer  to  this  objection   depends  very  much  on  which  account  of  trust  one  endorses.    I  will  articulate  these  differences   in  greater  detail  in  Section  2.6.    For  now,  let  us  consider  an  example  that  might  help  illustrate   how  various  accounts  differentiate  mere  reliance  from  trust.    In  the  case  of  food  enrichment,   some  might  say  the  public  relies  on  the  food  production  process  to  add  substances  that  fulfill   nutritional  needs  and  simultaneously  trusts  the  motives  of  food  manufacturers  to  produce  a   quality  product.    For  those  who  envision  this  wider  notion  of  trust,  having  any  vested  interest  in                                                                                                                           87  Ibid.,  chap.  7.       71     the  welfare  of  another  may  be  enough  to  constitute  the  right  kind  of  motivation  characteristic   88 of  trusting  relationships.    In  other  words,  once  humans  are  involved,  the  question  of  their   motives  is  always  a  matter  of  trust,  distrust,  or  one  of  the  other  variants.       However,  others  might  set  the  bar  higher,  saying  that  even  highly  abiding  benevolent   motives  are  not  enough  –  that  trust  is  founded  in  another’s  commitment  to  acting  on  the   89 notion  that  someone  else  is  counting  on  them.    On  this  view,  merely  wishing  everyone  well   (or  no  harm)  is  not  enough;  rather,  one  must  take  the  possibility  of  disappointing  others  as   significant  reason  for  action.    This  second  conception  of  trust  drastically  shifts  the  way  we   understand  the  distinction  between  mere  reliance  and  trust.    Under  this  second  view,  if  our   food  producer  complies  with  regulations  because  she  fears  she  might  otherwise  have  to  pay  a   fine,  this  is  merely  public  reliance  on  motives  that  mimic  the  actions  of  the  trustworthy.    In   other  words,  conditions  can  be  properly  aligned  such  that  agents  with  great  power  over  public   health  must  behave  as  if  they  truly  care  about  the  dependency  of  others  on  their  action.    But  if   such  agents  do  not  in  fact  care,  then  this  regularity  of  behavior  more  closely  resembles  the   reliability  of  inanimate  objects  and  processes.    My  argument  here  is  that  human  behavior,   under  the  proper  conditions,  can  be  remarkably  similar  to  the  activities  of  a  train  system  set  up   to  run  punctually.    Put  in  the  right  starting  conditions,  and  the  train  will  arrive  on  time.    Put  in   the  right  incentives,  and  agents  will  behave  rightly.    According  to  this  view,  however,  we  should   not  consider  the  fact  that  we  count  on  incentives  to  motivate  others  the  same  as  trusting                                                                                                                           88  Russell  Hardin,  Trust  and  Trustworthiness  (New  York:  Russell  Sage  Foundation,  2002),  90.  For   Hardin,  trust  is  belief  that  another  has  reason  to  act  in  your  interests,  whereas  distrust  is   believing  another  has  reason  to  not  to  act  in  your  interest;  the  middle  ground  is  wariness,  when   an  agent  may  not  be  convinced  either  way  regarding  the  motives  of  another.   89  Karen  Jones,  “Trust  as  an  Affective  Attitude,”  Ethics  107,  no.  1  (1996):  4–25.       72     others.    Rather,  we  should  consider  this  a  case  in  which  the  public  merely  relies  on  both  food   90 production  and  the  self-­‐interest  of  producers.       Reliance  on  public  health  professionals  and  practices  is  a  laudable  public  health   relationship  to  aim  for.    I  have  argued  in  this  section,  however,  that  at  times  in  developing  and   implementing  public  health  policy  it  may  not  be  enough.  That  human  behavior  is  so  unlikely  to   become  so  regular,  or  that  we  may  have  good  reason  to  desire  greater  flexibility  than   regulations  can  assure  (e.g.,  allowing  for  the  use  of  discretion),  leads  us  to  the  conclusion  that   trust  will  play  a  significant  role  in  public  health.  At  such  times,  communities  may  want  to  know   that  their  dependence  on  public  health  professionals  is  a  motivating  force  influencing  the   design  and  application  of  public  health  interventions.      Such  motives  are  the  central  feature  of   the  trustworthy,  which  I  address  in  the  next  section.     2.6  Interpersonal  Trust  and  Trustworthiness   In  Section  2.4  I  outlined  the  general  agreement  amongst  theorists  regarding  the  nature   of  relationships  of  trust,  especially  its  distinction  from  reliance.  In  establishing  that  trust  is  a   relationship  that  is  sometimes  ideal  in  public  health,  it  will  be  helpful  to  delineate  a  matter  of   contention  amongst  such  theorists,  i.e.,  what  makes  someone  trustworthy.    In  this  section,  I   outline  the  two  main  competing  understandings  of  interpersonal  trust  and  their  corollary                                                                                                                           90  O’Neill,  "Autonomy  and  Trust  in  Bioethics.”    O’neill’s  contends,  however,  that  reliance  often   only  removes  trust  to  a  farther  distance  does  imply  that  the  public  trusts  someone  when   evaluating  public  health  policy.    Thus,  in  our  food  enrichment  case,  trust  is  redirected  from  food   manufacturers  to  regulatory  agencies  or,  even  farther,  to  those  who  oversee  the  regulators.     Whether  this  implies  that  there  are  no  instances  of  mere  reliance  depends  on  how  far  out  in   the  policy  framework  one  goes  to  find  who  is,  ultimately,  trusted.    If  one  truncates  the  field  of   vision,  it  is  possible  to  describe  all  that  is  going  on  within  that  frame  in  terms  of  reliance.       73     notions  of  trustworthiness,  including  Russell  Hardin’s  notion  of  trust  as  encapsulated-­‐interest,   and  affective  notions  of  trust  as  goodwill,  or  optimism  about  goodwill.    I  defend  the  affective   notions  of  trust  and  a  virtue  approach  to  trustworthiness.       2.6.1  The  Encapsulated-­‐Interest  Account   Russell  Hardin’s  notion  of  encapsulated-­‐interest  is  perhaps  the  most  well-­‐known  and   utilized  conceptualization  of  trust.    Let  us  recall  that  the  distinction  between  reliance  and  trust   is  that  the  trusted  party  finds  the  dependence  of  another  a  motivating  reason  for  action.     According  to  Hardin,  what  matters  for  trust  is  “that  you  deliberately  take  my  interests  into   91 account  because  they  are  mine.”  In  public  health,  there  may  be  many  reasons  for   professionals  to  consider  the  interests  of  citizens  (as  a  group,  or  as  individuals),  and  Hardin’s   analysis  attempts  to  cast  a  wide  net  to  capture  all  such  reasons.    He  identifies  encapsulated-­‐ interest  as  coinciding  with,  or  grouped  under,  a  more  general  desire  to  sustain  a  continuing   92 relationship.  There  can  be  many  reasons  for  desiring  a  relationship  to  continue,  and  Hardin   seeks  an  account  of  trust  that  can  accommodate  all  such  motives  for  trust,  without  being  so   broad  as  to  capture  untrustworthy  motives.    With  this  in  mind,  he  rules  out  merely  coincidental   interests.  For  example,  a  public  health  professional  may  be  motivated  to  stem  the  tide  of  an   epidemic  in  order  to  limit  her  own  exposure.    While  this  may  make  her  motivated  to  perform   well,  common  or  shared  interests  alone  do  not  capture  the  nature  of  a  trusting  relationship.     Rather,  the  professional  must  have  genuine  reason  for  taking  on  board  the  interests  of  others.                                                                                                                             91  Hardin,  "Trust  and  Trustworthiness,"  11.   92  Hardin,  "Trust  and  Trustworthiness,"  1.       74     Such  reasons  might  include  a  concern  for  reputation,  economic  incentive,  a  desire  for   promotion,  or  even  personal  affection  or  particularity.       Hardin’s  account  is  grounded  in  rational  choice  theory.    For  trusting  parties  to  develop   knowledge  of  another’s  potential  for  encapsulating  her  interests,  she  must  engage  in  a  series  of   iterated  encounters  that  confirm  or  refute  her  belief  in  the  other’s  possession  of  appropriate   motives  for  grounding  trust.    Hardin  wishes  to  encompass  the  range  of  relationships  that  we   can  allow  constitute  trust,  drawing  us  out  of  the  classic  “thick”  relationships  of  mutual,   enduring,  and  wide-­‐ranging  trust. 93    Rather,  Hardin  contends  that  thick  relationships  are   merely  an  excellent  way  to  obtain  knowledge  about  the  capacity  and  tendency  of  another  to   encapsulate  one’s  interests.    Rather  than  assuming  that  trust  can  only  obtain  in  such   relationships,  Hardin’s  encapsulated-­‐interest  account  allows  for  a  wider  range  of  trusting   relationships,  and  especially  helps  to  challenge  our  predilection  for  characterizing  trust  as   mutual.    Such  an  account  may  prove  especially  helpful  for  public  health  professionals,  where   unidirectional  trust  may  especially  characterize  initial  or  fleeting  public  health  relationships,   especially  in  public  health  emergencies.   For  Hardin,  drawing  a  wider  boundary  for  trust  in  part  derives  from  a  desire  to   distinguish  relationships  of  trust  from  the  traits  that  inspire  trust,  or  trustworthiness.      Too   often,  Hardin  claims,  trust  is  assumed  to  be  something  desirable,  a  moral  good,  whereas  Hardin   thinks  an  account  of  trust  ought  to  make  room  for  the  less  laudable  instances  of  the   relationship.    Hardin  identifies  his  highly  rationalistic  account  as  potentially  consistent  with   Aristotle’s,  noting  particularly  the  connection  between  the  ancient  usage  of  the  term  pistis  for                                                                                                                           93  Ibid.       75     trust,  confidence,  and  belief.    Hardin  interprets  this  as  evidence  that  an  Aristotelian  account  of   94 trust  would  be  cognitivist  in  nature.  This  is  consistent  with  Hardin’s  determination  to  develop   not  only  a  cognitive  account  of  trust,  but  also  one  that  eschews  moralization  of  trust.      Hardin’s  encapsulated-­‐interest  account  is  broad  enough  to  allow  for  a  wide  variety  of   motives  within  the  trusted,  including  motives  we  do  not  normally  admire.    Thus,  Hardin’s   quintessential  example  of  trust  is  drawn  from  literature,  and  Dostoyevsky’s  The  Brother’s   Karamazov  is  meant  to  offer  us  an  illustration  of  the  wide  range  of  contexts  for  trust.    Hardin   offers  up  the  story  of  a  lieutenant  colonel  who  embezzles  funds  in  exchange  for  profit  ensured   by  his  partner  in  crime,  the  merchant  Trifonov.    Upon  the  eve  of  discovering  impending   exposure,  Trifonov’s  motive  for  a  continued  relationship  has  been  undermined,  and  he  betrays   the  lieutenant  colonel  by  refusing  to  return  the  most  recently  “borrowed”  sum  of  public  funds   and  denying  any  previous  relationship.    Hardin  wishes  to  develop  an  account  of  trust  that   allows  us  to  understand  what  occurs  between  these  two  characters  as  a  legitimate  instance  of   trust,  not  misplaced  trust,  or  unjustified  trust.    And  indeed,  on  Hardin’s  account,  this  follows.     For  prior  to  discovery,  both  the  lieutenant  colonel  and  Trifonov  benefit  from  their  illicit   cooperation,  and  have  reason  to  continue  their  relationship.    Trifonov  has  reason  to  maintain  a   good  reputation  with  the  lieutenant  colonel  in  order  to  profit  from  future  transactions,  and  to   avoid  reprisals  from  a  powerful  man.    The  lieutenant  can  rely  on  their  mutual  interests  to   motivate  Trifonov  to  continue  returning  his  periodic  installments,  with  added  interest.  In  other   words,  Hardin  wishes  to  establish  an  account  of  trust  that  allows,  if  not  for  honor  among   thieves,  then  trust  between  them  –  even  if  it  is  a  fragile  or  contingent  trust.    According  to                                                                                                                           94  Ibid.,  Chap.  1,  note  7.       76     Hardin’s  view,  a  normative  account  of  trustworthiness,  one  that  requires  ethical  motives  for   trust  and  trustworthy  behavior,  would  reject  such  an  instance  as  one  of  genuine  trust.    Or,  it   would  try  to  project  more  noble  motives  onto  the  agents  in  question,  which  Hardin  interprets   as  unnecessary.   There  are  three  reasons  to  think  that  the  encapsulated-­‐interest  account  of   trustworthiness  is  inadequate,  especially  within  a  virtue  ethics  approach.    First,  interpretation   of  Aristotelian  rationality  is  incorrect.    Virtues  are  more  commonly  understood  to  include  both   95 cognitive  and  affective  aspects,  including  emotions  and  emotional  sensitivity.    Second,  the   encapsulated  interest  account  tries  to  eradicate  moral  motives,  and  indeed  all  aspects  of   character,  explaining  relationships  of  trust  as  existing  due  to  the  mutual  self-­‐interest  of  those   involved.  As  such,  Hardin’s  view  implies,  contrary  to  virtue  ethics,  “that  ‘being  moral’  does  not   96 count  among  my  interests”  (see  Chapter  1).    These  first  two  reasons  are  not  a  points  against   an  encapsulated-­‐interest  account  generally,  but  do  give  us  reason  to  reject  its  place  in  a  virtue   approach  to  public  health  ethics.       However,  one  reason  to  think  that  Hardin’s  account  of  trust  is  not  adequate  is  that   character  is  sometimes  necessary  to  explain  some  instances  of  trust.  Thomas  Simpson  gives  a   more  extensive  defense  of  this  view,  but  in  the  context  of  public  health  I  will  merely  point  to   97 one  of  his  main  contentions.    According  to  Simpson,  “high  stakes”  scenarios  provide   counterexamples  to  Hardin’s  account  of  trust  because  on  his  view,  it  would  be  irrational  for                                                                                                                           95  Nancy  Nyquist  Potter,  How  Can  I  Be  Trusted?    A  Virtue  Theory  of  Trustworthiness  (Oxford:   Rowman  &  Littlefield,  2002),  14.   96  Thomas  W.  Simpson.  “Trustworthiness  and  Moral  Character,”  Ethical  Theory  and  Moral   Practice  (2012):  1-­‐15  DOI  10.1007/s10677-­‐012-­‐9373-­‐4.   97  Simpson,  “Trustworthiness  and  Moral  Character.”         77     anyone  to  trust  in  such  cases  –  those  in  power  might  be  too  tempted  to  feel  any  compulsion  to   continue  the  relationship.    However,  such  relationships  are  often  at  play  in  public  policy   matters,  or  whenever  someone  gives  another  person  great  power  from  which  she  might  gain  a   great  deal  without  having  to  fulfill  trust.    In  other  words,  there  are  times  when  trusting  grants   another  person  such  powers  that  enable  them  to  take  advantage  of  us,  and  to  accomplish  a   great  deal  that  may  be  of  personal  worth  to  the  trusted.    Arguably,  public  health  powers  are   precisely  the  kind  that  Simpson  has  in  mind.    Given  what  public  health  professionals  can  do   with  the  capacity  to  perform  surveillance,  muster  public  resources,  and  compel  citizens,  on   Hardin’s  account  it  would  be  irrational  to  risk  the  possibility  that  professionals  would  be   tempted  to  use  such  extensive  powers.    The  potential  for  such  abuse  is  not  out  of  the  realm  of   imagination,  as  exhibited  by  Soviet  public  health  practices,  and  expanding  public  health  powers   98 in  response  to  acts  of  terrorism  that  arguably  create  the  potential  for  abuse.    Simpson   contends  that  when  self-­‐interest  (in  Hardin’s  sense)  cannot  explain  all  instances  of  trust,  then   another  aspect  of  human  psychology  must.    He  concludes  the  stable  character  traits  –  such  as   the  virtues  –  can  provide  the  missing  element.     2.6.2  Affective  Accounts  of  Trust  and  Trustworthiness   On  an  alternative  account  of  trust,  Annette  Baier  and  Karen  Jones  articulate  a  view  that   proposes  that  trust  is  not  merely  a  matter  of  beliefs  about  another’s  motives,  but  also  a  matter   of  trusting  attitudes.    On  Baier’s  goodwill  account,  trust  is  a  relationship  that  makes  one                                                                                                                           98  Ronald  Bayer  and  James  Colgrove,  “Public  Health  Vs.  Civil  Liberties,”  Science  297,  no.  5588,   New  Series  (2002):  1811.       78     vulnerable  to  betrayal;  therefore,  what  we  seek  in  those  we  trust  is  evidence  of  motives  to   99 handle  that  vulnerability  carefully.    As  Baier  observes,  an  account  of  trust  acknowledges  that   relationships  of  trust  are  always  marked  by  inequality  –  one  partner  has  the  power  to  betray   the  other.    For  Baier,  trust  provides  us  with  “a  morality  to  guide  us  in  our  dealings  with  those   who  either  cannot  or  should  not  achieve  equality  of  power.” 100    Such  an  observation  is  highly   pertinent  to  public  health  practice,  where  members  of  the  public  are  inherently  in  positions  of   lesser  power  than  professionals  for  two  distinct  reasons:  first,  due  to  a  lack  of  epidemiological   knowledge  and  experience  that  might  help  them  form  their  own  independent  views  of  public   health  policy  and  practice,  and  second,  as  dependent  parties,  as  trusters  in  a  relationship  of   trust,  citizens  make  themselves  vulnerable  to  the  possibility  of  betrayal  in  the  form  of  abuse,   neglect,  and  abdication  of  public  health  professional  discretion.    I  will  discuss  in  greater  detail  in   Chapter  3  the  nature  of  public  health  risk,  but  it  is  sufficient  for  my  purposes  here  to  identify   the  trusting  relationship  itself  as  a  matter  of  vulnerability  for  members  of  the  public.     Baier’s  account  departs  from  Hardin’s  in  that  she  adds  attitudes  to  the  beliefs  that   ground  trust.  It  is  not  enough  that  a  citizen  believes  that  the  public  health  professional  has  her   interests  in  mind.    Such  expectations  are  also  accompanied  by  a  hopefulness  or  optimism  about   public  health  motives.    Such  an  account  does  not  rule  out  fragile  or  tentative  relationships  of   trust  –  we  can,  after  all,  be  cautiously  optimistic.  Similarly,  Karen  Jones  wishes  to  further   articulate  what  kind  of  attitude  is  at  play  in  relationships  of  trust,  and  claims  that  it  is  not   merely  some  kind  of  hopeful  attitude  combined  with  beliefs  about  the  goodwill  of  another,  but                                                                                                                           99  Baier,  “Trust  and  Antitrust.”   100Ibid.,  249.       79     specifically  optimism  about  the  goodwill  of  another.    For  Jones,  a  consistent  attitude  of  goodwill   101 may  simply  reveal  beneficence,  not  trustworthiness.    What  such  affective,  or  non-­‐cognitive,   depictions  of  trust  offer  are  an  account  of  the  ways  in  which  attitude-­‐belief  complexes  structure   the  perceptions  and  behaviors  of  those  who  trust:  “…the  attitude  of  optimism  constitutive  of   trust  is  a  distinctive  way  of  seeing  another…The  cognitive  set  constitutive  of  trust  restricts  the   interpretations  of  another’s  behavior  an  motives  that  we  consider.” 102  While  beliefs  can  also   structure  how  we  perceive  the  world,  the  addition  of  emotions  and  attitudes  has  explanatory   power  in  helping  to  establish  why  such  beliefs  can  be,  as  is  often  the  case  in  matters  of  trust,   evidence-­‐resistant.    This  is  especially  true  in  “thick”  relationships  of  trust,  where  we  might  rule   out  condemnatory  evidence  precisely  because  it  is  inconsistent  with  our  experience  and   103 knowledge  of  the  trusted  party.    Thus,  in  a  long-­‐lasting  relationship  with  a  clinician,  one   patient  may  disregard  the  complaints  of  another  patient,  considering  them  to  be  anomalous   with  respect  to  her  own  judgments  of  the  physician’s  nature  and  intentions.    Such  evidence-­‐ resistance  may  be  unlikely  in  the  more  fleeting  personal  encounters  citizens  have  with  public   health  personnel.    And  yet  the  contrary  case  may  be  highly  relevant;  attitudes  of  distrust  may   frame  experiences  so  as  to  confirm  the  suspicions  and  wariness  of  those  who  are  hesitant  to   trust.    This  is  highly  pertinent  in  public  health,  where  distrust  of  government  generally  impedes   upon  trust  of  public  health  as  a  distinct  practice.    Thus,  affective  accounts  offer  us  some  vision   of  the  ways  in  which  relationships  are  not  a  matter  of  evidence  and  belief  alone,  but  also  of                                                                                                                           101  Jones,  “Trust  as  an  Affective  Attitude.”   102  Ibid.,  11.   103  Judith  Baker,  “Trust  and  Rationality,”  Pacific  Philosophical  Quarterly  68  (1987):  1–13.       80     ongoing  perceptions  that  include  both  beliefs  and  attitudes,  which  simultaneously  influence   one’s  understanding  and  perspective  on  potential  relationships.     The  importance  of  public  perceptions  cannot  be  overemphasized,  as  they  explain  the   disconnect  between  being  trustworthy  and  being  trusted.  While  trustworthiness  provides  a   justified  foundation  for  trust,  this  does  not  always  mean  that  agents  will  perceive  the  evidence   that  provides  the  justification.    Because  we  do  not  always  have  access  to  another’s  motives,  we   may  be  unable  to  assess  whether  they  are  trustworthy.      I  mentioned  this  possibility  in  the  last   section  –  while  regulatory  oversight  may  sometimes  fall  short  by  encouraging  compliance  in   place  of  trustworthiness,  it  nevertheless  can  also  provide  the  context  for  trustworthiness  to   flourish  by  emphasizing  the  importance  of  accountability  and  the  protective  purposes  that   initiate  the  creation  of  such  systems.    But  because  such  systems  are  so  complex  and  distant,   they  may  paradoxically  decrease  trust  by  obscuring  access  to  the  motives  of  public  health   professionals.    This  is  known  as  the  Cassandra  problem,  named  for  the  greek  mythical  woman   104 who  had  the  gift  of  foresight,  but  was  cursed  to  have  no  one  believe  her.    One  frustrating   implication  for  those  in  public  health  is  that  they  can  be  extraordinarily  trustworthy,  and   nevertheless  not  trusted.    But,  as  Aristotle  notes,  it  is  the  work  of  civil  servants  to  provide   assurances  nonetheless:  “the  task  of  the  legislator  is  to  manage  perceived  as  well  as  real   injustices  and  hence  to  strengthen  the  civic  bond.” 105                                                                                                                           104  O’Neill,  "Autonomy  and  Trust  in  Bioethics,"  chap.  7.   105  Schwarzenbach,  “On  Civic  Friendship,”  106.  Thus  Aristotle  conceives  of  cultivating  civic   friendship  as  a  central  purpose  of  public  professionals.    I  argued  in  Chapter  1  that  this  aspect  of   public  health  work  can  increase  public  cooperation  with  interventions.  The  possibility  of  distrust   despite  what  professionals  do  calls  our  attention  to  a  need  to  consider  the  limits  to  public   health  professionals’  role  in  creating  community.       81     Nancy  Nyquist-­‐Potter’s  virtue  account  of  trustworthiness  corresponds  well  to  the   affective  approach  to  trust,  as  it  provides  a  character  foundation  for  the  expression  of  goodwill.     According  to  Nyquist-­‐Potter,  trustworthiness  is  the  trait  that  ensure  that  “one  can  be  counted,   on  as  a  matter  of  the  sort  of  person  he  or  she  is,  to  take  care  of  those  things  that  other  entrust   to  one  and…whose  ways  of  caring  are  neither  excessive  nor  deficient.” 106    Nyquist-­‐Potter’s   approach  to  trustworthiness  places  the  vulnerability  of  the  trusting  party  at  the  center  of  the   relationship  of  trust.    Trustworthy  individuals  are  those  who  consistently  respond  to  that   vulnerability  appropriately,  including  understanding  that  burden  of  proof  lies  on  those  in  a   position  of  relative  power.    In  placing  interdependency  at  the  center  of  public  health   relationships,  a  virtue  approach  fits  well  with  the  need  to  develop  a  relational  approach  to   107 public  health.    For  public  health,  the  distance  between  cultivating  trustworthiness  and  establishing   trust  is  integral  to  public  health  communication  and  interaction.    The  most  frustrating  aspect  of   trust  is  that  expectations  are  built  on  perceptions  of  trustworthiness,  which  means  that  public   distrust  can  be  unfounded,  and  the  contrary,  that  public  trust  can  be  misplaced.    Nyquist-­‐ Potter’s  account  of  the  virtue  of  trustworthiness  attempts  to  bridge  this  divide  by  establishing  a   need  for  the  trustworthy  to  signal  trustworthiness,  or  provide  evidence  that  professionals  or   programs  are  designed  with  such  vulnerability  in  mind.    To  provide  assurance  of   trustworthiness  is  one  of  the  main  indicators  of  the  trustworthy,  as  the  tendency  to  distrust  or   be  wary  of  trust  is  a  defense  mechanism  employed  by  the  more  vulnerable  party  in                                                                                                                           106  Nyquist  Potter,  "How  Can  I  Be  Trusted?,"  16.   107  Francoise  Baylis,  Kenny  Kenny,  and  Susan  Sherwin,  “A  Relational  Account  of  Public  Health   Ethics,”  Public  Health  Ethics  (2008):  1–14.       82     relationships  of  trust.    It  is  therefore  more  incumbent  on  those  with  greater  power  in  public   health  relationships  to  bear  the  burden  of  establishing  trustworthiness,  even  when  distrust  or  a   hesitancy  to  trust  is  unfounded. 108  The  virtue  account  of  trustworthiness  also  acknowledges   that,  paradoxically,  sometimes  breaking  a  trust  is  the  most  trustworthy  thing  to  do.    For   example,  even  justified  quarantine  procedures  in  public  health  may  undermine  public  trust.     Unlike  more  principled  approaches,  however,  the  virtue  approach  can  accommodate  the  moral   remainder  of  such  a  decision.  The  trustworthy  person  will  recognize  that  in  the  aftermath  of   broken  trust,  the  proper  response  is  to  make  amends,  even  if  betrayal  was  necessary  in  the   moment.   109     It  is  easy  to  conflate  the  difference  between  the  relationship  of  trust  and  the  features   that  we  believe  ought  to  inspire  or  provide  a  foundation  for  such  relationships.  In  public  health,   trust  often  receives  attention  when  it  is  deemed  essential  for  public  safety  or  critical  to  the   success  of  a  particular  intervention.    And  while  a  great  deal  of  the  work  done  to  suggest  greater   transparency,  reciprocity,  and  minimal  intrusiveness  on  the  part  of  public  health  policies  may   inspire  greater  trust  in  the  midst  of  a  public  health  crisis,  it  is  likely  that  relationships  of  trust   110 are  established  well  before  the  onset  of  an  emergency.  Additionally,  emphasis  on  building   trust  draws  attention  to  the  importance  of  how  to  respond  to  perceived  and  real  public  health   failures.    As  this  analysis  shows,  such  failures  will  not  only  disappoint,  but  also  be  publicly   understood  as  instances  of  betrayal.    On  this  account,  unfulfilled  trust  provides  confirmation  to   existing  skeptics,  and  new  evidence  of  untrustworthiness  to  those  who  were  previously                                                                                                                           108  Nyquist  Potter,  "How  Can  I  Be  Trusted?,"  Chapter  2.   109  Ibid.,  chap.  3.   110  Larson  and  Heymann,  “Opportunity  to  Build  Public  Trust.”       83     supportive  of  health  policy.    If  public  health  professionals  wish  to  build  greater  participation,  it   will  be  as  important  to  cultivate  relationships  before  and  after  public  health  disasters,  not  just   during  them.   The  interpersonal  accounts  of  trust  display  limitations  because  in  order  to  account  for   trust  outside  of  relationships  between  two  individuals,  they  must  be  stretched.    As  Annette   Baier  observes  of  her  own  goodwill  account,  it  “ignores  the  network  of  trust,  and  treats  only   two-­‐party  trust  relationships.” 111    Similarly,  Hardin  acknowledges  that  in  trying  to  account  for   trust  outside  of  interpersonal  relationships  “the  central  problem  is  the  translation  of  individual-­‐ 112 to-­‐individual  relationships  to  individual-­‐to-­‐group  or  individual-­‐to-­‐institution  relationships.”   This  “individualist  limitation”  will  be  necessary  to  overcome  for  any  account  of  trust  that  wishes   to  contend  for  a  more  complex  operation  of  trust  in  public  health  practice.     2.7  Group  Trust,  Institutional  Trustworthiness     In  this  section,  I  will  examine  the  notion  of  social  capital,  which  attempts  to  account  for   trust  as  a  social  phenomenon  in  addition  to  outlining  the  ways  in  which  different  interpersonal   accounts  of  trust  can  be  “stretched”  to  account  for  trust  in  society  and  in  institutions.    I  will  also   address  the  difficulties  of  such  strategies,  since  they  risk  anthropomorphism.                                                                                                                                     111  Baier,  “Trust  and  Antitrust,”  258.   112  Hardin,  "Trust  and  Trustworthiness,"  152.       84     2.7.1  Social  Capital   Before  turning  to  how  an  affective  or  encapsulated-­‐interest  conception  of  trust  could  be   extended  outside  the  context  of  interpersonal  relationships,  I  will  first  examine  an  account  of   that  takes  social  networks,  rather  than  individuals,  as  the  basis  for  trust.    Robert  Putnam’s   account  of  trust  in  relation  to  social  capital  offers  an  alternative  to  conceiving  of  trust  on  an   interpersonal  level.    According  to  Putnam,  social  capital  constitutes  “the  features  of  social  life  –   networks,  norms,  and  trust  –  that  enable  participants  to  act  together  more  effectively  to  pursue   113 shared  objectives.”      Thus,  the  connections  one  has  as  a  member  of  society  give  one  social   capital  -­‐  the  ability  to  engage  in  collective  activity,  or  to  harness  the  resources  of  the  others  in   one’s  network.    Drawing  on  the  purported  link  between  cooperation  and  trust,  the  social  capital   account  builds  trust  in  as  what  makes  collective  action  possible,  or  what  lends  individuals  who   have  greater  social  connections  increased  capacity  to  achieve  their  own  ends.   One  benefit  of  the  social  capital  account  is  that  it  attempts  to  account  for  the  historical   and  social  context  in  which  trust  takes  place.    In  this  way,  the  social  capital  account  is  a  part  of   “social  contextualism”  reactions  to  interpersonal  trust  accounts.    The  social  capital  account   attempts  to  understand  changes  in  trust  as  resulting  from  changing  social  conditions,  rather   than  solely  a  matter  of  individual  beliefs  or  attitudes. 114    One  consistent  weakness  of  the   account,  however,  is  that  it  fails  to  articulate  the  relationships  between  social  capital  and  trust,                                                                                                                           113  Robert  Putnam,  “Tuning  In,  Tuning  Out:The  Strange  Disappearance  of  Social  Capital  in   America,”  PS:  Political  Science  &  Politics  28,  no.  4  (1995):  664–665.   114  Roderick  M  Kramer  and  Tom  R.  Tyler,  eds.,  Trust  in  Organizations:  Frontiers  of  Theory  and   Research,  (New  York:  Russell  Sage  Foundation,  1995),  3.       85     leaving  social  capital  both  conceptually  indeterminate  and  methodologically  difficult  to   measure.     2.7.2  Generalized  Trust   What  concerns  Putnam  most  are  declining  levels  of  social  capital  throughout  society.     Relying  on  survey  data  that  inquires  into  people’s  trust  in  society  Putnam  points  to  a  striking   decline  in  social  capital  in  society,  or  what  we  might  otherwise  call  generalized  trust.     Generalized  trust  is  the  degree  to  which  individuals  in  society  are  willing  to  trust  unidentified   others,  or  the  “average”  person.    As  I  mentioned,  the  relationship  between  trust  and  social   capital  is  not  entirely  clear;  in  the  case  of  generalized  trust,  relationships  of  trust  appear  to  be   115 the  most  significant  subjective  ties  that  bind  individuals  into  a  social  network.    Research  on   generalized  trust  bears  significant  importance  to  public  health  practice  since  these  other  levels   or  relationships  of  trust  are  likely  to  mediate  the  relationships  that  can  and  will  be  formed   between  citizens  and  public  health  professionals.   Levels  of  generalized  trust  in  a  society  are  gathered  via  the  American  National  Election   Studies  survey,  which  has  been  performed  for  decades  and  was  originally  designed  to  assess   levels  of  voter  cynicism.    The  questions  asked  as  part  of  the  survey  include  the  following:   1. Do  you  think  most  people  would  try  to  take  advantage  of  you,  or  would  they  try  to   be  fair?                                                                                                                           115  Pamela  Paxton,  “Is  Social  Capital  Declining  in  the  United  States?  A  Multiple  Indicator   Assessment,”  American  Journal  of  Sociology  105,  no.  1  (1999):  88–127.       86     2. Would  you  say  that  most  of  the  time  people  try  to  be  helpful,  or  that  they  are  mostly   looking  out  for  themselves?   3. Generally  speaking,  would  you  say  that  most  people  can  be  trusted,  or  that  you  can’t   be  too  careful  dealing  with  people?   Such  questions  have  been  critiqued  for  being  poorly  worded  and  therefore  not  accurate  at   116 capturing  the  kind  of  trust  in  question.    They  fail  to  acknowledge  the  general  agreement   among  theorists  that  trust  is  a  three-­‐part  relationship,  leaving  it  up  to  those  answering  to  fill  in   the  blanks  regarding  what  the  average  person  is  being  trusted  to  do  or  be.    In  addition,  each   respondent  is  expected  to  provide  her  own  interpretation  of  who  the  phrase  “most  people”   includes.117    However,  the  answers  of  people  over  time  do  appear  to  reflect  declining  levels  of   generalized  trust  (or  perhaps  confidence)  in  society,  not  just  over  time,  but  also  over  successive   generations. 118    Whether  such  data  reveal  a  “crisis”  in  public  trust  is  not  clear,  nor  are  the   subsequent  ramifications  for  public  health.    If  public  health  is  understood  as  “what  we,  as  a   society,  do  collectively  to  assure  the  conditions  in  which  people  can  be  healthy,”  then  it  is  likely   that  decreased  trust  in  society  will  undermine  public  health  efforts  broadly.    However,  given  the   many  bases  on  which  trust  can  be  founded,  it  will  be  difficult  to  tease  out  what  effects   decreasing  levels  of  generalized  trust  have  on  public  health  efforts.    Nonetheless,  determining   causes  of  falling  levels  of  trust  in  society  has  important  ties  to  public  health  practice.                                                                                                                             116  Alan  S.  Miller  and  Tomoko  Mitamura,  “Are  Surveys  on  Trust  Trustworthy?,”  Social   Psychology  Quarterly  66,  no.  1  (2003):  62–70.   117  Peter  Nannestad,  “What  Have  We  Learned  About  Generalized  Trust,  If  Anything?,”  Annual   Review  of  Political  Science  11,  no.  1  (2008):  413–36.   118  Miller  and  Mitamura,  “Are  Surveys  on  Trust  Trustworthy?”;  Robert  V.  Robinson  and  Elton  F.   Jackson,  “Is  Trust  in  Others  Declining  in  America?  An  Age-­‐Period-­‐Cohort  Analysis,”  Social   Science  Research  30,  no.  1  (2001):  117–45.       87           Recent  efforts  in  public  health  ethics  have  sought  for  a  foundation  of  public  health  in   social  justice. 119    Such  efforts,  as  well  as  those  aimed  at  improving  trust  in  public  health,  can  be   bolstered  by  evidence  indicating  links  between  inequality,  civic  participation,  and  trust.  For   example,  Ulsaner  and  Brown  found  that  likely  linkages  include  the  potential  for  inequality  to   influence  lower  levels  of  generalized  trust  by  decreasing  individuals’  optimism  about  the  future,   120 and  by  undermining  a  sense  of  shared  fate  or  communal  wellbeing.      More  recent  research   confirms  that  falling  levels  of  trust  are  causally  linked  to  both  inequality  and  health  outcomes   independently  of  public  expenditures  on  health  care. 121    In  the  context  of  public  health,   disparities  in  health  outcomes  may,  in  a  parallel  fashion,  reduce  individual  optimism  about  the   possibility  for  leading  healthy  lives,  as  well  as  increase  skepticism  that  public  health   interventions  are  likely  to  deliver  benefits  equitably.    However,  the  authors  also  conclude  the   context  of  inequality  and  trust  matters  greatly;  what  holds  for  improving  community   participation  may  not  hold  for  political  participation,  and  it  is  even  more  difficult  to  determine   how  low  generalized  trust  will  affect  more  immediate  instances  of  interpersonal  trust  between   a  single  professional  and  a  citizen.     This  analysis  of  generalized  trust  has  important  implications  for  public  health,  some   conceptual,  some  empirical,  and  some  practical.    First,  if  public  health  professionals  wish  to   increase  public  trust,  it  will  behoove  them  to  consider  the  faults  and  strengths  of  the  various                                                                                                                           119  Madison  Powers  and  Ruth  Faden,  Social  Justice:  The  Moral  Foundations  of  Public  Health   and  Health  Policy,  (Oxford:  Oxford  University  Press,  2008);  Jennifer  Prah  Ruger,  Health  and   Social  Justice,  (Oxford:  Oxford  University  Press,  2012).   120  Eric  Uslaner  and  Mitchell  Brown,  “Inequality,  Trust,  and  Civic  Engagement,”  American   Politics  Research  33,  no.  6  (2005):  868–94.   121  Frank  J.  Elgar,  “Income  Inequality,  Trust,  and  Population  Health  in  33  Countries,”  American   Journal  of  Public  Health  100,  no.  11  (2010):  2311–15.       88     conceptions  of  trust.    Social  capital  may  be  best  suited  to  institutional  or  population  contexts   where  the  trust  in  question  is  that  of  a  group,  not  individuals.    If  one  finds  the  various   conceptions  of  interpersonal  trust  more  appealing,  they  will  need  to  be  adapted  to   accommodate  how  we  come  to  assess  the  “average”  person’s  motives,  whether  they  be   encapsulating  or  of  goodwill.    Second,  whatever  conception  of  trust  one  settles  on,  researchers   will  need  to  reconsider  methods  for  assessing  generalized  trust  and  determine  if  they  are   adequate  –  if  not,  what  we  claim  to  know  of  generalized  trust  so  far  may  be  knowledge  of  some   other  unnamed  social  phenomenon.    Third,  public  health  professionals  need  to  decide  how  and   when  levels  of  generalized  trust  pertain  to  their  work.    In  some  cases,  levels  of  generalized  trust   may  be  irrelevant,  while  in  others,  the  general  level  of  trust  in  society  may  place  limits  on  the   degree  of  trust  public  health  professionals  can  hope  to  inspire.     2.7.3  Trust,  Trustworthiness,  and  Institutions     It  might  appear  that  interpersonal  accounts  of  trust  are  impossible  to  extend  to   institutions.    Indeed,  if  motives  are  required  to  distinguish  trust  from  mere  reliance,  then  it   would  appear  that  since  institutions  are  inanimate,  they  cannot,  by  default,  be  trusted,  only   relied  upon.    However,  it  is  possible  to  pursue  limited  extension  of  both  the  encapsulated-­‐ interest  account  and  the  affective  account  of  trust  in  institutions.  As  Jones  claims,  “insofar  as  it   is  metaphorical  to  attribute  affective  states  to  nonnatural  agents,  the  meaning  (of  trust)  is  not   precisely  the  same...Sometimes  government  policies  can  enact  something  similar  to  the   selective  vision  characteristic  of  trust,  and  the  rationale  for  those  policies  can  duplicate  the       89     122 expectation  constitutive  of  trust.”  Here,  Jones  is  concerned  that  one  might  be  able  say  that   institutions  place  trust  in  others,  whereas  elsewhere,  Hardin  and  Baier  express  concern  about   whether  it  is  reasonable  to  talk  about  trust  in  institutions.    To  do  so,  there  are  two  alternatives:   first,  one  might  develop  an  aggregate  account  of  trust  that  reduces  trust  in  institutions  to  trust   in  professionals  within  those  institutions;  secondly,  one  might  take  a  more  collective  approach   to  trust,  and  extend  to  institutions  the  motives  characteristic  of  trust,  at  least  figuratively,  and   explain  how  this  is  possible.   National  Election  Survey  data  on  trust  in  the  government,  mirroring  that  of  generalized   trust,  reveals  falling  levels  over  time.  As  public  health  professionals  are  also  government   employees,  national  levels  of  trust,  or  distrust,  in  government  will  mediate  interpersonal   relationships  of  trust.    In  addition,  because  encounters  in  institutional  settings  will  not  always   provide  an  opportunity  for  citizens  to  determine  the  intentions  of  individual  professionals,  they   may  use  roles  or  categories  to  fill  in  the  gaps  in  order  to  assess  professional  motivations  for   protecting  civic  vulnerability. 123    Thus,  an  individual’s  trust  in  medical  professionals  will  also   mediate  his  or  her  trust  in  public  health,  as  will  her  trust  of  the  social  groups  associated  with   the  professional  in  question.    In  addition,  institutional  practice  and  cultures  create  a  context  for   interpersonal  forms  of  trust.    According  to  Hardin,  “We  can  build  institutional  devices  that   mimic  the  incentives  of  the  encapsulated-­‐interest  account,  so  that  we  can  relatively  easily  see                                                                                                                           122  Jones,  “Trust  as  an  Affective  Attitude,”  14.   123  Kramer  M.  Roderick  and  Karen  S.  Cook,  eds.,  Trust  and  Distrust  in  Organizations:  Dilemmas   and  Approaches  (New  York:  Russell  Sage  Foundation,  2007).       90     how  to  overcome  problems  of  the  lack  of  trust  in  trustworthiness  in  many  contexts  in  which,  for   example,  ongoing  relationships  cannot  motivate  cooperation.”   124   The  account  that  Hardin  develops  as  the  institutional  corollary  to  encapsulated-­‐interest   account  is  aggregative. 125    However,  “in  principle  at  least,  the  encapsulated-­‐interest   conception  of  trust  can  be  generalized  to  fit  institutions,  although  in  practice  it  might  not   126 generally  fit  because  the  knowledge  and  the  iterated  interaction  conditions  cannot  be  met.”   The  main  challenge  to  this  view  is  that  people  simply  do  not  have  the  knowledge  of  the  motives   of  professionals  within  institutions  that  would  be  necessary  to  form  opinions  of  institutional   trustworthiness.  Thus,  Hardin  is  concerned  that  while  citizens  may  reasonably  be  expected  to   encounter  evidence  of  institutional  reliability,  they  are  unlikely  to  obtain  knowledge  of  any   intentional  design  or  conscious  institutional  effort  to  take  the  interests  of  citizens  directly  into   consideration.      Hardin  also  allows  that  a  less  demanding  account  of  institutional  trust  might   allow  for  citizens  to  trust  in  the  role  held  by  various  professionals,  believing  it  to  ensure  certain   interests  or  motives.  This  role  approach  might  be  interpreted  as  a  kind  of  collective  approach  to   trust  in  that  it  attempts  to  link  trust  in  institutions  to  roles,  structures,  and  policies,  without   reducing  it  to  the  behavior  of  individuals.    Hardin  again  identifies  the  main  obstacle  to  finding   such  role-­‐trust  in  practice:  to  trust  an  institutional  role,  one  would  require  knowledge  of  the                                                                                                                           124  Hardin,  "Trust  and  Trustworthiness,"  52.   125  Ibid.,  Chapter  7.   126  Ibid.,  153.       91     structure  and  incentives  offered  to  those  within  particular  roles.    In  the  case  of  government   127 institutions  like  public  health,  it  is  again  unlikely  many  citizens  will  have  such  knowledge.     Baier’s  affective  account  of  trust  directly  addresses  the  limits  to  her  interpersonal   account  without  directly  addressing  how  trust  in  groups  or  systems  is  possible.    Nevertheless,   she  obliquely  addresses  trust  in  institutions  in  the  context  of  systemic  injustice,  where   members  of  a  group  may  assess  that  structures  in  question  are  systematically  opposed  to  their   own  interests;  “in  such  conditions,  it  may  take  fortitude  to  display  distrust  and  heroism  to   disappoint  the  trust  of  the  powerful.” 128  Baier  warns  institutions  like  public  health,  then,  of   inferring  trust  from  compliance  alone.      A  distrustful  populace  may  act  as  if  they  trust  if  the   penalties  of  distrust  are  too  great.    In  addressing  this  possibility,  she  opens  the  door  to  trust  of   groups  and  institutions,  and  we  might  wonder  how  to  extend  her  affective  account.    To  do  so   would  require  addressing  how  individuals  acquire  understanding  of  institutional  intent,   whether  these  are  interpretations  of  professional  behavior  or  roles,  or  perceptions  of   intentions  embedded  in  the  structures  and  practices  of  institutions  themselves.    Nyquist-­‐ Potter’s  account  adds  to  this,  asserting  that  trust  involves  a  process  of  induction  in  which  trust   can  shift  from  individuals  to  groups  when  institutions  appear  to  endorse  or  condone  abuses  of   trust,  or  protection  of  interests  is  only  extended  to  some  groups  at  the  expense  of  others.   129 The  attribution  of  intention  to  institutions,  or  at  least  the  group  agency  they  may  exhibit   reveals  one  option  for  attributing  the  virtue  of  trustworthiness  to  institutions.    In  addition,   institutions  can  create  the  conditions  for  individual  trustworthiness,  cultivating  the  skills  and                                                                                                                           127  Ibid.,  154.   128  Baier,  “Trust  and  Antitrust,”  259.   129  Nyquist  Potter,  "How  Can  I  Be  Trusted?,"  24.         92     character  traits  necessary  for  professional  capacities  to  build  relationships  of  interpersonal  trust   with  individual  citizens.    Making  the  case  for  the  latter  kind  of  institutional  virtue  is  much  easier   than  the  former  –  trust  that  accrues  to  institutions  as  a  result  of  some  kind  of  aggregation  of   virtue  in  the  individuals  that  comprise  its  members  is  certainly  more  intuitive  than  the  kind  of   virtue  that  can  be  ascribed  distinctly  to  the  institution  independently.       Susan  Goold  claims  that  normative  structure  is  built  into  the  very  fabric  of  institutions,   and  is  expressed  in  various  dimensions  of  institutional  design.    For  example,  by  creating  role   expectations,  institutions  shape  professional  behavior,  creating  the  conditions  for  the   encouragement,  development,  and  expression  of  trustworthiness  in  individual  professionals.    In   terms  of  virtue,  creating  an  environment  or  culture  of  trustworthiness  entails  processes  of   enculturation  and  habituation  in  which  what  it  means  to  be  trustworthy  in  public  health   practice  by  cultivating  trustworthiness  through  education,  training,  and  mentoring  as   professionals  are  groomed  for  public  health  practice.      As  Annette  Baier  expressed  it,  “we  take  it   for  granted  that  people  will  perform  their  role-­‐related  duties  and  trust  any  individual  worker  to   look  after  whatever  her  job  requires  her  to.    The  very  existence  of  that  job,  as  a  standard   occupation,  creates  a  climate  of  some  trust  in  those  with  that  job.”   130   The  case  for  organizational  virtue  beyond  the  aggregate  view  requires  some  kind  of   parallel  not  just  to  the  intentions,  but  also  the  thought  processes,  attitudes,  and  perceptions   that  so  characterize  the  trustworthy  person.    In  other  words,  what  is  required  is  an  account  of   group  agency.    Many,  including  Peter  French,  have  advanced  that  we  may  treat  groups  as                                                                                                                           130  Baier,  “Trust  and  Antitrust,”  254.       93     131 having  agency.    Drawing  on  his  work  view,  Michael  Smith  asserts,  “in  certain  contexts  acts   by  persons  will  count  as  decisions  or  acts  by  an  organization.” 132    This  may  especially  be  true  of   public  health  leadership,  which  may,  as  a  body,  direct  policy  formation  and  articulation.      The   same  might  be  said  of  working  groups  that  gather  information  and  provide  policy   recommendations  in  the  form  of  consensus  expert  opinion,  including  unresolved  issues  where   professionals  could  not  reach  agreement.  Furthermore,  when  such  actions  are  normatively   laden,  or  the  specific  goals  of  an  organization  are  explicitly  ethical  in  nature,  then  it  is  possible   133 to  view  such  agency  as  the  proper  object  of  moral  attribution.    Thus  the  policies  and   structures  of  an  institution,  like  the  actions  and  decisions  of  individuals,  can  be  said  to  exhibit   virtue.    For  example,  setting  goals  and  expressing  values  in  policies  can  be  interpreted  as   institutions  actions  that  reflect  global  institutional  intent  in  policy  design. 134    On  this  analysis,  it   can  be  argued  that  institutions  can  be  said  to  be  virtuous  not  solely  due  to  the  virtue  of  the   individuals  within  the  institution  but  due  to  a  capacity  to  exhibit  a  collective  kind  of  virtue.   To  attribute  intentions  to  institutions  has  potential  drawbacks  using  either  an   aggregative  or  collective  tack.    The  aggregative  approach  carries  a  great  risk  of  committing  a   fallacy  of  composition. 135    That  professionals  within  an  institution  have  developed  motivations                                                                                                                           131  Peter  A.  French,  Individual  and  Collective  Responsibility,  (Cambridge:  Schenkman  Books,   1998).   132  Michael  D.  Smith,  “The  Virtuous  Organization,”  Journal  of  Medicine  and  Philosophy  7,  no.  1   (1982):  36.   133  Ibid.;  Stephen  Holland,  “The  Virtue  Ethics  Approach  to  Bioethics,”  Bioethics  25,  no.  4   (2011):  192–201.     134  Susan  Dorr  Goold,  “Trust  and  the  Ethics  of  Health  Care  Insitutions,”  The  Hastings  Center   Report  31,  no.  6  (2001):  27.   135  Hardin,  "Trust  and  Trustworthiness.”       94     is  not  reason  to  believe  that  the  institutions  can  be  attributed  to  also  protect  interests  in  the   same  way.    Such  inferences  disguise  any  diversity  of  intentions,  character,  and  disagreement   within  an  institution.    In  contrast,  the  collective  approach  to  trust  in  groups  tends  to  reify  the   independence  of  institutions  from  those  who  comprise  them,  divorcing  institutional  design  and   function  from  those  who  keep  the  institution  functioning.    If  intentions  are  “read”  off   institutional  roles,  policies,  and  structures,  the  collective  approach  must  reconcile  how  such   supra-­‐intentions  may  conflict  with  the  explicit  and  expressed  intentions  of  individuals  within  an   organization.    For  example,  the  collective  account  must  explain  how  trustworthy  professionals   work  within  untrustworthy  cultures,  or  how  the  collective  attribution  of  trustworthiness  may  be   apt  even  when  facing  corruption  amongst  a  significant  minority.     Attributions  of  agency  and  virtue  to  groups  ought  to  be  done  with  caution,  at  the  risk  of   reifying  the  nature  of  the  group  over  its  component  parts,  and  forgetting  the  integral   relationship  between  them.    When  this  occurs,  we  will  end  up  with  not  just  an  inflated   ontology,  but  misattribution  of  moral  worth.    For  example,  virtues  are  often  compared  to  good   habits  because  they  are  said  to  result  in  regularity  of  behavior.    And  such  regularity  may  inspire   the  attribution  of  virtue:   we  ought  to  accord  a  very  special  kind  of  moral  admiration  to  those  [institutions]   that  not  only  manage  to  [satisfy  their  obligations]  but  are  so  structured  that  we   can   feel   confident   that   they   will   do   so   easily   and   regularly   what   they   ought   to   136 do.     Regularity  of  intentions  that  capture  and  respond  to  the  vulnerability  of  the  public  –  attitudes   towards  and  perceptions  of  that  vulnerability  which  trigger  appropriate  responses  –  are  indeed                                                                                                                           136  Smith,  “The  Virtuous  Organization,”  41.       95     the  kind  of  features  that  I  have  in  mind  as  deserving  of  the  name  of  virtue.    However,  it  was  my   purpose  in  Section  3.4  to  warn  against  conflating  trust  with  reliance,  and  the  same  is  true  of   the  conditions  that  inspire  such  relationships;  we  ought  not  confuse  trustworthiness  with   reliability.    And  institutional  regularity,  even  of  ensuring  right  behavior,  is  not  identical  to   trustworthiness.    Just  as  oversight  and  incentives  can  align  professional  behavior  to  mirror  that   of  the  trustworthy,  institutions  thrive  on  uniformity.    We  ought  not  attribute  trustworthiness   where  mere  reliability  exists,  nor  seek  institutional  trustworthiness  when  reliability  is  all  that  is   required.    In  public  health,  we  may  desire  our  professionals  to  cultivate  and  sustain   trustworthy  motives,  but  reliability,  in  its  many  forms  of  institutional  regulation,  or   appropriate  professional  compensation  and  promotion,  can  provide  a  failsafe  when  individual   and  institutional  virtue  falter.    That  I  wish  to  make  room  for  the  possibility  of  institutional   trustworthiness  does  not  mean  we  ought  to  mistake  it  for  something  much  easier  to  come  by.   In  conclusion,  faulty  arguments  for  public  health  paternalism  and  deference,  as   illustrated  by  the  MMR-­‐vaccination  debate,  offer  us  examples  of  unexamined  proposals  for   public  health  relationships.    As  citizens  are  increasingly  raised  in  an  era  in  which  patient   autonomy,  not  clinical  deference,  is  the  order  of  the  day,  they  expect  that  the  burden  of  proof   falls  on  professionals  to  make  the  case  for  public  cooperation.    And  in  an  odd  turn  of  events,   137 this  is  perhaps  consistent  with  Sorell’s  call  for  a  “division  of  labor.”    Except,  in  this  new  light,   parents  and  citizens  see  expert  consultation  as  an  opportunity  to  gain  more  information  about   how  and  why  one  might  want  to  raise  one’s  children  in  a  certain  way  –  not  as  an  interaction  in   which  advice  and  recommendations  are  provided  with  the  expectation  of  adherence  to  without                                                                                                                           137  Sorell,  “Parental  Choice  and  Autism,”  100.       96     question.    I  have  suggested  here  that  deference,  reliance,  and  trust  offer  us  three  different   relationships  to  consider  in  public  health.    We  ought  not  consider  these  as  mutually  exclusive   alternatives;  deference  to  legal  authority  may  be  required  in  times  when  public  safety  can  no   longer  afford  to  wait  for  individual  compliance  –  and  indeed,  we  may  epistemically  defer   precisely  because  we  trust.    In  addition,  it  is  also  quite  likely  that  success  in  public  health   employs  both  relationships  simultaneously,  employing  mechanisms  to  ensure  reliability  as  a   back  up  to,  or  reinforcement  of,  normative  expectations  of  trustworthiness.      In  such  a  way,   institutions  may  prove  to  the  public  to  have  ensured  professional  behaviors  that  can  both  be   relied  upon  and  trusted,  or  even  relied  upon  to  be  trustworthy.       97       CHAPTER  3:  COURAGE  IN  PUBLIC  HEALTH  RISK  COMMUNICATION  AND  MANAGEMENT     It  is  a  major  assumption  of  public  health  practice  that  illness  and  death  constitute  harms   –  as  such,  they  are  reasonable  objects  of  fear.    Unlike  medicine,  however,  the  hazards  of  public   health  are  almost  always  characterized  in  probabilistic  terms.    This  again  leads  to  a  scientific   view  of  public  health  risk  characterization,  one  that  I  contend  fails  to  acknowledge  attributions   of  character  at  work  in  public  health  discourse.      Of  specific  interest  is  courage,  which  is   primarily  correct  attitudes  that  inspire  proper  reactions,  to  objects  of  fear.    In  this  chapter,  I   advance  a  conception  of  the  virtue  of  courage,  which  can  contribute  to  greater  clarity  in  risk   discourse  and  provide  guidance  to  appropriate  responses  to  fear  in  public  health  practice.    The   main  contention  in  this  chapter  is  that  cultivation  of  the  virtue  of  courage  will  help  to  place   attitudes  and  perspectives  regarding  fearsome  objects  at  the  center  of  discussions  of,  and   reactions  to,  public  health  risks.    I  argue  that  the  virtue  of  courage  helps  to  initiate  a  discussion   as  to  what  kinds  of  attitudes  of  fear  we  might  consider  appropriate  and  inappropriate  in   response  to  public  health  hazards,  especially  in  public  health  professionals.       In  Section  1  I  outline  different  perspectives  on  risk  and  argue  that  latent  notions  of   courage  are  at  play  in  risk  identification  and  management.    In  Section  2  I  examine  an   Aristotelian  notion  of  courage  and  its  associated  vices  that  includes  attitudes  of  fear,  the  trait  of   boldness  that  moves  one  to  act,  self-­‐confidence  in  one’s  capacity  to  respond.      I  then  consider   the  ways  in  which  an  understanding  of  the  virtue  of  courage  can  help  public  health   professionals  clarify  some  aspects  of  risk  discourse,  and  also  the  ways  in  which  exhibiting   courage  will  enable  professionals  to  better  respond  to  public  health  hazards.  In  Section  3  I       98     examine  other  ways  in  which  one  can  fear  in  the  wrong  way  which  are  not  captured  by  terms  of   excess  and  deficiency,  and  contend  that  such  reactions  exhibit  the  need  for  public  health   professionals  to  model  courageous  behavior  for  the  public.    In  the  remaining  sections,  I   consider  different  kinds  of  courage  in  public  health,  courage  and  institutions,  and  the  candidate   alternative  response  to  risk  –  prudence.       3.1  Risk     In  public  policy  circles  ‘risk’  refers  to  the  relative  probability  that  a  hazard  is  likely  to   cause  harm.    In  such  contexts,  risk  is  contrasted  against  uncertainty.    Under  conditions  of   uncertainty,  the  probability  of  an  event  occurring  is  unknown,  and  the  nature  of  the  hazard  in   question  may  also  be  unclear.    In  contrast,  when  probabilities  have  been  calculated  and  hazards   causally  linked  to  detrimental  outcomes,  risk  can  be  clearly  articulated.      Thus,  professionals   involved  in  risk  assessment  differentiate  the  probability  of  a  risk  occurring  from  the  degree  or   severity  of  the  harm  in  question.    As  a  result,  there  may  be  a  low  risk  of  a  hazard  causing   serious  harm,  or  a  high  risk  of  a  hazard  causing  minimal  harm.    The  purpose  behind  this  way  of   the  thinking  is  a  desire  to  develop  a  solid  empirical  foundation  for  public  health  policy.    Once   again,  the  driving  responsibility  of  risk  assessors  is  interpreted  in  terms  of  veracity  and   accuracy.    Let  us  consider  food  safety  as  an  example  that  illustrates  this  way  of  thinking.    Under   this  conception  of  risk,  risk  assessment  is  meant  to  answer  such  questions  as:  Can  we  causally   connect  the  substance  in  question  to  an  undesired  outcome?    What  is  the  likelihood  that   exposure  will  result  in  such  an  outcome?  Is  the  degree  of  exposure  from  food  production   different  than  levels  of  exposure  elsewhere  in  human  life?    How  strong  is  the  evidence  that       99     establishes  such  claims?  Risk  assessment,  then,  is  characterized  as  an  empirical  process  by   which  the  facts  about  potential  hazards  are  discovered.    For  risk  assessors  involved  in  public   health  matters,  normative  considerations  –  values  judgments  –  do  not  enter  into  consideration   until  we  decide  when  and  if  we  need  to  manage  the  potential  hazard.   This  picture  has  been  criticized  for  artificially  truncating  where  values  enter  into   discussions  about  and  evaluations  of  risk.    Before  examining  the  contribution  of  virtue  ethics  to   risk  discourse  in  public  health  practice,  let  us  first  consider  one  way  the  problem  of  risk  can  be   characterized  in  terms  of  scientific  values  for  accuracy  and  objectivity,  and  then  reconsider  the   same  problems  in  light  of  other  values  at  play.    According  to  many  in  the  field  of  risk   characterization,  one  of  the  most  difficult  problems  facing  risk  analysts  involves  the  process  of   considering  evidence,  especially  regarding  determinations  of  statistical  significance. 138    Such   determinations  change  the  likelihood  of  making  faulty  causal  inferences.    Slight  variations  in   statistical  analysis  vary  whether  one  is  more  likely  to  commit  two  kinds  of  errors.    Select  one  set   of  preconditions  for  statistical  analysis,  and  one  may  be  more  likely  to  erroneously  conclude   that  a  correlation  or  causal  relationship  does  exist  (a  Type  I  error),  select  another  set  of   statistical  assumptions  and  one  is  more  likely  to  make  the  false  inference  that  a  correlation  is   not  present  (a  Type  II  error).      For  example,  when  considering  whether  a  substance  presents  a   hazard  to  human  health,  a  Type  I  error  would  falsely  imply  that  the  substances  is  in  fact   hazardous,  raising  undue  alarm.    In  contrast,  a  Type  II  error  would  incorrectly  indicate  that  the                                                                                                                           138  Robert  E.  McKeown  and  R.  Max  Lerner,    "Ethics  in  Public  Health  Practice."  in  Ethics  and   Epidemiology,  2nd  ed.,  ed.  Stephen  Coughlin,  Dan  Beauchamp,  and  Douglas  L.  Weed  (Oxford:   Oxford  University  Press,  2009),  175;  Douglas  L.  Weed,  “Precaution,  Prevention,  and  Public   Health  Ethics,”  The  Journal  of  Medicine  and  Philosophy  29,  no.  3  (2004):  313–32.       100     substances  is  safe,  or  presents  no  harm.    For  those  concerned  with  accuracy,  the  decision  as  to   which  evidence  counts  is  also  a  potential  matter  of  stacking  the  deck,  or  faulty  science.    In  a   discipline  where  causal  inferences  are  often  made  conservatively  on  the  sound  basis  of   historical  trends  to  the  contrary,  statisticians  often  prefer  more  and  better  data  to  ground  their   conclusions,  i.e.,  they  prefer  to  avoid  Type  I  errors.    Out  of  concern  for  scientific  rigor  and   integrity,  from  this  perspective,  it  is  better  to  have  high  standards  of  evidence  and  find  no   causal  relation  for  the  moment,  because  such  a  conclusion  does  not  rule  out  the  possibility  that   such  a  relationship  might  be  discovered  farther  on  down  the  line.    In  science,  there  is  always   more  data  to  be  gathered.        To  lower  evidential  standards  and  get  things  wrong  is  viewed  as   poor  science,  to  have  high  standards  and  perhaps  not  have  found  the  truth  yet  is  considered   rigorous.    In  the  end,  for  scientists,  what  matters  is  arriving  at  the  most  powerful  explanation,   and  getting  it  right  may  mean  taking  the  long  view.   The  analysis  above  is  already  value-­‐laden,  invoking  the  importance  of  rigor  and  integrity,   truth  and  accuracy.        But  while  these  are  scientific  values,  it  is  possible  to  express  the  nature  of   the  problem  not  in  terms  of  factual  error,  but  about  which  type  of  moral  error  is  more   important  to  avoid.    It  is  possible  to  express  this  concern  not  in  terms  of  the  importance  of   139 veracity  but  in  terms  of  injustice.    Carl  Cranor  captures  this  concern  using  a  legal  analogy.     Let  us  imagine  not  a  potential  hazard,  but  a  potential  criminal.    According  to  this  comparison,   risk  analysis  is  like  putting  a  substance,  industrial  process,  or  even  a  potential  pathogen  on  trial.       In  the  United  States  justice  system  we  proceed  on  the  assumption  that  the  burden  of  proof  is                                                                                                                           139  Carl  F.  Cranor,  “Toward  Understanding  Aspects  of  the  Precautionary  Principle,”  The  Journal   of  Medicine  and  Philosophy  29,  no.  3  (2004):  259–279.       101     on  the  prosecution  –  the  accused  is  innocent  until  proven  guilty.    We  make  such  an  assumption   because  we  wish  to  avoid  the  judicial  equivalent  of  a  Type  I  error  –  wrongful  conviction.    But   imagine  a  contrary  justice  system,  in  which  the  assumption  is  guilt,  not  innocence. 140    In  such  a   system,  the  driving  concern  is  to  prevent  the  analogy  of  a  Type  II  error  –  releasing  a  guilty   criminal  onto  the  unprotected  public.    Cranor’s  analogy  captures  an  additional  moral  concern   involved  in  risk  assessment.      In  public  health  matters,  do  we  create  a  system  with  a  high  bar  of   evidentiary  proof,  with  the  potential  outcome  that  harmful  substances  are  considered  innocent   and  let  loose  on  the  community,  or  do  we  construct  a  process  that  leans  toward  raising  the   alarm  unnecessarily,  and  wrongfully  convicts  some  substances  (or  often  an  industry,  or   technology)  in  the  hopes  that  it  will  effectively  capture  more  culprits?    When  risk  assessors   characterize  this  choice  as  a  concern  for  precision  alone,  they  fail  to  capture  the  presence  of   this  other  value  judgment  present  in  the  process.     According  to  this  more  explicitly  normatively  laden  analysis,  risk  assessment  is  not   merely  concerned  with  upholding  the  scientific  values  of  accuracy  and  rigor,  but  also  with   creating  a  process  that  strikes  a  proper  balance  between  the  societal  values  of  safety  and   fairness.    At  other  times,  the  values  at  play  include  economic  benefits,  the  potential  for   progress,  and  establishing  assurances  of  accountability.      In  public  health,  such  debates  take   place  with  respect  to  workplace  safety  and  environmental  contaminants  that  bear  implications   for  human  health.    Less  obviously,  however,  the  same  concern  for  balance  affects  risk                                                                                                                           140  Cranor’s  analogy  is  actually  more  nuanced  than  I  have  represented  it  here.    He  delineates   the  ways  in  which  burdens  of  proof,  standards  of  proof,  and  presumptions  all  play  a  role  in  the   legal  system,  and  analogously,  in  risk  assessment.    I  focus  on  burden  of  proof  here,  although   similar  arguments  could  be  made  mutatis  mutandis  with  respect  to  the  other  elements  of  the   analogy.       102     assessment  and  management  with  respect  to  epidemic  preparedness. 141    In  this  arena  of  public   health,  Type  I  errors  have  serious  economic  repercussions,  as  the  quarantine  of  economic   goods  and  travel  restrictions  can  result  in  serious  costs,  and  some  worry  these  will  be  imposed   unnecessarily.    Epidemiological  risks  are  also  complicated  by  the  involvement  of  disease   vectors.    Because  people  are  often  a  source  of  contagion  the  counterpart  to  the  criminal   element  in  Cranor’s  analogy  –  pathogens  –  often  cannot  be  the  sole  object  of  containment   strategies.  Whereas  in  matters  of  crime  human  defendants  can  themselves  be  imprisoned,  in   public  health  matters  it  is  not  potential  pathogens,  but  their  human  vectors,  whose  liberties   might  be  constrained.    In  such  instances,  the  concern  for  avoiding  Type  II  errors  involves  a  third   party  who  is  often  simultaneously  a  victim. 142    Thus,  while  the  judicial  analogy  helps  to  make   the  ethical  aspect  of  risk  more  explicit,  the  analogy  can  be  harmful  insofar  as  it  only  partially   captures  what  is  at  stake.         While  professionals  in  risk  management  understand  the  concept  of  risk  to  be  a  metric  of   probability  distinct  from  evaluations  of  severity  of  the  harm,  members  of  the  public  operate   using  a  different  conception  of  risk,  and  often  such  common  understandings  incorporate  the   probability  and  severity  aspects  that  policy  experts  prefer  to  differentiate.    In  addition,  the   public  is  also  highly  concerned  about  the  source  of  harm,  as  well  as  the  potential  distribution  of   damage.  Thus,  whereas  risk  assessment  often  tries  to  disentangle  the  quantitative  and                                                                                                                           141  Elizabeth  Wishnick,  “Dilemmas  of  Securitization  and  Health  Risk  Management  in  the   People’s  Republic  of  China:  The  Cases  of  SARS  and  Avian  Influenza,”  Health  Policy  and  Planning   25,  no.  6  (2010):  454–66.   142  For  an  in-­‐depth  analysis  of  how  this  dual  nature  of  patients  has  been  neglected  in  bioethics   more  generally,  see  Margaret  P.  Battin  et  al.,  The  Patient  as  Victim  and  Vector  (Oxford:  Oxford   University  Press,  2008).       103     evaluative  aspects  of  risk,  the  public  conception  of  risk  does  not,  and  folds  in  additional   features  of  danger.    For  the  public,  who  (as  well  as  what)  causes  a  potential  hazard  and  who  will   bear  the  brunt  of  exposure  are  central  concerns.       The  result  is  that  normative  aspects  of  risk  are  an  inextricable  aspect  of  conversations   about  risk:  “one  must  assume  an  ethical  point  of  view  in  order  to  discuss  risks  meaningfully  at   all.    Risk  determinations  are  based  on  mathematical  possibilities  and  social  interests.” 143       Discussions  of  risk,  then,  involve  both  a  concern  for  greater  knowledge  of  outcomes,  but  in  such   a  way  that  this  knowledge  is  not  easily  separated  from  the  ways  in  which  those  outcomes  are   valued  and,  I  would  add,  what  decision-­‐making  about  risk  reveals  about  who  we  are   individually,  and  collectively.    “In  short,  people  want  to  know  the  things  that  scientists  can  tell   them,  as  opposed  to  what  philosophers  can  tell  them,  but  they  would  prefer  that  scientists   have  some  ability  to  present  their  information  in  an  ethics-­‐oriented  framework.” 144    The   conception  of  courage  and  its  counterparts  that  I  offer  here  is  meant  to  provide  public  health   professionals  with  such  a  picture.   In  part,  to  risk  something  is  to  take  a  chance;  it  is  an  expression  of  one’s  attitudes   toward  the  fearful  aspects  of  our  world,  and  one’s  willingness  to  face  them  for  the  sake  of   something  of  even  greater  value.  For  members  of  the  public,  questions  about  whether   something  constitutes  a  risk  are  intricately  tied  to  our  attitudes  toward  that  risk.    The  question   whether  something  is  a  hazard  is  in  part  a  question  of  whether  it  is  something  to  fear.    The   decisions  about  what  risks  to  study  and  which  risk  management  policies  to  prioritize  are                                                                                                                           143  Ulrich  Beck,  Risk  Society:  Towards  a  New  Modernity,  trans.  Mark  Ritter  (London:  Sage   Publications,  1992),  29  original  emphasis.   144  Paul  B.  Thompson,  Food  Biotechnology  in  Ethical  Perspective  (Springer,  2007),  287.       104     reflections  of  what  we  fear,  to  what  degree  we  fear  them,  and  how  this  informs  our  behavior.     With  this  alternative  vision  of  risk  in  mind,  an  action  or  policy  endorsed  by  public  health   professionals  may  be  interpreted  as  indicative  of  a  predilection  to  assess  the  world  more   optimistically  or  pessimistically,  to  take  chances  or  avoid  them,  i.e.,  as  a  reflection  of  policy-­‐ makers’  characters.  In  the  next  section,  I  will  present  a  conception  of  the  elements  of  courage   that  map  on  to  these  attitudes.    To  the  extent  that  public  health  professionals  appear  risk-­‐ averse  or  risk-­‐prone,  the  public  will  evaluate  risk  assessment  and  management  policies  not   merely  on  the  criterion  of  accuracy,  but  also  interpret  such  policy  in  light  of  such  attitudes.    My   contention,  then,  is  that  latent  notions  of  courage  and  its  related  character  traits  are  at  play  in   risk  discourse.    If  the  public  will  view  policies  as  incorporating  attitudes  to  risk,  as  including   normative  assessments  of  whether  what  may  be  lost  is  worthy  of  such  possible  sacrifice,  then  a   better  understanding  of  the  nature  of  courage  can  help  public  health  professionals  frame   responses  to  risk  in  a  way  that  makes  these  implicit  notions  more  explicit.     3.2  Public  Health  Courage   In  this  section,  I  (1)  present  examples  to  indicate  the  initial  plausibility  for  courage  on   the  part  of  public  health  professionals;  I  then  (2)  provide  an  Aristotelian  account  of  courage,   which  consists  of  three  aspects,  of  which  fear  is  the  most  important;  and  finally  (3)  defend  the   contribution  a  conception  of  courage  can  make  to  public  health  risk  discourse  and  the  practical   assistance  the  virtue  of  courage  provides  to  risk  management,  or  public  health  practice.           105     3.2.1  Professional  Courage  in  Public  Health  Practice   So  far  in  this  chapter  I  have  spoken  very  generally  about  courage,  especially  in  public   health  risk  assessment  and  management.    Intuitively,  we  can  imagine  that  courage  might  be   important  for  public  health  professionals  in  a  variety  of  public  health  contexts,  such  as  facing   possible  exposure  and  infection  during  an  epidemic,  or  potential  harm  while  identifying  new   pathogens  (e.g.,  in  the  early  stages  of  severe  acute  respiratory  syndrome,  or  SARS).        In  such   cases,  the  uncertainty  surrounding  the  nature  of  the  harm,  and  the  urgent  need  to  act  quickly   are  additional  pressures  that  public  health  professionals  must  face  and  overcome.    In  general,   public  health  emergencies  –  including  disaster  relief  –  may  require  that  public  health   professionals  confront  daunting  challenges  such  as  geographic  barriers  in  reaching  rural   locations  with  much-­‐needed  medical  supplies,  chaos  due  to  damaged  infrastructure,  and   unanticipated  problems  that  require  professionals  to  think  and  act  quickly.    There  are  many   character  traits  that  might  serve  professionals  well  under  such  circumstances,  but  among  them   are  the  proper  attitudes  and  perspective  required  to  overcome  fear  of  personal  harm  in  order   to  achieve  public  health  purposes.    The  lesser  among  us  would  quail,  or  be  overwhelmed,  in   similar  circumstances.   Thus,  the  physical  dangers  of  public  health  work  are  quite  obvious  sources  of  personal   harm  that  professionals  must  overcome  if  they  are  to  serve  the  public.    But  we  must  also  think   of  the  psychological  burdens  and  the  personal  sacrifices  that  must  be  born  to  provide  excellent   public  health  service.    Consider  the  potential  for  retribution  if  a  public  health  worker  speaks  out   against  corruption  –  both  internally  within  the  profession,  but  also  perhaps  externally  in  other   areas  of  government  or  society  where  public  health  work  may  reveal  underhandedness.  In  such       106     cases,  public  health  professionals  will  need  to  overcome  their  fear  of  the  damage  that  might  be   done  to  their  financial  security  or  their  professional  reputation  if  they  are  to  speak  out.    In   addition,  outside  the  realm  of  acute  emergencies,  public  health  activities  require  a  great  deal  of   endurance.    Let  us  consider  the  parallel  of  curative  medicine,  where  American  culture  often   reflects  a  deep  admiration  for  the  courage  of  physicians  (with  notable  exceptions).    It  is  not  just   that  doctors  risk  physical  exposure  to  all  kinds  of  pathogens  in  the  process  of  healing,  but  also   that  they  confront  a  number  of  common  sources  of  anxiety  including  the  pain  and  suffering  of   the  ill,  tragic  deaths,  and  perhaps  just  as  disconcerting,  mortality  itself  and  its  inevitability.    We   admire  physicians  not  only  because  they  face  physical  harm  in  performing  their  obligations,  but   also  because  their  work  requires  a  kind  of  psychological  bravery  in  order  to  shoulder  the  weight   of  such  experiences  day  in  and  day  out.    Similarly,  I  argue,  a  good  public  health  worker  faces   psychological  encumbrances.    I  expand  on  this  point  in  more  detail  in  Section  3.4.   In  addition,  I  contend  that  public  health  professional  courage  is  also  required  due  to  its   relation  to  civic  courage.    While  I  will  not  here  defend  the  view  that  citizens  are  required  to  be   courageous  when  faced  with  public  health  hazards,  I  do  contend  that  public  attitudes  and   responses  to  such  jeopardy  are  mediated  by  professional  responses.    Thus,  while  professionals   and  citizens  need  to  be  courageous  in  different  ways,  professional  public  health  courage  can  set   the  tone  for  public  responses  to  epidemics  and  other  potential  hazards.    In  virtue  terms,  the   virtuous  public  health  professional  serves  a  model,  a  phronimos,  for  exemplary  behavior.                 107     3.2.2  What  is  courage?     Virtues  are  character  traits  that  have  both  rational  and  affective  elements,  i.e.,  virtues   are  dispositions  that  complexes  of  belief,  attitude,  emotion,  sensitivity,  desire,  and  especially  in   145 the  case  of  courage,  aversion.    For  Aristotle,  virtue  is  a  kind  of  balance  or  harmony  of  the   affective  and  desiderative  elements  with  the  rational  ones.    Such  ideal  combinations  enable  us   to  pursue  the  human  good  in  the  most  excellent  way.    In  the  case  of  courage,  beliefs  about   what  is  harmful  contribute  to  the  fear  we  feel.    For  Aristotle,  courage  involves  an  attitude  of   fear  (which  is  primary),  an  honest  evaluation  of  one’s  abilities  given  the  circumstances,  which   he  articulates  in  terms  of  optimism  and  pessimism  (or  hope),  and  a  degree  of  boldness  that   propels  one  into  action.    I  will  expand  on  these  in  turn.   According  to  Aristotle,  courage  can  be  understood  as  an  appropriate  emotional  and   practical  response  to  what  is  fearsome  as  well  as  a  balanced  attitude  of  boldness.  (NE  III.6-­‐III.8)     In  envisioning  each  component  as  a  lying  on  a  continuum,  he  offers  an  array  of  possible   explanations  for  cowardly  and  rash  behavior.    On  the  first  continuum  of  fear,  to  feel  too  little   fear  can  lead  to  foolhardiness,  or  the  kind  of  impetuous  actions  of  the  young  and   inexperienced.    To  feel  too  much  fear,  especially  when  this  results  in  immobility,  is  a   quintessential  component  of  cowardice.    The  second  continuum,  known  in  ancient  greek  as   tharos,  does  not  have  an  exact  translation.      It  is,  however,  roughly  equivalent  to  boldness,  or   gumption.      To  be  excessively  bold  is  to  be  intrepid,  but  headstrong.    To  be  deficient  in   gumption  can  again  lead  a  person  to  exhibit  cowardice,  but  in  a  way  that  results  not  from  being                                                                                                                           145  McDowell,  “Virtue  and  Reason.”;  Hursthouse,  Rosalind.  "Virtue  Ethics  and  the  Emotions"  in   Virtue  Ethics:  A  Critical  Reader,  ed.  Daniel  Statman  (Washington,  D.C.:  Georgetown  University   Press,  1997),  99-­‐117.         108     immobilized  by  fear,  but  rather  lacking  enough  nerve  to  overcome  even  a  moderate  amount  of   fear.    In  the  case  where  boldness  is  wanting,  a  person  may  recognize  what  is  at  stake  but   nonetheless  find  herself  unable  to  impel  herself  to  action.   Aristotle  also  acknowledges  that  one’s  worldview  is  also  in  important  part  of  her   understanding  and  attitudes  toward  objects  of  fear.    Attitudes  of  confidence,  or  optimistic  and   pessimistic  perspectives,  correspond  to  the  virtues  and  vices  associate  with  courage:  “The   coward,  then,  is  a  kind  of  person  who  lacks  hope  (elpis),  because  he  is  afraid  about  everything.     The  rash  man  is  in  the  contrary  condition;  for  someone  who  has  too  much  hope  has  an  overly   bold  attitude.”    (NE  III.7  1116a2-­‐3)    On  this  account,  calculation  of  success  and  failure  also   appear  to  mediate  other  aspects  of  courage.  While  confidence  can  lessen  fear  of  harm,   pessimism  can  put  a  damper  on  boldness.    In  turn,  hubris  can  encourage  rash  behavior.     Aristotle  emphasizes  that  of  the  continuums,  fear  is  primary;  i.e.  one  may  achieve  the   intermediately  bold  attitude  and  yet  not  be  courageous  due  to  an  excess  or  deficiency  of  fear.     Hope  also  fails  to  be  exclusively  constitutive  of  courage  in  a  similar  fashion.    One  may  correctly   judge  both  one’s  own  abilities  and  accurately  assess  the  harm  in  question,  but  in  matters  of   courage,  attitudes  of  fear  are  the  most  important.    Both  cognitive  and  affective  aspects  of  the   character  trait  of  courage  inform  one’s  perspective,  or  worldview.    The  inclusion  of  hopefulness   in  Aristotle’s  account  also  acknowledges  that  a  frank  assessment  of  probability  is  never  value-­‐ neutral  –  one’s  general  tendency  toward  optimism  or  pessimism  will  inevitably  shade  one’s   assessment  of  the  odds.    Together,  these  aspects  of  the  virtue  reveal  that  a  courageous  person   is  one  who  can  be  counted  on,  due  to  the  kind  of  person  she  is,  to  assess  and  respond   appropriately  to  objects  of  fear.       109     3.2.3  Courage  and  public  health  communication     The  affective  components  of  courage  are  essential  to  acknowledge  and  articulate   because  they  help  to  reveal  that  there  is  more  going  on  in  risk  assessment  and  management   than  a  need  for  accuracy.    For  example,  in  response  to  recent  outbreaks  of  H1N1  influenza,   public  health  professionals  were  concerned  about  the  possibility  of  a  pandemic  flu  that   resembled  the  1918  outbreak.      In  such  a  context,  McKee  and  Coker  observe,  the  media  tended   toward  two  contrary  characterizations  of  public  health  response:  an  excess  of  fear,  sounding  a   needless  alarm  and  advocating  for  responses  that  are  “overkill,”  and  the  opposite,  a  deficiency   of  fear,  in  which  professionals  are  characterized  as  blasé  in  the  face  of  grave  and  serious   146 harm.    Thus,  notions  of  excess  and  deficiency  are  arguably  already  involved  in  risk  discourse.   In  a  striking  resemblance  to  Aristotle’s  understanding  of  virtue  as  moderation,  the   authors  advocate  for  a  way  to  interpret  public  health  attitudes  to  the  outbreak  in  terms  of   moderation;  contrary  to  media  exaggeration,  the  authors  assert,  actions  of  the  World  Health   Organization  and  British  public  health  workers  exemplify  how  “it  is  possible  to  find  a  middle   way.” 147    However,  McKee  and  Coker  also  note  that  the  success  of  public  health  professionals   to  “get  it  right”  requires  that  policy  makers  communicate  by  making  their  normative   commitment  and  perspectives  explicit.    Such  assumptions  “may  be  optimist,  pessimistic,  and   sometimes  hopelessly  heroic,”  but  by  making  them  explicit,  professionals  make  it  possible  for   the  public  to  have  a  greater  understanding  of  the  professional  values  that  govern  the  creation                                                                                                                           146  Martin  McKee  and  Richard  Coker,  “Trust,  Terrorism  and  Public  Health,”  Journal  of  Public   Health  31,  no.  4  (2009):  462  –65.   147  Ibid.,  464.       110     of  policy. 148    Thus,  for  example,  it  is  necessary  for  public  health  professionals  to  place  concerns   for  future  influenza  outbreaks  into  the  context  of  the  1918  outbreaks,  but  also  the  1957   slowness  to  vaccinate  and  the  arguably  reactive  1978  efforts  to  institute  a  national  vaccination   program  prematurely.    As  Harvey  Fineberg  notes,     Policymaking  for  avian  influenza  preparedness  is  problematic  in  part  because  an   influenza   pandemic   is   a   low-­‐likelihood,   high   consequence   event.   In   such   cases,   steps   toward   preparedness   are   subject   to   criticism   as   both   unnecessary   (in   the   likely   case   of   no   event)   and   inadequate   (if   a   catastrophic   event   occurs).     This   politically   precarious   double   bind   reinforces   the   value   of   learning   the   strategic   lessons   from   past   errors   of   over-­‐   and   underreaction   and   applying   them   to   the   149 realities  of  today.         Such  context  provides  experience  from  which  public  health  professionals  can  draw,  but  also   examples  from  which  public  health  professionals  can  illustrate  why  new  policies  do  not  exhibit   the  features  of  excess  and  deficiency  that  marked  the  past.    While  Fineberg  expresses  concern   that  “the  public,  like  many  experts,  has  a  hard  time  separating  likelihood  from  severity,”  and   yet  simultaneously  uses  character  terms  to  describe  the  mistakes  of  the  past,  including   “overconfidence”  and  a  “zealous”  desire  on  the  part  of  public  health  professionals  to  be   “heroes.” 150    Given  his  advocacy  for  a  more  dispassionate  rhetoric  in  risk  discourse,  is  difficult   to  tell  if  he  employs  such  terms  with  any  intentional  sense  of  irony.     Fineberg’s  analysis  raises  the  possible  objection  that  the  route  forward  for  public  health   discourse  ought  not  to  be  a  call  for  more  talk  of  courage,  rashness,  or  heroism,  but  rather  to   make  such  character  talk  explicit  in  order  to  eliminate  it.    It  is  certainly  the  case  that  the  media,                                                                                                                           148  Ibid.   149  Harvey  V.  Fineberg,  “Preparing  for  Avian  Influenza:  Lessons  from  the  ‘Swine  Flu  Affair,’”  The   Journal  of  Infectious  Diseases  197,  no.  s1  (2008):  S18.   150  Ibid.,  17.       111     which  always  love  a  good  story,  can  hijack  such  narratives.    Public  health  narratives  that  invoke   character  so  intentionally,  it  might  be  argued,  can  create  professional  a  blind  spot  where   contradicting  evidence  or  other  perspectives  are  ignored  or  silenced  because  they  fail  to  match   151 the  dominant  narrative.    Thus,  a  virtue  approach  to  public  health  ethics  must  meet  this   objection  by  explaining  why  talk  of  the  virtues  and  vices  of  professionalism  may  not  do  more   harm  than  good.     A  virtue  proponent  must  respond,  I  think,  that  stories  are  a  part  of  the  way  in  which  we   do,  and  should,  approach  moral  questions.    Unlike  other  ethical  approaches,  the  central   question  is  not  “what  should  we  do?”  but  “how  should  we  live?”    As  this  discussion  reveals,  the   public  tends  to  think  of  risk  policy  in  such  terms  –  but  so  do  the  professionals.    Notions  of   courage  and  heroism  are  invoked  to  inspire  public  health  professionals  to  bear  the  burdens  that   I  have  outlined  here.  Furthermore,  it  is  not  only  that  the  public  reads  attitudes  off  of  policy-­‐ makers’  determinations.    Public  policy  in  a  democracy  is  also  representative  of  national   attitudes.    This  is  why  risk  determinations  are  often  inflected  with  the  notion  that  regulation  is   obstructive  to  the  entrepreneurial  spirit  of  the  American  people.    It  is  also  why  members  of  the   public  may  feel  so  personally  invested  in  how  risks  to  society  are  publicly  handled.    For  it  is  not   only  the  public’s  safety  or  other  values  on  the  line.    It  is  also  that  rash  policy  is  performed  on   their  behalf,  and  it  thereby  paints  Americans  as  rash.    From  the  other  side,  overly  cautious   policy,  it  is  argued,  depicts  the  United  States  as  a  timid  society.  I  argue  that  such  language  is   already  at  work,  and  that  policy-­‐makers  might  benefit  from  a  framework  that  explicitly   acknowledges  it,  and  may  also  give  them  a  more  varied  set  of  character  language,  and  virtue                                                                                                                           151  For  extensive  arguments  on  vaccination  specifically,  see  Heller,  "The  Vaccine  Narrative.”       112     conceptions,  to  draw  from.    Courageousness,  optimism,  and  boldness  are  just  a  few  suggestions   –  but  as  current  debates  are  dominated  by  invoking  contrary  vices  of  excesses  and  deficiencies,   the  significant  contribution  of  virtue  theory  may  be  inflecting  risk  discourse  with  some  more   positive  alternatives.         3.2.4  Practical  excellence  and  courage  in  public  health  practice   It  is  not  just  useful  for  public  health  professionals  to  describe  their  actions  in  terms  of   virtue.    Rather,  as  Feinberg’s  analysis  reveals,  it  is  important  for  public  health  professionals  to   learn  from  their  mistakes  –  the  times  when  they  have  erred  by  being  too  pessimistic  about  the   potential  for  a  pathogen  to  cause  real  harm  before  the  evidence  was  in,  or  to  react  too  slowly   out  of  fear  for  the  lives  that  might  be  lost.    This  call  for  greater  attention  to  past  experience  is  in   keeping  with  the  picture  of  virtue,  which  is  deeply  connected  to  experience.    Unlike  principles,   which  can  be  general  guides  for  action,  virtues  are  the  attributes  of  those  with  the  most   experience,  which  lends  knowledge  of  particulars  and  the  skills  to  grapple  with  different   contexts  (NE  VI.8  114a15).      Thus,  it  is  important  to  cultivate  proper  professional  attitudes   toward  fearsome  public  health  hazards  so  that  they  may  be  sensitive  to  the  fine-­‐tuned  aspects   of  their  work,  not  just  the  more  general  features.    This  attention  to  particulars  is  often  lauded   as  a  admirable  aspect  of  a  virtue  approach  in  contrast  to  other  ethical  theories  which  often   abstract  away  from  the  details.    Virtue  ethics,  therefore,  may  make  a  good  match  for  public   health  ethical  challenges  that  require  sensitivity  to  context.    And,  as  the  rapidly  changing  nature   of  emerging  public  health  hazards  demonstrates,  public  health  professionals  need  to  be   prepared  to  react  to  changing  circumstances,  to  resist  feeling  daunted  by  uncertainty,  and  to       113     keep  in  mind  the  lessons  of  the  past.    As  the  pandemic  flu  cases  reveal,  this  is  how  professionals   learn  to  know  what  it  is  to  react  to  fears  inappropriately,  or  to  misjudge  the  necessity  for   action.      Thus,  it  is  not  only  important  for  public  health  professionals  to  describe  their  actions  in   terms  of  virtue,  it  is  important  for  them  to  be  virtuous.       This  attention  to  context  also  reveals  partly  why  public  health  professionals’  courage   differs  from  that  of  the  public,  or  even  other  contexts  in  which  courage  is  displayed.    The   objects  of  fear  (public  health  hazards)  are  different  for  professionals  and  members  of  the   public,  and  so  are  the  reasons  one  strives  to  overcome  fear.    For  public  health  professionals,  the   goal  may  be  expressed  in  terms  of  professional  excellence,  or  integrity.    To  attain   improvements  in  public  health,  professionals  must  bear  burdens  that  the  public  does  not,  and   therefore  overcome  their  fear  in  distinctive  ways,  some  of  which  I  have  outlined  in  the  previous   section.      However,  we  also  need  professionals  to  display  and  defend  an  ideal  of  proper   attitudes  to  public  health  hazards  in  order  to  aid  public  understanding  of  how  to  react.    I  turn   more  to  this  leadership  aspect  of  courage  in  the  next  section.   One  advantage  of  the  views  I  have  presented  here  is  that  they  expand  beyond  the   judicial  analogy  depicted  by  Cranor.    Viewing  risk  assessment  in  terms  of  justice  leads  us  to   think  of  risk  determinations  in  terms  of  the  binaries  of  “innocent”  or  “guilty.”    On  my  view,   courage  can  contribute  to  risk  discourse  by  offering  a  wider  array  of  alternative  reactions  to   fear  of  potential  hazards  than  Cranor’s  judicial  analogy  suggests.    The  options  are  not  expressed   in  terms  of  binaries,  but  as  along  several  gradients  which  allow  for  more  or  less  optimism,   excess  and  deficiency  of  fear,  and  greater  or  lesser  moderation  in  bold  attitudes.    I  argue  that   such  language  has  the  advantage  of  providing  an  explicitly  ethical  framework  that  McKee  and       114     Coker  reveal  is  already  implicitly  at  work  in  public  health  risk  discourse.    In  addition,  by   providing  a  vocabulary  that  stresses  a  matter  of  degree,  the  responses  available  to  public  health   professionals  in  risk  policy  may  avoid  the  “double  bind”  that  Fineberg  envisions.    Rather,  a  more   nuanced  view  of  human  tendencies  when  reacting  to  fear  may  allow  for  professionals  to  make   the  case  for  a  “middle  way.”      In  addition,  by  constructing  right  action  in  contrast  to  a  variety  of   ways  to  go  astray,  an  Aristotelian  model  of  courage  does  provide  some  guidance  for  practical   action  in  risk  management  policy;  by  knowing  which  reactions  to  avoid,  policy-­‐makers  are  more   likely  to  aim  correctly.    In  the  next  section  I  expand  on  the  picture  of  courage  and  its  associated   vices  that  I  have  developed  here.    In  doing  so,  I  identify  other  ways  in  which  public  health   professionals  can  be  courageous,  thereby  illustrating  the  practical  guidance  provided  by   thinking  in  terms  of  virtues.      3.3  Beyond  the  Doctrine  of  the  Mean     Thus  far  I  have  presented  an  account  of  courage  that  is  in  keeping  with  Aristotle’s  praise   for  moderation  and  the  Doctrine  of  the  Mean.    Already  in  his  account  of  courage  Aristotle   muddies  the  waters  by  lauding  moderation  along  three  different  continua,  resulting  in  a  picture   of  courage  that  accounts  for  mistakes  in  kind,  not  just  degree.    However,  even  this  structure  of   courage  is  incomplete,  for  there  are  many  other  ways  of  reacting  to  fear  and  uncertainty  than   described  thus  far.    In  this  section,  I  combine  some  of  the  concerns  of  Deborah  Lupton’s   account  of  risk  in  public  health  with  an  account  of  courage  as  virtue.    By  placing  dispositions  to   fearsome  objects  at  the  center  of  risk  discourse,  I  argue  that  virtue  ethics  can  facilitate  a  more   open  acknowledgement  of  problematic  attitudes  to  objects  of  fear  without  pushing  such       115     elements  to  the  level  of  subtext. 152    The  account  of  courage  needed,  however,  must   accommodate  the  psychological  reactions  to  fear  that  do  not  fit  a  model  of  excess  and   deficiency.    These  responses  are  not  necessarily  what  we  might  consider  fearing  too  much,  or   too  little,  but  examples  of  how  people  “don’t  fear  in  the  way  one  should.”  (EN  III.7  115b16)       There  are  two  such  reactions  that  are  of  special  concern  to  Lupton:  (1)  denial  and  (2)  victim-­‐ blaming;  both  reactions  are  more  fully  illuminated  when  viewed  in  light  of  courage  and  its   associated  character  traits.      Throughout  this  section  I  am  concerned  with  the  ways  in  which   anyone  –  including  public  health  professionals  and  the  public  –  can  exhibit  such  attitudes  in   response  to  threats  to  the  public’s  health.   While  public  health  hazards  are  in  and  of  themselves  fearsome  objects,  risks  are  not  the   same  as  dangers  due  to  the  association  with  probability.    One  of  the  most  noted  aspects  of  the   development  of  risk  in  modern  society  is  the  way  in  which  potential  hazards  permeate  every   aspect  of  daily  life,  but  average  individuals  have  limited  capacity  to  identify  and  manage   exposure  on  their  own.    In  times  of  great  uncertainty  with  regards  to  health  hazards,  people   must  turn  to  public  health  expertise  for  a  way  out  of  epistemic  obscurity.    Whether  something   constitutes  a  hazard,  how  likely  such  a  hazard  is  to  inflict  harm,  what  the  consequences  are  of   such  harms,  are  all  matters  of  contestation  during  public  health  crises,  or  even  only  potential   public  health  crises  that  are  not  even  certain  to  emerge.    It  is  likely  that  experts  may  find  the   loudest  voices  during  such  times,  when  “expertise  is  seen  as  a  potential  means  of  bringing  light                                                                                                                           152  Deborah  Lupton,  “Risk  as  Moral  Danger:  The  Social  and  Political  Functions  of  Risk  Discourse   in  Public  Health,”  International  Journal  of  Health  Services  23,  no.  3  (1993):  425–35.       116     153 to  the  shadows  and,  in  doing  so,  aiding  the  sense-­‐making  process  and  reducing  uncertainty.”     The  spotlight  placed  on  public  health  expertise  in  such  circumstances  helps  reveal  that  harms  of   living  in  a  society  characterized  by  the  ubiquity  of  risk  cannot  be  solely  attributed  to  the  hazards   themselves.    Rather,  risks  to  the  public  health  draw  our  attention  to  the  vulnerability  resulting   from  dependency  on  expert  opinion:  “the  extent  and  the  symptom’s  of  people’s  endangerment   are  fundamentally  dependent  on  external  knowledge.” 154    Thus,  if  we  turn  back  to  our  example   of  the  safety  of  vaccinations  in  Chapter  2,  members  of  the  public  have  no  means  to  assure   themselves  of  safety  –  to  obtain  by  their  own  investigation  –  whether  vaccines  are  indeed  safe.     They  must  rely  on  the  evidence  gathered  and  conclusions  drawn  by  others.    The  same  can  be   said  about  food  safety,  environmental  contaminants,  or  the  development  of  new  strains  of   infectious  disease.    Part  of  what  is  terrifying  about  risk,  then,  is  not  the  hazard  in  question  but   its  attendant  exposure  of  human  frailty  and  lack  of  control.    Ulrich  Beck  identifies  such  lack  of   155 control  over  what  one  can  even  know  as  a  “loss  of  cognitive  sovereignty,”  but  the   associated  feeling  of  disempowerment  is  not  only  associated  with  an  inability  to  know  about   the  harm,  but  also  with  anxiety  that  one  lacks  control  to  protect  oneself  against  harm.                                                                                                                             153  Denis  Fischbacher-­‐Smith,  Alan  Irwin,  and  Moira  Fischbacher-­‐Smith.  “Bringing  light  to  the   shadows  and  shadows  to  the  light:  risk,  risk  management,  and  risk  communication,”  in  Risk   Communication  and  Public  Health,  2nd  ed.,  ed.  Peter  Bennett  et  al.,  (Oxford:  Oxford  University   Press,  2010),  25.   154  Ulrich  Beck,  "Risk  Society,"  53,  original  emphasis.   155  Ibid.       117       First,  one  possible  way  to  react  to  risk  is  to  reclaim  control  by  projecting  that   156 susceptibility  onto  others.    In  identifying  threats  to  population  health,  public  health   professionals  may  inadvertently  become  part  of  a  tendency  to  equate  vectors  of  disease  with   the  threat  itself.    Historical  associations  of  disease  with  immigrant  groups  especially  help  to   illustrate  the  ways  in  which  fear  was  directed  not  at  disease,  but  a  group  linked  (rhetorically  or   otherwise)  to  that  disease.    For  example,  during  the  SARS  epidemic,  the  origins  of  SARS  in  China   resulted  in  a  media  discourse  that  identified  “traditional”  practices  as  setting  the  stage  for  the   development  of  new  zoonotic  pathogens.    Anthropologist  Laura  Eichelberger  attributes  the  30-­‐ 70%  loss  of  business  in  New  York  city’s  Chinatown  to  such  framing  of  the  epidemic,  which   157 overshadowed  the  lack  of  a  single  incident  of  SARS  within  that  community.    This  example   illustrates  a  form  of  psychological  deflection  in  response  to  vulnerability.    As  Lupton  observes,   the  “notion  of  risk  thus  servers  to  categorize  individuals  or  groups  into  ‘those  at  risk’  and  ‘those   posing  a  risk’  ”  thereby  enabling  individuals  to  maintain  a  sense  of  control  over  their  exposure                                                                                                                           156  As  articulated  here,  deflection  involves  projecting  vulnerability  on  to  others.    Another   strategy  can  be  to  project  vulnerability  onto  everyone,  thereby  downplaying  the  gravity  of  the   harm  in  question.  This  form  of  deflection  may  accompany  a  kind  of  personal  identity  ennui  that   results  from  not  being  able  to  locate  oneself  within  the  categories  of  those  who  are  and  are  not   at  risk.    The  more  risk  permeates  society  –  the  more  we  recognize  that  risk  is  an  ineliminable   part  of  life  –  the  more  this  presents  a  challenge  to  the  view  of  health  as  a  stable  source  of   identity.    Rather,  each  person  becomes  one  who  is  potentially  ill,  and  as  such  it  is  not  clear   where  one  stands,  or  more  precisely,  who  one  is.    As  the  boundaries  of  “healthy”  and   “unhealthy”  become  obscured,  public  health  messaging  may  lose  its  sense  of  immediacy  when   individuals  feel  inundated  and  even  desensitized  by  the  prospect  of  fearsome  health  detriments   underlying  every  apparent  course  of  action.     157  Laura  Eichelberger,  “SARS  and  New  York’s  Chinatown:  The  Politics  of  Risk  and  Blame  During   an  Epidemic  of  Fear,”  Social  Science  &  Medicine  65,  no.  6  (2007):  1284–95.       118     by  avoiding  exposure  to  a  particular  group,  or  by  identifying  oneself  as  less  vulnerable  because   one  is  not  part  of  the  “at  risk”  group.   158       This  kind  of  response  to  fear  is  problematic  when  it  is  inaccurate  because  it  will  result  in   ineffective  responses  to  public  health  hazards.    There  is  a  risk  that  policy-­‐makers,  and  the  public   in  following  their  lead  (but  also  on  their  own),  will  associate  the  risk  with  one  community,  and   as  such  conceive  of  others  as  safer  than  they  really  are.    This  will  lead  to  ineffective  methods  of   controlling  the  spread,  and  ineffective  distribution  of  efforts  and  resources.      The  example  of   HIV-­‐AIDS  exhibits  some  of  these  problems  by  illustrating  the  ways  in  which  the  problem  was   conceived  of  as  limited  to  homosexual  communities.      While  in  this  case,  it  is  more  common  for   public  health  professionals  to  now  see  the  HIV  epidemics  as  affecting  all  communities,  during   the  early  stages  of  the  epidemic,  it  is  still  possible  to  see  the  disease  linked  to  “risky  behaviors”   in  some  health  promotion  circles.     Second,  another  possible  way  to  react  to  the  vulnerability  revealed  by  public  health   hazards  is  to  locate  responsibility  for  the  hazard  in  those  who  suffer  the  harms  of  exposure.     According  to  anthropologist  Robert  Crawford,  “the  individual’s  fear  of  loss  of  control  and  loss  of   life  engenders  a  defense:  a  perception  of  the  afflicted  as  particularly  susceptible  due  to  their   distinctive  behaviors,  emotional  predispositions,  social  or  geographic  environment,  or   159 unexplained  susceptibilities  believed  to  be  the  property  of  the  group.”    This  kind  of  reaction   is  similar  and  often  coupled  with  the  first,  but  rather  than  causally  equating  the  health  hazard   with  populations  that  may  be  vectors,  this  form  of  “blaming  the  victim”  more  directly  attributes                                                                                                                           158  Lupton,  “Risk  as  Moral  Danger,”  428.   159  Crawford,  “The  Boundaries  of  the  Self  and  the  Unhealthy  Other:  Reflections  on  Health,   Culture  and  AIDS,”  Social  Science  &  Medicine  38,  no.  10  (1994),  1355.       119     responsibility  for  the  disease  to  the  behaviors  and  moral  failures  of  members  of  the  group  in   question.        Combined,  reactions  to  public  health  hazards  that  locate  the  threat  in  others,  and   then  attribute  responsibility  for  suffering  in  the  actions  of  those  others,  exemplify  a  kind  of   denial  rooted  in  self-­‐protection.         This  kind  of  reaction  is  problematic  because  it  can  attribute  culpability  for  illness   without  adequately  establishing  the  ways  in  which  those  who  are  ill  behaved  inappropriately.     This  happens  both  when  attributions  of  claims  to  behavioral  causality  are  correct,  and   incorrect.    When  incorrect,  this  kind  of  reaction  deflects  away  from  the  real  causes  of  diseases.     Even  when  behavior  is  partly  to  explain  for  an  individual’s  illness,  projecting  responsibility  onto   the  individual  as  a  coping  mechanism  for  fear  can  also  distract  attention  away  from  the   structural  factors  that  influence  behavior.    Both  kinds  of  distraction  will  be  a  detriment  to  public   health  practice.    Even  when  accurate  (assuming  the  claim  is  causal),  attributing  personal   responsibility  for  illness  can  be  a  way  of  imposing  extra  burdens,  such  as  social  ostracism,  on   individuals  who  are  sick.    Mere  causal  responsibility  is  not  enough  to  attach  moral  culpability.     The  workers  in  nuclear  facilities  in  Japan  are  causally  responsible  for  any  subsequent  illness  that   results  from  radiation  exposures  (since  they  are  volunteering  to  continue  exposing  themselves),   but  we  would  not  say  such  actions  are  morally  reprehensible.      Professionals  should  be   especially  wary  of  claims  for  moral  responsibility  for  ill  health,  as  the  implication  is  that  such   individuals  –  and  communities  –  are  less  deserving  of  public  health  resources.    Public  health   professionals  should  also  be  alive  to  the  likelihood  that  the  tendency  to  deflect  in  these  ways  is   often  linked  to  biases  –  the  groups  blamed  are  often  those  who  are  already  oppressed,  building   on  racial,  class,  and  national  prejudices.       120     Public  health  professionals  would  do  well  to  consider  these  two  additional  ways  of   handling  fear  of  public  health  risks,  both  to  cultivate  proper  attitudes  of  their  own  as  well  as   model  appropriate  reactions  for  the  public,  and  mitigate  projection  of  fears  onto  marginalized   groups.    In  the  case  of  SARS,  a  large  community  health  center  worked  to  do  precisely  this,  both   discouraging  discriminatory  reactions  to  fear  of  exposure,  as  well  as  working  to  reduce  the  very   high  levels  of  anxiety  that  were  in  part  behind  such  deflection. 160    It  is  often  difficult  in  such   settings  to  see  courage  at  work  when  we  focus  on  the  language  of  cowardice  or  rashness.     Earlier  in  this  section  I  identified  public  health  contexts  in  which  we  sometimes  do  make  use  of   such  contrasts.    Here,  I  have  presented  examples  of  reactions  to  fear  that  require  us  to   articulate  an  account  of  courage  that  anticipates  responses  to  fear  which  are  often  better   understood  in  terms  of  anxiety,  deflection,  and  in  their  extreme,  paranoia.      Our  contemporary   terms  do  not  easily  attach  to  character,  but  visceral  reactions  to  fear  of  vulnerability.   Understanding  such  reactions  in  terms  of  attitudes  of  fear  helps  to  avoid  the  tendency  to   characterize  problematic  reactions  to  public  health  hazards  solely  in  terms  of  inaccuracy,  or   merely  false  “risk  perceptions.”    Such  characterization  implies  that  all  that  is  needed  is  more   information,  rather  than  marking  out  a  contrasting  attitude  required  on  the  part  of  public   professionals,  and  perhaps  citizens. 161    Such  character  development  is  important  for                                                                                                                           160  Eichelberger,  “SARS  and  New  York’s  Chinatown.”   161  I  endeavor  in  this  chapter  to  focus  on  the  attitudes  of  professionals,  since  the  account   offered  here  is  meant  to  be  one  of  professional  virtue,  not  civic  virtue.    When  necessary,  I  point   to  some  important  connections  between  the  two.           121     professionals,  especially  given  historical  trends  that  depict  professional  attitudes  of  deflection,   162 which  “tell  a  story  of  racial  restrictions  masquerading  as  public  health  policy.”     I  contend  that  such  reactions  are  more  completely  understood  in  the  light  of  the   impulse  to  regain  a  sense  of  self-­‐sufficiency  that  is  shattered  during  public  health  crises  –  both   acute  and  chronic.  This  possibility  reveals  one  way  in  which  professional  courage  differs  from   civic  courage,  and  ways  in  which  professional  courage  will  need  to  overlap  with  professional   trustworthiness,  as  both  require  sensitivity  to  the  vulnerability  of  others.  Courage  as  a  virtue   has  a  dual  utility  for  public  health  ethics  –  it  suggests  strategies  for  public  health   communication  by  creating  discursive  room  for  public  health  professionals  to  articulate  views   of  public  health  policy  as  collective  and  collaborative  responses  to  fear  –  in  contrast  to   unidirectional  relationships  of  dependency.    By  articulating  the  ways  in  which  public  health   interventions  are  inherently  collective,  public  health  professionals  can  reveal  the  need  for   cooperation.    By  making  it  clear  that  public  health  professionals  need  the  public  to  respond   appropriately  in  order  to  make  public  health  interventions  successful,  public  health   professionals  can  restore  a  sense  of  control  to  the  public.    Secondly,  I  have  argued  that  by   exhibiting  courage  themselves,  public  health  professionals  will  serve  communities  by  avoiding   the  inappropriate  reactions  to  fear  outlined  here,  and  in  doing  so,  I  contend  that  public  health   professionals  can  help  show  the  way  for  the  public  by  leading  by  example.                                                                                                                               162  Amy  L.  Fairchild,  “Policies  of  Inclusion:  Immigrants,  Disease,  Dependency,  and  American   Immigration  Policy  at  the  Dawn  and  Dusk  of  the  20th  Century,”  American  Journal  of  Public   Health  94,  no.  4  (2004):  528–39.       122     3.4  Types  of  Courage     In  this  section  I  consider  different  kinds  of  courage  and  some  of  their  implications  for   public  health  practice.  I  consider  the  courage  needed  by  public  health  professionals  when   facing  physical  harm,  psychological  harm,  and  also  ways  in  which  courage  and  justice  may   overlap.     3.4.1  Heroic  Courage       First,  we  must  consider  those  contexts  in  public  health  that  do  seem  to  fit  with  the   traditional  greek  notion  of  courage,  or  courage  on  the  battlefield.    It  is  rather  obvious  that   when  public  health  professionals  must  risk  their  lives  to  stop  the  spread  of  a  disease  that  would   otherwise  kill  many,  such  circumstances  parallel  those  of  battle.  As  Giovanni  De  Grandis   observes,  both  war  and  infectious  disease  share  the  common  features  of  disruption  of  daily  life   and  uncertainty  regarding  the  future,  and  as  a  result  create  the  opportunity  for  “extremes  of   selfish,  anti-­‐social  and  cowardly  behavior  or  the  opposite:  selflessness,  courage,  and  extreme   endurance.” 163    And  we  have  excellent  reasons  to  believe  that  in  the  “battle”  to  contain  an   epidemic,  all  public  health  professionals  will  be  equally  likely  to  confront  fear  of  personal  harm   and  endure  for  the  sake  of  others.    We  might  imagine  it  important  for  all  public  health   professionals  to  cultivate  this  form  of  courage  in  light  of  the  possibility  that  those  in  the  field   may  encounter  such  tests  of  character.    But  while  personal  tales  of  public  health  courage  ought   to  inspire  others,  we  also  ought  to  beware  the  pitfalls  of  comparing  public  health  action  to  war.                                                                                                                           163  Giovanni  De  Grandis,  “On  the  Analogy  Between  Infectious  Diseases  and  War:  How  to  Use  It   and  Not  to  Use  It,”  Public  Health  Ethics  4,  no.  1  (2011):  71–2.       123       We  are  prone  to  use  the  imagery  of  battle  in  the  context  of  epidemics  and  other  public   health  hazards  in  ways  that  require  more  thoughtful  consideration  for  the  messages  we  may   inadvertently  endorse  through  the  use  of  violent  imagery.  Many  authors  have  observed  that   there  are  serious  drawbacks  to  using  wartime  analogies  with  respect  to  health. 164    For   example,  such  metaphors  can  encourage  those  who  buy  into  them  to  overlook  harmful  effects   of  public  health  interventions  themselves  as  part  of  the  expected  “costs  of  war.”    In  public   health  especially,  such  a  mentality  complements  an  unsophisticated  public  health  utilitarianism   that  is  willing  to  sacrifice  a  few  for  the  sake  of  the  many.    Thus,  an  adequate  public  health  ethics   will  need  to  resist  the  rhetoric  of  war  due  its  tendency  to  distort  and  normalize  human  loss  of   life.      However,  De  Grandis  is  also  right  to  examine  the  possibility  that  such  analogies  may   possibly  hold  useful  insights.    He  contends  that  the  imagery  of  battle  or  fighting  an  enemy  can   also  sometimes  be  helpful  in  the  context  of  public  health  challenges  such  as  responding  to   drug-­‐resistant  bacteria.      By  highlighting  why  some  pathogens  are  not  merely  a  threat  to   personal  health,  but  a  danger  to  the  community,  public  health  can  help  place  individual   infections  into  a  wider  institutional  and  social  context.    For  example,  while  finishing  off  a  round   of  antibiotics  may  offer  no  immediate  individual  benefit,  it  provides  great  social  benefit.    Rather   than  viewing  those  infected  as  a  threat  to  society,  by  characterizing  pathogens  as  a  “common   enemy,”  public  health  professionals  can  thereby  help  to  re-­‐envision  those  who  have                                                                                                                           164  George  Annas,  “Reframing  the  Debate  on  Health  Care  Reform  by  Replacing  Our   Metaphors,”  New  England  Journal  of  Medicine  332,  no.  11  (1995):  745–8;  Ann  Mongoven,  “The   War  on  Disease  and  the  War  on  Terror:  A  Dangerous  Metaphorical  Nexus?,”  Cambridge   Quarterly  of  Healthcare  Ethics  15,  no.  4  (2006):  403–16;  Susan  Sontag,  Illness  as  Metaphor  and   AIDS  and  Its  Metaphors,  (New  York:  Picador,  2001).       124     experienced  the  disease  as  survivors,  part  of  efforts  to  defend  others  against  public  health   165 hazards,  and  help  to  motivate  collective  public  health  actions  in  terms  of  shared  efforts.     The  difficulty  is  that  disease  and  war  analogies  are  so  prevalent  in  modern  discussions  of  health   already,  and  so  likely  to  be  taken  up  and  amplified  by  media  sources,  that  they  may  inevitably   carry  their  pitfalls  with  them,  not  allowing  us  to  choose  between  their  capacity  to  unite  and   their  potential  to  mislead.         3.4.2  Courage-­‐Fortitude     Next  we  must  turn  to  the  second  route  for  pursuing  a  revise  account  of  courage,  one   that  reconsiders  the  notion  that  courage  is  exhibited  only  in  short  bursts,  or  as  overcoming  fear   of  personal  physical  harm.    The  writings  of  Aristotle  and  Plato  do  indicate  that  discourse  on   courage  should  address  what  contexts,  outside  the  battlefield,  create  the  opportunities  to   demonstrate  the  virtue  of  courage.    The  examples  we  find  include  a  novice  at  sea  in  the  midst   of  a  storm,  and  someone  facing  the  harms  of  illness  or  poverty.  (NE  III.6  1115a29-­‐11156;  Lch.   191d-­‐e;  195d)  Such  cases  illustrate  a  range  of  instances  in  which  we  think  individuals  may   manifest  courage,  in  part  because  there  appears  to  be  something  fearsome  to  face.    David   Pears  identifies  these  as  examples  of  courage  in  the  “extended  sense.” 166    I  argue  that  much  of   the  fearsome  prospects  that  characterize  the  work  and  sacrifice  of  public  health  professionals   illustrate  this  wider  notion  of  courage  as  endurance,  or  steadfastness.    In  public  health,  such                                                                                                                           165  De  Grandis,  “On  the  Analogy  Between  Infectious  Diseases  and  War,”  71.   166  David  Pears.  “Courage  as  a  Mean,”  in  Essays  on  Aristotle's  Ethics,  ed.  Amélie  Oksenberg   Rorty  (Berkeley:  University  of  California  Press,  1980),  185.       125     courage  will  be  necessary  in  the  face  of  continuous  public  health  hazards,  and  in  the  difficult   work  of  persevering  when  success  is  uncertain.     To  re-­‐envision  what  courage  can  be  requires  challenging  common  assumptions  about   courage,  including  the  intuition  that  “being  a  decent  parent  or  a  good  teacher  may  sometimes   167 require  courage,  though  it  is  hard  to  see  how  that  could  be  a  routine  requirement.”      Such   observations  reflect  our  notions  of  courage  as  rare  and  infrequent  tests  of  one’s  mettle.    One   might  object  that  the  attribute  I  have  described  here  is  more  akin  to  patience  –  an  ability  to   168 respond  appropriately  to  despair  and  frustration.    This  objection  does  well  to  illustrate  how   virtues  are  often  traits  that  enable  us  to  overcome  common  human  failings  –  or  act  as   169 correctives  to  the  most  frequently  encountered  excesses  and  deficiencies  of  character.     However,  I  believe  that  heroic  courage  often  depicts  the  harms  that  befall  us  as  physical  in   nature,  and  in  remapping  the  terrain  of  courage  we  ought  to  consider  how  much  we  also  fear   psychological  burdens,  and  how  few  of  us  are  willing  to  carry  the  weight  of  others’  suffering.    I   have  argued  here  that,  at  times,  the  kind  of  work  that  public  health  professionals  do,  takes   endurance,  time  (and,  yes,  patience),  but  also  a  willingness  to  face  the  potential  for  both   physical  and  psychological  harm  -­‐  including  professional  burnout  –  for  the  sake  of  others.    I   conclude  that  in  articulating  courage  as  appropriate  responses  to  fear,  we  must  consider  the   personal  costs  that  are  a  long  time  coming,  that  require  repeated  sacrifice  for  their  effects  to                                                                                                                           167  Eamonn  Callan,  “Patience  and  Courage,”  Philosophy  68,  no.  266  (1993):  526.   168  Ibid.   169  Philippa  Foot,  “Virtues  and  Vices,”  in  Virtue  Ethics,  ed.  Stephen  L.  Darwall  (Malden:   Blackwell  Publishing,  2003),  105–20.       126     become  apparent,  and  which  may  result  from  consistent  and  sustained  efforts  to  fulfill  a   commitment  to  the  public  good.         The  possibility  of  sacrifice  is  not  lost  on  the  courageous  –  they  knows  the  value  of  their   own  lives  and  wellbeing,  especially  since  under  Aristotle’s  notion,  the  virtuous  are  living  the   very  best  of  lives:  “for  to  such  a  person,  most  of  all,  is  living  worth  while,  and  this  person  will   knowingly  be  depriving  himself  of  goods  of  the  greatest  kind.”    (NE  III.7  1117b10-­‐13)    For   Aristotle,  a  person  is  inspired  to  be  courageous  because  she  perceives  that  the  sacrifice  is   paradoxically  also  good  for  her.    He  does  not  go  so  far  as  Socrates  to  claim  that  the  act  fails  to   be  a  harm  to  her,  but  he  does  think  that  the  virtuous  sometimes  judge  that  some  harms  are   worth  undergoing  to  obtain  something  of  value  to  the  agent  as  well  to  others  who  may  benefit.     It  is  from  this  larger  goal,  whether  it  is  victory,  or  helping  others,  that  courage  gets  its  nobility,   and  its  distinction  from  mere  risk-­‐taking.         In  understanding  the  psychological  harms  public  health  professionals  face,  we  must   envision  courage  as  a  virtue  that  can  be  sustained  over  time,  not  merely  displayed  in  bursts   during  times  of  extreme,  but  short-­‐lived,  danger.    In  truth,  war  can  be  a  grueling  process,  one   that  tests  not  just  one’s  capacity  to  respond  to  immediate  and  grave  danger,  but  to  endure  long   and  arduous  tests  of  one’s  endurance.    For  public  health  professionals  this  kind  of  courage,   which  I  will  call  courage-­‐fortitude,  can  be  as  important  to  cultivate  given  the  complexity  and   duration  of  public  health  challenges.  Fortitude  alone  is  an  admirable  trait,  but  I  categorize  the   trait  I  have  in  mind  under  the  wider  category  of  courage  because  it  requires  the  same  force  of   will,  the  same  vision  of  possibilities,  and  the  same  frank  assessment  of  what  there  is  to  fear.             127         Courage-­‐fortitude  is  important  in  public  health  practice  that  requires  ongoing   investments  of  public  health  professionals’  time  and  energy.    For  example,  as  chronic  disease   rather  than  infectious  disease  increasingly  accounts  for  population  morbidity  and  mortality,   public  health  professionals  need  to  cultivate  this  enduring  form  of  courage.    Several  features  of   chronic  diseases  set  them  apart  from  other  forms  of  illness.    Chronic  diseases  like  diabetes,   arthritis,  and  chronic  obstructive  pulmonary  disorder  (COPD)  may  require  long-­‐term  behavioral   changes  that  professionals  may  find  both  daunting  and  wearing  to  achieve  via  both  preventive   and  ameliorative  public  health  efforts.    As  providers  of  interventions  aim  at  reducing  the   incidence  of  such  chronic  ailments  and  their  attendant  comorbidities,  a  kind  of  courage  linked   with  patience  will  prove  invaluable.    The  same  might  be  said  of  overcoming  health  disparities,   given  the  magnitude  of  social  change  that  may  be  required  to  achieve  real  and  lasting  health   justice.    The  internal  resources  needed  to  meet  such  challenges  cannot  be  captured  by  the   military  analogy.    Instead,  they  require  public  health  professionals  to  take  the  long  view,  and   conceive  of  public  health  interventions  over  a  lifetime.    Simultaneously,  such  fortitude  requires   cultivating  a  willingness  to  overcome  the  despair  characteristic  of  professional  burnout  and  the   psychological  pressures  that  such  commitments  may  entail.    Due  to  their  less  immediate  and   pressing  nature,  such  health  detriments  may  receive  less  public  attention  than  acute  illnesses,   but  also  less  public  admiration  for  ameliorating.    Developing  the  kind  of  attitudes  and  character   to  respond  to  the  repeating  and  enduring  nature  of  human  vulnerability  over  time  is  the  mark   of  the  truly  courageous  public  health  professional.     The  decision,  then,  to  commit  oneself  to  the  profession  of  public  health  must  be   acknowledged  to  entail  the  possibility  of  great  sacrifice,  which  on  balance  helps  professionals       128     feel  they  have  made  a  contribution,  a  difference,  or  lived  the  best  kind  of  life  they  could.    The   vivid  images  and  more  acute  impeding  peril  of  contagion  and  mortality  that  characterize   epidemics  are  often  what  come  to  mind  when  such  costs  are  considered  part  and  parcel  of  the   role  played  by  public  health  professionals.    But  there  is  also  a  kind  of  courage  required  of  the   public  health  professional  that  is  less  glorious,  and  even  less  likely  to  receive  the  recognition  it   merits.    In  facing  the  enormity  of  the  task  of  a  wide  web  of  causal  forces  that  affect  disease,  in   tackling  complex  and  lasting  widespread  detriments  to  health,  the  public  health  professional   commits  a  lifetime  to  what  is  often  a  grueling  or  marathon-­‐like  task.    What’s  more,  the   successes  that  may  result  from  such  efforts  are  likely  to  go  unnoticed.    Even  those  public  health   workers  whose  endeavors  lead  to  close  work  with  specific  individuals  or  communities  may  only   find  themselves  able  point  to  statistical,  not  tangible,  evidence  of  success.    Like  the  statistical   nature  of  the  evidence  that  informs  the  derivation  and  employment  of  risk  policies,  the  metrics   of  epidemiological  success  will  measure  victory  in  statistical  years  gained,  or  probabilities  of   lives  saved.    The  absence  of  faces  and  stories,  personal  connection  and  professional   recognition,  can  render  public  health  steadfastness  invisible.    For  all  its  collective  emphasis,  the   invisibility  of  the  profession  can  make  public  health  work  a  lonely  practice,  requiring  a  durability   of  spirit,  or  courage-­‐fortitude.     3.4.3  Courage  and  Justice       In  the  previous  section  I  briefly  mentioned  courage  in  response  to  health  disparities.     The  judicial  analogy  also  calls  attention  the  ways  in  which  courage  and  justice  may  both  be  at   issue  when  public  health  risks  are  discussed  and  managed.    In  this  section,  I  expand  on  this       129     overlap  between  courage  and  justice  by  examining  the  contexts  in  which  justice  may  call  on   public  health  professionals  to  be  brave.    In  such  instances,  it  is  not  a  notion  of  public  good  that   lends  courage  its  nobility,  but  a  concern  for  justice.  This  kind  of  courage  is  not  a  subtype  of   courage,  but  required  in  the  context  where  the  virtues  of  courage  and  justice  overlap.  I  address   the  degree  to  which  both  forms  of  courage  (heroic  and  fortitude)  can  help  to  counter  the   potential  for  creating  and  exacerbating  injustice  in  public  health.   Some  analyses  of  public  health  draw  attention  to  the  ways  in  which  health  promotion   and  risk  communication  strategies  can  serve  to  reinforce,  create,  and  exacerbate  forms  of   social  ostracism.  Health  promotion  exemplifies  a  shift  in  modern  understandings  of  risk:   “whereas  what  assails  the  individual  was  previously  considered  a  ‘blow  of  fate’  sent  by  God  or   nature  (e.g.,  war,  natural  catastrophes,  death  of  a  spouse),  it  is  now  much  more  likely  to  be   events  that  are  considered  a  ’personal  failure,’  such  as  not  passing  an  examination,   170 unemployment  or  divorce.”    As  a  result,  public  health  campaigns  can  result  in  the  creation  of   expectations  that  individuals  will  constantly  pursue  self-­‐regulation  and  self-­‐improvement  in   171 order  to  avoid  culpability  in  their  own  ill  health.    Insofar  as  individuals  fail  to  live  up  to  the   expectations  for  behavioral  modification  and  self-­‐reconstruction,  such  efforts  can  stigmatize   morbidity,  characterizing  infection,  chronic  disease,  or  disability,  as  due  to  lack  of  self-­‐control.     Stigmatization  is  a  process  by  which  “the  sick  are  not  only  made  responsible  for  their  illness,   172 they  are  also  made  different.”    As  I  mentioned  in  Section  3.3,  sometimes  such  blame  is                                                                                                                           170  Alan  Petersen,  “Foucault,  Health  and  Medicine,”  in  Foucault,  Health  and  Medicine,  ed.  Alan   Petersen  and  Robin  Burton  (Florence,  KY:  Routledge,  1997),  216.   171  Ibid.,  194.   172  Crawford,  “The  Boundaries  of  the  Self  and  the  Unhealthy  Other,”  1356.       130     assigned  as  a  way  of  denying  that  harm  can  happen  to  anyone,  but  it  is  also  a  way  of  avoiding   any  social  responsibility  for  remediation.           The  main  danger  is  that  public  health  interventions  may  increase  the  tendency  to   connect  health  and  normality  with  moral  worth. 173    Because  epidemiology  and  prevention  use   counterfactual  notions  of  causation,  the  profession  has  the  potential  to  construct  a  conception   of  the  self  as  malleable.    In  doing  so,  public  health  can  participate  in  the  cultural  construction  of   two  forms  of  social  identity,  one  actual  and  one  virtual.      When  the  moral  valance  of  these  two   selves  is  significantly  different,  the  result  is  a  discrepancy  between  the  actual  and  virtual   174 versions  of  social  identity,  i.e.,  a  stigma.    This  discrepancy  can  mark  a  person  as  not  merely   different  from  who  she  could  have  been,  but  “in  the  extreme,  a  person  who  is  quite  thoroughly   bad,  or  dangerous,  or  weak.” 175    Thus,  public  health,  in  constructing  a  self  that  is   counterfactually  distinguishable  from  a  self  that  otherwise  could  have  been,  creates  the   opportunity  for  stigmatization.     Furthermore,  when  the  metaphorical  language  comparing  epidemics  to  war  are   interpreted  too  literally,  the  resulting  stigmatization  and  victim-­‐blaming  can  result  in  a   tendency  to  treat  the  infected  as  enemies,  rather  than  as  vectors  or  survivors.    In  the  context  of   quarantine  implementation,  viewing  the  sick  as  the  source  of  the  threat  can  create  a  climate   rife  with  the  potential  for  violations  of  human  rights.    Even  if  the  infected  are  not  equated  with                                                                                                                           173  Petersen,  “Foucault,  Health  and  Medicine,”  198.   174  Erving  Goffman,  Stigma:  Notes  on  The  Management  of  Spoiled  Identity  (Englewood  Cliffs,   NJ:  Prentice-­‐  Hall,1963),  Chapter  1.   175  Ibid.,  3.       131     an  “invading  force,”  the  language  of  war  may  imply  that  such  individuals  can  be  considered   “collateral  damage”  in  the  efforts  to  win  the  battle  against  the  spread  of  disease.         Outside  the  context  of  infectious  disease,  chronic  disease  can  be  feared  on  the  basis  of   biased  opinions  that  the  disabled  experience  a  lower  quality  of  life. 176    Indeed,  public  health   practices  like  pre-­‐natal  screening  have  been  accused  of  perpetuating  the  notion  that  disabled   lives  are  less  worthy,  or  even  not  worth  living  at  all. 177    The  arguments  as  to  what  extent  such  a   position  is  defensible  are  too  in-­‐depth  to  consider  here.    However,  what  I  wish  to  draw   attention  to  are  the  possibility  that  public  health  can  fail  to  adequately  distinguish  between  the   fearsome  prospect  of  a  disease,  and  the  fearsome  prospect  of  the  stigma  that  accompanies  the   disease.    The  harms  that  come  from  each  are  difficult  to  extricate  from  each  other,  but  the  lens   of  courage  may  be  of  service  to  public  health  professionals  by  calling  on  them  to  think  clearly   about  what  harms  we  ought  to  fear.    Thus,  courage  can  support  the  observation  that  the  good   life  is  more  open  to  those  with  disabilities  that  is  commonly  assumed:   brief  acquaintances  with  people  who  have  disabilities  and  who  work,  play,  study,   love,   and   enjoy   the   world   should   demonstrate   that   few   conditions   preclude   participating   in   the   basic   activities   of   life,   even   if   some   conditions   limit   some   classes  of  them,  or  methods  of  engaging  them. 178   By  illustrating  that  some  diseases  do  not  impose  the  harms  we  often  think  they  do,  such   observations  clarify  the  need  for  proper  attitudes  of  fear  in  public  health.    Public  health   professionals  must  be  open  to  conversations  about  which  forms  of  disease  entail  a  lower                                                                                                                           176  Trude  Arnesen  and  Erik  Nord,  “The  Value  of  DALY  Life:  Problems  with  Ethics  and  Validity  of   Disability  Adjusted  Life  Years,”British  Medical  Journal  319,  no.  7222  (1999):  1423–5.   177  Adrienne  Asch,  “Disability  Equality  and  Prenatal  Testing:  Contradictory  or  Compatible,”   Florida  State  University  Law  Review  30  (2003):  315.   178  Ibid.,  3204.       132     quality  of  life,  and  why.    Thus  part  of  the  contribution  of  courage  is  in  part  to  call  on   professionals  to  seriously  question  what  detriments  to  human  health  are  truly  fearsome,  and  to   avoid  overreaction  to  any  risk  of  illness.    If  professionals  incorrectly  identify  a  malady  as   something  fearsome,  they  may  attempt  to  protect  others  when  unnecessary.    Insofar  as  such   protection  is  based  on,  or  perpetuates,  faulty  views  of  the  quality  of  life  such  individuals  lead,   179 they  are  arguably  unjust.       In  conclusion,  courageous  public  health  professionals  will  need  to  attend  to  the   possibility  of  fear  that  leads  to  injustices  such  as  stigma,  but  also  to  overcome  their  own  fear  of   reprisal  for  speaking  out  against  injustices  supported  or  created  by  public  health  itself.    Thus,   one  can  envision  that  both  forms  of  courage  –  heroic  and  enduring  fortitude  –  will  be  necessary   in  public  health  efforts  as  far  ranging  as  whistle-­‐blowing  to  redressing  health  disparities.    It  is  in   such  work  that  public  health  professionals  have  the  potential  to  prove  themselves  to  be  those   who  may  not  share  stigmatization,  but  understand  and  sympathize  with  those  who  experience   the  harmful  effects  that  reflect  injustice,  not  misfortune.    In  such  circumstances,  public  health   professionals  can  prove  themselves  to  be,  in  a  sense,  “wise”  to  the  flaws  of  some  societal   attitudes,  and  join  in  conversations  regarding  the  comparative  harms  injustice  causes  relative  to   harms  of  the  illness  itself. 180    In  demonstrating  such  understanding,  the  courageous  reveal  a                                                                                                                           179  This  argument  is  not  meant  to  endorse  an  expressivist  view  that  all  public  health  actions  to   forestall  illness  imply  that  unhealthy  lives  are  less  worth  living.    Rather,  because  some   evaluations  of  disability  and  illness  are  arguably  faulty,  public  health  professionals  should  avoid   perpetuating  such  problematic  misconceptions  and  be  aware  of  the  possibility  that  the  harms   of  some  health  conditions  arise  from  societal  attitudes.    For  a  very  different  view,  cf.  Ronald   Bayer,  "Stigma  and  the  ethics  of  public  health:  Not  can  we  but  should  we,"  Social  Science  and   Medicine.  67  (2008):  463-­‐72.   180  Goffman,  "Stigma,"  28.       133     nexus  of  virtue,  public  health  ethics,  and  their  compatibility  with  human  rights,  where  the  locus   of  attention  is  fixed  on  the  ways  in  which  those  “at  the  margins  of  society”  often  bear  the   181 burdens  of  disease.     3.5  Institutional  Courage   One  objection  to  the  virtue  approach  I  have  suggested  here  is  that  it  merely  shifts  and   amplifies  the  rhetoric  of  blame  to  public  health  professionals.    By  explicitly  characterizing  public   health  responses  to  risk  in  terms  of  cowardice  and  rashness,  some  would  argue  we  merely   entrench  a  problematic  moralization  of  public  policy.    This  argument  claims  that  the  problem  is   not  that  the  imagery  of  cowardice  and  rashness  is  implicit,  but  that  it  ought  to  be  eliminated   from  risk  discourse  entirely.    Attributing  errors  in  public  health  to  failures  in  moral  character  of   professionals  merely  facilitates  the  tendency  to  seek  scapegoats,  rather  than  legitimately   improve  accountability  in  public  health.    The  objection  against  character,  however,  does  have   merit  in  that  not  all  errors  in  public  health  policy  are  moral  errors,  and  not  all  moral  errors  are   solely  attributable  to  human  character.    The  human  proclivity  for  seeking  to  blame  someone’s   human  frailty  when  things  go  wrong  may  be  a  reason  to  examine  other  sources  that  lead  to   mistakes,  including  the  main  concern  of  risk  assessors  –  uncertainty  and  ignorance  –  as  well  as   the  structures  that  surround  moral  agents  that  contribute  to  moral  and  immoral  behaviors.     Thus  the  concern  for  a  downside  to  talk  about  virtues  in  public  health  policy  is  also  tied  to  the   more  theoretical  objection  that  virtue  ethics  tends  to  focus  too  exclusively  on  the  individual,   and  so  may  be  an  inappropriate  match  to  public  health  activities.    I  hope  that  my  analysis  of                                                                                                                           181  Mann,  “Medicine  and  Public  Health.”       134     courage  so  far  reveals  that  concern  for  character  is  at  play  even  in  policy,  but  I  have  also   throughout  identified  a  need  to  place  the  virtues  in  their  proper  setting.    Excellence  of   character,  for  all  of  the  ancients,  does  not  emerge  from  the  ether.    Thus  the  question  of   whether  the  virtues  can  be  learned,  and  how  it  is  that  the  ancients  seemed  to  think  institutions   could  be  virtuous,  will  be  important  for  a  virtue  ethics  of  public  health  to  spell  out.         I  believe  that  virtue  ethics  offers  us  the  resources  to  meet  this  critique  by  forging  a   strong  link  between  structural  forces  and  personal  character.    Central  to  ancient  discussions  of   virtue  are  notions  of  moral  education,  development,  and  how  one  acquires  the  virtues.  For   Aristotle,  the  process  of  a  habituation  is  learning  until  something  has  become  internalized,  or   second  nature. 182    For  virtue  theorists,  understanding  moral  behavior  in  terms  of  who  a  person   has  become  is  to  simultaneously  direct  attention  to  the  social,  and  in  this  case  professional,   structures  that  mold  character  and  create  incentives  and  disincentives  for  right  action.      In  reply   to  the  concern  that  virtue  ethics  will  merely  foster  witch  hunts  for  professional  “bad  apples”   when  things  go  poorly  in  public  health,  a  virtue  ethics  of  public  health  points  to  the  professional   tradition  in  which  individual  public  health  workers  are  trained.    Virtue  cannot  be  separated   from  such  practices;  on  the  contrary,  it  is  what  makes  them  possible  both  by  creating  them,  but   also  by  creating  the  context  which  lends  them  value:  “the  ability  of  a  practice  to  retain  its   integrity  will  depend  on  the  way  in  which  the  virtues  can  be  and  are  exercised  in  sustaining  the   institutional  forms  which  are  the  social  bearers  of  the  practice.” 183    To  grossly  simplify,  it  is                                                                                                                           182  M.  F.  Burnyeat,  “Aristotle  on  Learning  to  Be  Good,”  in  Essays  on  Aristotle’s  Ethics,  ed.   Amelie  Rorty  (Berkeley:  University  of  California  Press,  1980),  69–92.   183  Alasdair  MacIntyre,  After  Virtue:  A  Study  in  Moral  Theory,  3rd  ed.  (Notre  Dame:  University   of  Notre  Dame  Press,  2007),  195.       135     impossible  to  be  an  excellent  public  health  professional  without  public  health.    A  virtue  ethics   approach  to  public  health  would  frame  the  question  of  how  this  one  professional  came  to  err  in   terms  of  how  the  institutions  of  public  health  facilitate  or  condone  such  errors.     The  possibility  that  institutions  can  be  the  bearers  of  character  predicates  like   “trustworthiness”  was  addressed  in  Chapter  2,  via  either  an  aggregate  or  collective  approach.     But  to  call  organizations  “courageous”  seems  to  stretch  the  imagination  even  more.     Institutional  trustworthiness  required  the  attribution  of  intent  or  attitudes  of  goodwill  to   groups  who  create  and  inhabit  structures  and  implement  practices.    Insofar  as  institutions  are   designed  both  to  cultivate  individual  virtue  and  to  forestall  the  possibility  of  inappropriate   collective  reactions  to  fear,  I  would  argue  they  could  be  said  to  be  virtuous.  The  connection  of   habituation  to  institutional  courage  can  also  be  found  in  Plato,  where  Socrates  observes  that  it   is  through  training  that  soldiers  “absorb”  beliefs  about  what  to  fear  and  how  to  respond.  (Rep.   IV,  429b-­‐430b)    And  yet,  Socrates  wishes  to  ascribe  the  virtue  of  courage  not  to  the  soldiers,  but   to  the  city,  by  virtue  of  its  capacity  to  cultivate  courage  in  its  soldiers.    It  does  so,  claims   Socrates,  via  its  “power  to  preserve  through  everything  belief  about  what  things  are  to  be   feared”  (Rep.  IV,  429c)  Thus,  institutions  that  (1)  cultivate  appropriate  attitudes  of  fear,  (2)   establish  awareness  of  what  public  health  can  accomplish,  and  (3)  inspire  the  boldness  to  act   can  be  said  to  be  courageous.    By  giving  greater  prominence  to  the  communal  nature  of   courage,  an  organization  “cannot  deny  that  it  has  any  influence  on  the  courage  shown  by  its   184 members  on  the  ground  that  courage  is  only  a  matter  for  individuals…”  In  developing                                                                                                                           184  Howard  Harris,  “Courage  As  A  Management  Virtue,”  Business  &  Professional  Ethics  Journal   18,  no.  3/4  (1999):  40.       136     accounts  of  how  institutions  cultivate  courage,  or  fail  to,  a  virtue  ethics  of  public  health   supports  greater  accountability  in  public  health  leadership.         3.6  Courage  and  Prudence     In  addition  to  Aristotle’s  account  of  virtue,  the  work  of  Plato  can  also  provide  insight   into  the  ancient  notion  of  the  character  trait  that  both  guides  our  understanding  of  –  and  our   reactions  to  –    what  inspires  fear.    In  this  section,  I  examine  Plato’s  analysis  of  courage  in  the   dialogue  of  the  Laches. 185    In  her  recent  analysis  of  courage,  Linda  Rabieh  identifies  the   Platonic  discussion  of  courage  as  a  series  of  revelations  regarding  conceptual  puzzles  regarding   186 the  nature  of  courage,  including  the  relationships  of  courage  to  knowledge.    Within  the   Laches,  the  character  of  Nicias  serves  as  a  foil  to  Laches’  refusal  to  view  courage  as  requiring   wisdom.    In  this  section,  I  consider  such  prospects  in  part  because  in  times  of  uncertainty,  it  is   natural  to  identify  prudence  as  a  solution  and  guide  for  practical  action.    In  this  section  I  point   to  the  ways  in  which  courage  is  a  distinct  character  virtue  related  to  the  capacity  for  practical   wisdom.     Laches  is  unable  to  defend  his  definition  of  courage  because  he  fails  to  understand  the   importance  of  an  external  goal.    Believing  that  courage  ought  to  be  chosen  for  its  own  nobility,   Laches’  view  of  courage  cannot  be  distinguished  from  risk-­‐taking  for  the  sake  of  risk-­‐taking.    The   other  participant  in  the  dialogue,  Nicias,  hopes  to  shed  further  light  on  the  virtue  of  courage  by                                                                                                                           185  Plato,  Plato:  Complete  Works,  ed.  John  M.  Cooper  and  D.  S.  Hutchinson  (Indianapolis:   Hackett  Publishing  Co.,  1997).   186  Linda  R.  Rabieh,  Plato  and  the  Virtue  of  Courage  (Baltimore:  The  Johns  Hopkins  University   Press,  2006).       137     avoiding  the  unsavory  conclusion  that  courage  requires  us  to  praise  the  foolhardy.    He  does  so   by  trying  to  articulate  a  stronger  relationship  between  courage  and  prudence.  Although   Socrates  often  seems  to  advocate  for  the  view  that  virtue  is  knowledge,  the  notion  that   knowledge  helps  to  differentiate  the  virtuous  from  the  vicious  has  appeal  in  contemporary   times  as  well.    In  Chapter  3  we  saw  that  knowledge  (including  skill)  in  the  form  of  competency   can  provide  a  foundation  for  trust  in  public  health  professionals.    Similarly,  knowledge  of  what   pathogens  or  public  health  hazards  are  harmful,  how  they  are  harmful,  and  how  to  meet  such   harms,  can  provide  a  foundation  for  courage  within  the  public  health  professional.  Indeed,  just   as  Nichias  contends  that  knowledge  is  central  to  the  nature  of  courage,  those  in  public  health   that  characterize  risk  assessment  as  a  mostly  cognitive  endeavor  appear  to  align  themselves   with  a  similar  position.   187     The  difficulty  with  this  tack  is  that  Nichias  sets  the  bar  of  knowledge  required  for   courage  impossibly  high,  claiming  that  the  kind  of  knowledge  needed  is  extensive.    For   example,  Nicias  denies  that  doctors  can  be  courageous  because  while  they  may  know  what   course  of  action  will  likely  lead  to  health,  the  courageous  would  know  more  than  this;  they   188 would  know  whether  health  is  in  fact  in  the  interest  of  their  patients.    Thus,  Nicias  takes  a   position  similar  to  the  one  I  outlined  in  Chapter  2  regarding  the  need  to  recognize  not  just  a   component  of  the  good  life  (health),  but  its  place  relative  to  other  goods.    While  I  argued  there                                                                                                                           187  This  is  especially  the  case  because  Nicias  initially  seems  to  identify  the  kind  of  knowledge   needed  for  courage  as  scientific  (episteme.)  Through  the  elenchus  (196d-­‐199e),  Socrates   reveals  that  the  kind  of  knowledge  at  play  in  courage  is  wisdom  (sophia),  while  others  still   believe  that  prudence  is  what  is  at  stake.  See  Rabieh,  “Plato  and  the  Virtue  of  Courage,”   Chapter  3  especially  p.  69.   188  Rabieh,  "Plato  and  the  Virtue  of  Courage,"  71–7.       138     that  such  perspective  sets  the  backdrop  for  relationships  of  trust,  Nicias  considers  complete   knowledge  of  the  good  as  constitutive  of  courage  as  well.  Nichias’  standard  of  knowledge  for   the  courageous  is  so  demanding  as  to  require  extensive  understanding  of  “the  grounds  of  fear   and  hope”  as  well  as  profound  insight  into  the  future.  (Lch.  196d;  198c)  Insofar  as  Nichias  goes   too  far  in  expecting  complete  understanding,  his  view  arguably  represents  some  of  what  is   concerning  about  the  search  for  enough  evidence  to  adequately  quantify  probabilities  during   the  course  of  risk  assessment.    Just  as  some  scientists  worry  that  evidentiary  standards  can  be   set  too  low,  those  concerned  for  public  safety  may  worry  that  such  standards  are  too   demanding.  Nicias  illustrates  to  us  how  expecting  such  firmly  grounded  foresight  can  be   mistakenly  identified  as  the  proper  response  to  fear  of  possible  harm,  i.e.,  in  circumstances  of   uncertainty  one  may  expect  that  the  proper  solution  is  to  seek  certainty.    The  Socrates  of  the   Laches  reveals  to  us  not  only  that  such  expectations  may  be  unrealistically  high,  but  that  the   kind  of  knowledge  Nichias  has  in  mind  is  not  merely  an  empirical  matter,  but  one  that  is  also   extraordinarily  moral;  to  have  complete  knowledge  of  “practically  all  goods  and  evils  put   together”  is  to  be  aiming  for  complete  virtue,  not  the  single  virtue  known  as  courage.  (Lch.   199d-­‐e)     The  Laches,  then,  is  partly  an  anticipation  of  one  possible  objection  to  the  arguments   presented  here,  and  my  main  contention  that  courage  is  the  character  trait  most  suited  to  risk   discourse  in  public  health.    Such  an  objection  would  counter  that  what  is  needed  is  not  courage,       139     189 but  prudence  itself.    This  seems  to  be  what  Pellegrino  and  Thomasma  had  in  mind  when   they  envisioned  the  role  of  prudence  in  clinical  medicine:   In   the   maelstrom   of   anxiety,   uncertainty,   and   urgency   characteristic   of   the   medical   encounter,   it   is   the   virtue   of   prudence   to   which   we   turn   to…Such   a   conclusion  is  worrisome  for  those  who  see  clinical  decision  making  as  an  exercise   in   probability   and   stochastic   reasoning   or   game   theory.     There   is   nothing   intrinsically  wrong  with  trying  to  make  the  process  of  moral  choice  as  rigorous,   explicit,   and   theoretically   sound   as   possible,   or   even   the   constructing   moral   algorithms.    What  must  be  kept  in  mind,  however,  is  that  at  every  junction,  some   prudential   assessment   of   competing   values,   principles,   or   virtues   must   be   made.     Without  such  decisions,  the  branching  decision-­‐making  tree  must  stop  growing.     Like   it   or   not,   the   decision   analyst,   as   well   as   the   clinician   whose   thought   190 processes  he  wishes  to  describe,  use  prudence.       And  indeed,  we  have  good  reason  to  consider,  in  public  health  matters,  whether  even   risk  is  the  appropriate  terminology  to  be  using.    For  example,  some  research  shows  that  when   individuals  engage  in  choices  about  food,  they  do  not  frame  such  choices  in  terms  of  risk  or   fear;  rather,  such  individuals  seem  concerned  with  aiming  toward  an  ideal,  rather  than  avoiding   or  facing  something  potentially  harmful.    As  Judith  Green  observes  in  the  context  of  analyzing   consumers’  food  selection,  “one  could  frame  this  [concern  with  nutrition]  as  about  ‘risk,’  in  that   it  relates  to  balancing  the  long  term  risks  to  health  for  their  families,  but  this  would  be  a   191 warping  of  the  data,  which  seemed  to  reflect  more  a  concern  with  a  ‘good  life…’”    Thus,  the   argument  for  prudence  is  a  claim  that  sometimes  risk  is  not  what  is  at  issue,  and  what  a  virtue   ethics  account  requires  is  a  more  general  character  trait,  one  that  is  involved  in  decision-­‐making                                                                                                                           189  Weed  and  McKeown,  “Epidemiology  and  Virtue  Ethics.”;  For  prudence  as  a  guide  during   times  of  uncertainty  see  Cynthia  M.  Geppert,  “Prudence:  The  Guide  for  Perplexed  Physicians  in   the  Third  Millienium,”  Pharos  58  (1995):  2–7.     190  Pellegrino  and  Thomasma,  "Virtues  in  Medical  Practice,"  89.   191  Judith  Green,  “Is  It  Time  for  the  Sociology  of  Health  to  Abandon  ‘Risk’?,”  Health,  Risk  and   Society  11,  no.  6  (2009):  499.       140     about  the  good  life  more  broadly.    To  characterize  many  human  behaviors  that  relate  to  health   in  terms  of  risk  is  to  read  risk  into  such  actions  inappropriately;  to  assume  that  courage  is   required  is  to  expect  that  fear  is  at  play.    The  case  for  prudence,  then,  is  in  part  a  claim  that  the   risk  mentality  currently  dominates  decision-­‐making,  and  that  we  ought  to  be  careful,  both   192 descriptively  and  normatively,  before  we  assume  that  such  a  framework  is  more  salient.     In  public  health  there  are,  however,  times  when  an  understanding  of  the  good  and  the   bad  more  generally,  or  an  articulation  of  a  vision  of  a  ‘good  life’  may  be  pertinent  to  public   discourse.    I  argued  in  Chapter  2  that  some  mistaken  justifications  of  public  health  paternalism   miss  this  point.    In  addition,  the  nutrition  example  above  indicates  that  health  promotion  may   be  more  concerned  with  what  we  wish  to  strive  toward  than  the  harms  to  health  that  inspire   aversion  and  fear.    This  possibility  indicates  that  public  health  professionals  may  be  primed  to   view  public  health  practice  in  terms  of  detriments,  not  ideals,  and  the  call  for  greater  prudence   may  facilitate  greater  caution.    But  in  many  cases  of  public  health  emergencies,  in  epidemics  or   natural  disasters,  in  occupational  safety,  and  environmental  contamination,  public  health   professionals  will  need  the  perspective  and  attitudes  of  courage  to  guide  their  reactions  to   fearsome  prospects.      I  contend  that  such  a  character  trait  has  distinct  value  in  public  health   practice  than  the  benefits  of  prudence.   As  Nichias  shows  us,  it  is  possible  to  reach  for  a  more  generalized  knowledge,  or   knowledge  with  a  wider  domain,  than  is  required  when  seeking  grounded  responses  to   fearsome  prospects.      Nichias  initially  considers  the  wisdom  necessary  to  be  scientific   knowledge,  but  Socrates  reveals  that  he  has  all  knowledge  of  the  good  in  mind,  or  all  of  virtue                                                                                                                           192  Ibid.,  507.       141     (Lch.,  199e),  and  an  Aristotlean  would  most  likely  counter  that  perhaps  what  Nichias  has   characterized  is  the  “capstone”  virtue  of  phronesis,  or  practical  wisdom.    But  character   excellence,  like  courage,  and  prudence  are  meant  to  work  in  conjunction  –  they  are  not  the   same  kind  of  character  virtues.    For  Aristotle,  virtue  is  what  helps  moral  agents  identify  good   ends,  and  prudence  (practical  wisdom)  is  the  faculty  that  enables  moral  agents  to  select   appropriate  means  to  achieve  these  ends.  (NE  VI.12  1144a8)    Thus,  virtue  and  prudence  are   always  employed  together.    It  is  beyond  my  resources  here  to  delineate  the  complex   relationship  between  prudence  and  courage.    I  will  merely  claim  that  if  we  are  to  seek  a   character  excellence  –  a  virtue  –  that  helps  professionals  evaluate  the  prospect  of  a  harm,   assess  their  own  capacities  for  success,  and  muster  their  own  boldness,  then  courage  is  the  trait   we  seek.      Prudence  may  be  employed  wherever  virtues  are  realized,  but  courage  provides  a   particular  guide  in  response  to  fear.     In  conclusion,  the  focus  on  many  writings  in  risk  is  “on  the  ‘rational’  strategies  that   people  adopt  when  conceptualizing  and  dealing  with  risk.    They  have  much  less  to  say  about   the  ways  in  which  risk  discourse  tends  to  operate  at  a  more  latent,  extra-­‐rational  level  of   meaning.” 193      By  making  character  a  central  part  of  public  health  responses  to  public  health   hazards,  virtue  ethics  helps  to  place  the  ethical  subtext  of  risk  discourse  at  center  stage.    It  does   so  in  part  by  articulating  how  and  why  ethical  attitudes  ought  to  be  a  part  of  professional   responses  to  health  hazards,  rather  than  artificially  relegating  emotions  and  values  to  a  realm                                                                                                                           193  Deborah  Lupton,  “Food,  Risk,  and  Subjectivity,”  in  Health,  Medicine,  and  Society:  Key   Theories,  Future  Agendas,  ed.  Jonathan  Gabe,  Michael  Calnan,  and  Simon  J.  Williams  (London:   Routledge,  2000),  205–18.       142     outside  public  policy.    I  have  argued  here  that  making  more  explicit  the  language  of  the  virtue   of  courage  already  at  play  in  risk  discourse  can  provide  greater  clarity  to  both  the  rational  and   “extra  rational”  aspects  of  such  decision-­‐making.  In  addition,  I  contend  that  the  virtues  of   courage  offers  us  a  conception  of  psychologically  how  such  rational  and  affective  aspects  can   combine  to  support  both  inappropriate  and  appropriate  action.         143       CHAPTER  4:  THE  BOUNDARY  PROBLEM  AND  THE  SCOPE  OF  PUBLIC  HEALTH   4.1  The  Boundary  Problem     To  take  a  virtue  ethics  approach  to  public  health  is,  in  part,  to  ask  what  unites  the  public   health  community  –  what  shared  ends  and  practices  are  commonly  held  to  be  standards  by   which  individual  actions  and  motivations  can  be  assessed.  Under  this  approach,  virtue  ethics   attempts  to  articulate  the  professional  standard  that  can  serve  as  a  “regulative  ideal”:   to  say  that  an  agent  has  a  regulative  ideal  is  to  say  that  they  have  internalized  a   certain   conception   of   correctness   or   excellence,   in   such   a   way   that   they   are   able   to   adjust   their   motivation   and   conduct   so   that   it   conforms   –   or   at   least   does   not   conflict  –  with  that  standard. 194   This  articulation  of  ideals  is  broader  than  a  mere  identification  of  professional  goals.    Rather,  the   ergon,  or  function,  of  public  health  includes  the  goals  (telos),  but  also  includes  standards  that   regulate  the  methods  by  which  such  goals  are  attained.    Aristotle  identified  this  aspect  of   teleology  in  the  function  argument.  (NE  I.7  1097b24-­‐1098a29)  By  focusing  on  activity  a  virtue   approach  links  the  means  and  ends  of  practices  to  an  integrated  standard  of  behavior  that   incorporates  a  concern  for  both  outcomes  and  the  methods  used  to  attain  these.    The  function   argument  also  links  virtues  to  an  agent’s  happiness  –  frustrated  attempts  to  perform  one’s   function  (due  to  vicious  character,  ignorance  of  the  proper  ends,  inexperience  in  achieving  these   ends,  or  poor  fortune)  will  result  in  an  incomplete  life.    In  this  chapter,  I  present  reasons  to   conclude  that  this  account  of  a  good  life  has  its  parallel  in  the  public  health  profession,  and  that  a   virtue  approach  offers  both  resources  to  approach  the  boundary  problem,  and  explanatory                                                                                                                           194  Justin  Oakley  and  Dean  Cocking,  Virtue  Ethics  and  Professional  Roles  (Cambridge:   Cambridge  University  Press,  2006),  25.       144     power  to  account  for  why  confusion  about  the  functions  of  public  health  account  for  professional   investment  in  both  initiating  and  relying  on  the  outcome  of  the  debate.     The  boundary  problem  in  public  health  concerns  how  public  health  problems  ought  to  be   identified  or  defined.    While  core  concerns  like  sanitation  and  contagious  diseases  provide   uncontested  examples  of  what  falls  within  the  scope  of  public  health,  problems  like  obesity,   violence,  and  income  inequality  are  all  disputed  objects  of  public  health  attention.      Positions  in   debates  on  the  boundary  problem  are  often  labeled  as  advocacy  for  “narrow”  versus  “broad”   approaches  to  public  health.    As  Powers  and  Faden  observe,  “part  of  what  may  make  such  diverse   things  as  war,  social  response  to  natural  disasters  and  environmental  hazards,  and  political   oppression  unjust  is  their  effect  on  health.    In  this  sense,  they  are  all  public  health  problems.” 195     Advocates  of  the  narrow  approach,  however,  are  concerned  that  an  ambitious  public  health   program  will  outstrip  the  political  will,  professional  expertise,  and  legitimate  limits  placed  on   public  authority.   196   This  chapter  consists  of  two  sections.    In  the  first,  I  consider  different  candidate  features   of  public  health  that  are  often  proposed  to  mark  the  field  as  distinctive  from  any  other.    Such   features  are  often  the  starting  points  for  articulating  the  goals  (telos)  of  public  health  (e.g.,  if   causal  determinants  of  disease  are  the  significant  features  of  public  health,  then  the  goal  of   public  health  may  be  to  disrupt  such  causal  mechanisms).  I  consider  the  merits  of  these  “models”                                                                                                                           195  Powers  and  Faden,  "Social  Justice,"  83;  for  another  example  of  arguments  in  favor  of  the   broad  approach,  see  Daniel  S.  Goldberg,  “In  Support  of  a  Broad  Model  of  Public  Health:   Disparities,  Social  Epidemiology  and  Public  Health  Causation,”  Public  Health  Ethics  2,  no.  1   (2009):  70–83.   196  See  for  example  Lawrence  O.  Gostin,  “Public  health,  ethics,  and  human  rights:  A  tribute  to   the  late  Jonathan  Mann,”  The  Journal  of  Law,  Medicine  and  Ethics  29,  no.  2  (2001):  121-­‐30,   especially  122–3.       145     of  public  health,  but  also  their  limitations  and  especially  their  potential  to  lead  to  problematic  or   objectionable  forms  of  “publichealthification.”    In  the  second  section,  I  provide  an  Aristotelian   account  of  hamartia,  or  missing  the  mark,  that  helps  to  capture  a  more  complex  picture  of  goal-­‐ oriented  behavior  by  collectives,  not  merely  by  individuals.    I  then  consider  what  resources  a   virtue  account  can  muster  in  order  to  provide  guidance  for  how  inquiry  into  a  philosophy  (and   ethics)  of  public  health  may  proceed.    I  then  conclude  with  some  considerations  of  the   implications  for  professional  flourishing.     4.2  Models  of  Public  Health     There  are  many  different  ways  professionals  could,  and  do,  go  about  defining  public   health  to  gain  greater  clarity  about  the  legitimate  goals  and  accurate  scope  of  the  profession.    It  is   a  common  method  to  identify  a  feature  of  public  health  practice  that  is  meant  to  be  unique  to   the  discipline.    While  the  following  list  is  not  meant  to  be  exhaustive,  I  consider  the  relative   merits  of  models  that  focus  on  the  following  distinctive  features  of  public  health:  causation,   critical  mass,  prevention,  collective  action,  redefinitions  of  health,  and  governmental  authority.   While  curative  medical  ethics  has  its  sister  discipline  of  philosophy  of  medicine,  an  ethics  of   public  health  must  also  have  a  philosophy  of  public  health  to  clarify  its  functions.       The  Causation  Model:  One  approach  focuses  on  disease  etiology  as  the  significant  feature  of   public  health  problems. 197    By  focusing  on  those  causal  factors  for  which  there  is  strong   epidemiological  evidence  of  causal  connection,  public  health  professionals  might  be  thought  to                                                                                                                           197  See,  for  example,  Bruce  G.  Link  and  Jo  Phelan,  “Social  Conditions  As  Fundamental  Causes  of   Disease,”  Journal  of  Health  and  Social  Behavior  35  (1995):  80–94.       146     provide  an  empirical  justification  for  the  professional  boundaries.    It  is  not  clear  how  far  out  in  a   causal  mechanism  a  determinant  may  be  if  it  is  to  count  as  a  public  health  problem.    A  focus  on   causes  too  proximal  to  individual  sickness  treads  on  the  toes  of  curative  medicine  by  approaching   what  leads  to  disease  in  a  particular  case,  rather  than  in  society  more  widely.    A  focus  on  causes   too  distal  risks  what  Meyer  and  Schwartz  call  “publichealthification,”  or  the  transformation  of  a   phenomenon  previously  not  associated  with  either  the  public  or  with  health  into  one   198 characterized  by  both  such  aspects.     The  causation  model  of  determining  the  scope  of  public  health  reveals  the  aptness  of  the   term  “boundaries;”  it  is  likely  that  some  causes  can  be  firmly  pinned  down  as  determinants  of   population  health,  while  the  importance  of  others  may  be  less  clear.      What  is  needed  is  not  only   an  account  of  determinants  of  public  health,  but  of  causal  significance.    As  others  have  argued,   public  health  professionals  might  deem  a  particular  determinant  significant  because  they  have   interventions  available  to  effectively  disrupt  that  determinant.199    Thus,  under  this  view,   expediency  is  one  reason  to  include  a  problem  under  the  public  health  banner.    This  implies  that   the  scope  of  public  health  will  expand  as  new  interventions  develop.    In  contrast,  the  impetus   behind  some  advocates  of  the  social  determinants  of  public  health  has  been  that  such  causal   forces  have  been  neglected  in  public  health.    The  significance  of  a  determinant  may  also  be  a   concern  for  correcting  an  oversight  committed  in  the  past.    In  addition,  a  philosophy  of  public   health  must  address  how  distal  causes  of  morbidity  and  mortality  rates  –  as  far  ranging  as                                                                                                                           198  Ilan  Meyer  and  Sharon  Schwartz,  “Social  Issues  as  Public  Health:  Promise  and  Peril,”   American  Journal  of  Public  Health  90,  no.  8  (2000):  1189–91.   199  Karhausen,  Lucien  R.,  ed.  “Causation  in  Epidemiology:  a  Socratic  Dialogue:  Plato.”   International  Journal  of  Epidemiology  30,  no.  4  (2001):  704–6.       147     socioeconomic  status,  public  transportation,  or  violence  –  are  also  causes  of  other  social  ills.    If   social  problems  have  a  public  health  aspect  to  them,  it  must  be  clear  how  public  health  resources   can  be  harnessed  to  mitigate  such  detriments  without  enveloping  the  entire  problem  under  the   umbrella  of  public  health.   The  Critical  Mass  Model:  An  alternative  way  to  identify  public  health  problems  is  to  claim  that   there  is  a  significant  level  or  threshold  incidence  of  disease  such  that  it  qualifies  as  a  public  health   problem.    Thus,  the  claim  that  a  disease  has  reached  “epidemic”  levels  is  a  reason  to  include  it  in   the  public  health  lexicon.    Public  health  discourse  regarding  obesity  in  the  United  States  arguably   follows  this  model,  perhaps  in  combination  with  causal  accounts  of  how  obesity  contributes  to   200 increased  morbidity  and  mortality.  Medicalization  of  obesity  dates  back  to  the  1950’s  but   arguably  also  gains  the  attention  of  public  health  around  the  same  time. 201    Initially  obesity  was   seen  by  the  public  health  community  as  a  risk  factor:  populations  with  greater  obesity  rates   exhibit  higher  rates  of  morbidity  with  regards  to  arthritis  and  Type  II  diabetes,  and  mortality  due   to  stroke  and  cardiovascular  disease.    As  new  metrics  reflect  increased  prevalence  of  obesity  in   both  developed  and  developing  contexts,  prevention  of  weight  gain  and  promotion  of  weight  loss   were  increasingly  accepted  as  a  major  concern  of  the  public  health  profession.       However,  as  Kerch  and  Morone  argue,  redefining  a  social  problem  as  a  public  health  one   in  part  requires  relocating  a  problem  fixed  in  the  private  sphere  into  the  public  sphere,  and  it  is                                                                                                                           200  Rogan  Kersh  and  James  Morone,  “How  the  Personal  Becomes  Political:  Prohibitions,  Public   Health,  and  Obesity,”  Studies  in  American  Political  Development  16,  no.  02  (2002):  162–175;  Cf.   Paul  Campos  et  al.,  “The  Epidemiology  of  Overweight  and  Obesity:  Public  Health  Crisis  or  Moral   Panic?,”  International  Journal  of  Epidemiology  35,  no.  1  (2006):  55–60.   201  Rebecca  K.  Simmons  and  Nicholas  J.  Wareham,  “Commentary:  Obesity  Is  Not  a  Newly   Recognized  Public  Health  Problem—a  Commentary  of  Breslow’s  1952  Paper  on  ‘Public  Health   Aspects  of  Weight  Control,’”  International  Journal  of  Epidemiology  35,  no.  1  (2006):  14–6.       148     202 not  obvious  that  the  process  is  complete  in  the  case  of  obesity.    The  authors’  examination  of   public  health  policy  implementation  indicates  that  empirical  evidence  of  increasing  incidence  is   insufficient  for  establishing  something  as  a  public  health  problem.    While  there  is  arguably  a  great   deal  of  public  interest  in  weight  loss,  such  measures  are  often  still  primarily  couched  in  private   terms  of  individual  self-­‐control,  rather  than  focusing  on  environmental  and  social  causes  that   effect  changes  at  the  level  of  population  health.  The  authors  present  an  overview  of  other   instances  of  “publichealthification”  –  from  prohibition  to  anti-­‐smoking  campaigns  –  that  indicate   the  importance  of  mass  movements,  or  popular  support  for  political  action.    Kerch  and  Morone   argue  that  the  subsequent  step,  policy  formation,  can  originate  from  a  variety  of  interest  groups,   among  which  public  health  professionals  are  included:  “perhaps  a  policy  actor  within  the  federal   203 government  could  play  the  same  role,  translating  protests  into  policies.”    According  to  this   view,  policy  formation  is  the  result,  not  the  cause,  of  “publichealthification.”  The  process  of   “publichealthification”  thus  bears  an  important  relationship  to  the  discussion  of  imaginative   engagement  I  mentioned  in  Chapter  1;  members  of  the  public  must  first  come  to  see  the   problems  they  experience  as  resultant  from  forces  outside  their  individual  control,  requiring  a   public  response.       It  is  a  mistake,  then,  to  oversimplify  public  health  problems  by  establishing  a  solely   quantitative  account  of  the  critical  mass  at  which  professionals  ought  to  become  concerned.    In   other  words,  it  matters  who  perceives  the  problem,  and  that  the  public  views  it  as  a  particular   kind  of  problem,  a  shared  or  collective  health  concern,  not  a  private  matter.    This  is  why  merely                                                                                                                           202  Kersh  and  Morone,  “How  the  Personal  Becomes  Political.”   203  Ibid.,  166.       149     documenting  a  significant  increase  in  the  incidence  of  disease  is  unlikely  to  be  sufficient  to   harness  public  health  resources.    Given  the  common  social  (and  arguably  problematic)   association  of  weight  with  personal  self-­‐control,  it  is  likely  that  a  critical  mass  approach  to   including  obesity  within  public  health  will  be  insufficient  because  it  fails  to  account  for  these   additional  elements  of  both  the  social  construction  of  public  health  problems,  and  the  practical   mechanisms  that  set  the  public  health  agenda. 204   In  addition,  the  metaphorical  language  invoked  by  referring  to  potential  public  health   problems  as  “epidemics”  can  be  stretched  too  far.    Take,  for  example,  the  argument  that   gambling  should  be  considered  a  public  health  problem:     Worldwide,   one   may   speak   of   the   expansion   of   gambling   as   a   "pandemic."   Groups   at   risk   of   developing   gambling   related   harms   may   be   termed   highly   "susceptible."   From   a   public   health   perspective,   we   can   characterize   the   prevention  of  gambling  related  problems  as  a  form  of  "prophylaxis,"  and  coping   skills  as  the  development  of  "resistance."  "Virulence"  may  develop  as  a  result  of   advances   in   technology   such   as   VLTs   [video   lottery   terminals].   Unwanted   gambling  environments  could  be  thought  of  as  "contaminated"  and  a  "reservoir"   205 for  problems.  There  may  be  a  need  for  "quarantine"  and  "disinfection."     Advocates  of  a  broader  public  health  agenda  are  pushed  by  the  critical  mass  approach  to  seek   parallels  between  their  candidate  problems  and  infectious  diseases,  which  are  paradigm   examples  of  a  public  health  problem.    Rothstein  is  correct,  however,  to  be  concerned  that  this   creates  confusion  as  to  when  it  is  legitimate  to  invoke  the  powerful  public  health  authority  to                                                                                                                           204  This  is  not  to  say  that  there  may  be  public  health  problems  that  go  unrecognized  by  the   public.    Given  the  degree  of  general  ignorance  regarding  what  constitutes  public  health  activity,   there  is  likely  to  be  a  difference  between  what  the  public  and  professionals  recognize  as  public   health  problems.    Nevertheless,  it  is  worth  asking  whether  such  differences  in  perspective   result  in  substantive  challenges  to  defining  the  boundaries  of  public  health,  rather  than   presenting  solely  practical  challenges  to  resolving  professionally-­‐identified  problems.   205  David  A.  Korn  and  Howard  J.  Shaffer,  “Gambling  and  the  Health  of  the  Public:  Adopting  a   Public  Health  Perspective,”  Journal  of  Gambling  Studies  15,  no.  4  (1999):  312.       150     use  coercive  action. 206    It  might  be  reasonable  to  call  for  quarantine  in  response  to  an   epidemic,  but  it  is  difficult  to  imagine  doing  so  due  to  the  “outbreak”  of  obesity  or  gambling.    It   is  equally  challenging  to  consider  what  about  such  health  conditions  would  justify  any  kind  of   limitation  on  civil  liberties  by  public  health  professionals.    Furthermore,  the  language  of   “contamination”  is  more  likely  to  result  in  a  public  health  reinforcement  of  the  social  stigmas   often  already  ascribed  to  those  with  “bad  habits.”    As  I  argued  in  Chapter  3,  public  health   professionals  have  an  obligation  not  to  exacerbate  stigmatization  and  to  do  their  best  to  design   policies  to  minimize  or  even  reduce  negative  social  attitudes  affixed  to  health  conditions.    The   symbolic  baggage  of  the  epidemic  metaphor  may  overwhelm  its  usefulness.   The  Prevention  Model:  It  is  also  commonly  asserted  that  the  distinctive  feature  of  public  health  is   its  focus  on  preventive  measures.  Rather  than  reacting  to  the  onset  of  disease,  disability,  and   death  by  providing  treatment,  public  health  seeks  to  be  proactive,  and  head  off  disease,   disability,  and  death  before  they  occur.    Thus,  one  approach  to  the  boundary  problem  is  to  claim   that  the  province  of  public  health  is  to  contend  with  only  those  health  outcomes  that  can  be   prevented.    For  example,  recent  advocates  of  using  public  health  resources  to  address   interpersonal  violence  argue  that  “the  essence  of  public  health  is  prevention,  and  it  is  that  very   essence  that  will  enable  the  public  health  community  to  address  the  issues  and  problems  [of   violence]  in  a  manner  that  complements  the  efforts  of  the  criminal  justice  system.” 207    Here,  the   authors  acknowledge  that  violence  is  not  solely  a  public  health  problem,  but  that  the  current                                                                                                                           206  Mark  A.  Rothstein,  “Rethinking  the  Meaning  of  Public  Health,”  The  Journal  of  Law,   Medicine  and  Ethics  30,  no.  2  (2002):  144–9.   207  Mark  L.  Rosenberg,  Patrick  W.  O’Carroll,  and  Kenneth  E.  Powell,  “Let’s  Be  Clear:  Violence  Is   a  Public  Health  Problem,”  The  Journal  of  the  American  Medical  Association  267,  no.  22  (1992):   3071.       151     categorization  of  the  problem  as  a  criminal  matter  results  in  limiting  public  response  to  reactive   measures,  not  proactive  ones.   On  this  preventive  view,  public  health  is  characterized  by  existing  public  health   methodologies  as  well  as  epidemiological  metrics  of  successful  interventions  that  indicate  new   avenues  for  prevention.    This  aspect  of  the  prevention  view  has  some  explanatory  power  by   capturing  the  changing  nature  of  public  health;  it  is  partly  the  increasing  evidence  for  social   determinants  of  health,  documentation  of  correlations  between  inequality  and  health,  etc.  that   have  initiated  and  bolstered  arguments  for  the  broad  approach.    Inter-­‐population  comparisons   are  especially  illuminating  as  they  reveal  the  potential  for  large-­‐scale  public  health  interventions   that  might  be  successful.  The  prevention  view,  when  combined  with  the  causation  model,   suggests  that  the  future  of  public  health  lies  in  developing  innovative  preventive  interventions   that  correspond  to  newly-­‐identified  determinants  in  addition  to  the  current  public  health  toolbox,   and  its  catalogue  of  previously-­‐identified  causal  factors.       One  drawback  to  this  approach  is  that  it  is  subject  to  an  interpretation  that  fails  to  place   any  reasonable  limits  on  the  preventive  efforts  of  public  health.    For  example,  public  health   professionals  might  aim  to  reduce  homeless-­‐related  morbidities  by  improving  mental  health   services  for  veterans.    However,  it  does  not  follow  that  public  health  ought  to  invest  resources   in  preventing  all  determinants  of  homelessness  itself.    For  example,  such  a  commitment  would   entail  public  health  involvement  in  foster  care,  or  preventing  children  and  adolescents  from   running  away  from  home,  which  are  also  contributing  factors  to  homelessness.    It  is  easy  to  slip   from  talk  of  preventing  outcomes  into  language  of  preventing  the  determinants  of  morbidity       152     and  mortality.    For  example,  public  health  professionals  speak  of  preventing  transmission  of  a   disease  in  order  to  prevent  the  spread  of  an  epidemic.       In  the  context  of  infectious  disease,  routes  of  transmission  are  arguably  the  sole  and   significant  modes  for  spreading  a  disease,  and  therefore  the  central  focus  of  public  health   efforts.    However,  in  directing  public  health  attention  to  structural  drivers  of  human  health   outcomes,  it  is  not  clear  that  public  health  can  be  similarly  focused.    As  Susser  et  al.  observe,   the  structural  forces  in  question  often  involve  dynamic  causal  pathways  and  feedback   mechanisms  that  are  not  easily  interrupted  at  one  point.    Thus,  while  psychiatric  disorders  are   highly  correlated  to  rates  of  homelessness,  so  are  low  levels  of  education,  housing  conditions,   and  disruptive  childhood  events  that  may  precipitate  entrance  into  foster  care  or  running  away.     Rates  of  homelessness,  and  as  a  result,  strategies  for  reducing  such  rates,  are  best  understood   in  terms  of  such  causal  interactions:     We  believe  that  the  role  individual-­‐level  risk  factors  play  in  homelessness  can   be  fully  understood  only  in  the  context  of  such  broad  societal  processes.  For   instance,   when   housing   is   scarce,   it   is   more   likely   that   the   functional   208 disabilities  of  a  person  with  mental  illness  will  lead  to  homelessness.     Advocates  of  the  broad  approach  to  public  health  are  correct  to  defend  the  claim  that   morbidity  and  mortality  rates  cannot  be  fully  understood  without  taking  into  account  social  and   structural  determinants  of  health.    However,  critics  of  this  approach  are  also  correct  that  the   209 broad  array  of  determinants  involved  goes  far  beyond  the  limits  of  public  health  expertise.     The  problem  of  homelessness  illustrates,  like  many  other  “broad”  candidate  public  health                                                                                                                           208  Ezra  Susser,  Robert  Moore,  and  Bruce  Link,  “Risk  Factors  for  Homelessness,”  Epidemiologic   Reviews  15,  no.  2  (1993):  552.   209  I  owe  this  point  to  Tom  Tomlinson.       153     problems,  the  importance  of  education  and  socioeconomic  status  in  determining  health   outcomes.    The  easy  slip  from  talking  of  preventing  health  outcomes  to  preventing  health   determinants  raises  the  question  of  whether  public  health  professionals  should  be  seriously   invested  in  reducing  secondary  education  attrition  rates,  or  in  the  foster  care  system.    In  other   words,  the  broad  approach  to  public  health  reveals  a  large  degree  of  interdependency  between   social  support  systems,  suggesting  a  greater  need  for  institutional  forms  of  cooperation.     However,  we  might  also  consider  whether  the  correlation  between  homelessness  and   education  and  disruptive  childhood  events  (for  example)  make  a  better  case  for  society  to   invest  in  education  and  health  and  social  work  rather  than  public  health.       The  prevention  approach  also  fails  to  acknowledge  that  prevention  is  a  central  aspect  of   clinical  medicine  as  well.    While  public  health  engages  in  prevention  of  disease  for  a  population,   such  efforts  can  and  do  often  overlap  with  medical  efforts  to  forestall  morbidity  and  mortality  in   an  individual  case.    It  is  not  enough  to  say  that  unqualified  prevention  is  involved.    Sometimes,   what  the  linguistic  slip  reveals  are  the  complex  relationships  between  elements  of  a  causal   network.    Rather  than  thinking  of  homelessness  as  a  public  health  problem  that  gives   professionals  good  reason  to  focus  on  public  mental  health  services,  narrow  approach  advocates   might  suggest  this  is  putting  the  cart  before  the  horse;  we  might  save  everyone  some  time  by   agreeing  that  increased  clinical  and  public  health  resources  ought  to  be  put  toward  improving   access  to  and  quality  of  mental  health  services.  On  such  a  view,  the  health  conditions  associated   with  homelessness  (like  hepatitis)  can  be  considered  co-­‐morbidities  of  psychiatric  illnesses.  Under   this  view,  individual  treating  physicians  can  arguably  handle  such  problems  better  than  public   health.    Or,  a  narrow  approach  advocate  might  claim,  the  health  detriments  of  homelessness       154     would  be  addressed  by  refocusing  on  mental  health  problems  within  public  health  –  something   much  more  palatable  to  traditionalists.      Thus,  the  argument  might  be  that  there  is  no  need  to   extend  public  health  prevention  to  all  determinants,  since  some  may  fall  under  the  clinical  realm,   and  elsewhere  might  be  accommodated  by  the  narrow  approach.      In  any  case,  it  will  be   important,  when  invoking  the  prevention  model,  for  advocates  to  not  merely  propound  the   importance  of  unqualified  prevention.    Rather,  the  broad  model  for  public  health  pushes  the   discipline  to  further  articulate  precisely  what  is  worth  preventing.   The  Collective  Action  Model:  The  most  commonly  cited  definition  of  public  health,  the  1988  IOM   definition,  employs  the  notion  of  collectivity:  public  health  is  “what  we,  as  a  society,  do   collectively  to  ensure  the  conditions  for  a  healthy  life.” 210    Thus,  one  way  of  identifying  public   health  problems  is  arguably  to  identify  those  health  problems  that  can  only  be  solved  by   211 collective  action.    This  invokes  what  Verweij  and  Dawson  identify  as  one  of  the  senses  of   ‘public’  evoked  by  the  practice  of  public  health;  it  is  both  for  the  public,  but  also  only  possible  via   212 action  taken  by  the  public.    The  collective  action  approach  to  defining  the  boundaries  of  public   health  thus  captures  an  important  aspect  of  the  means  by  which  public  health  achieves  its  ends.     Arguably,  focusing  on  prevention  as  a  signature  feature  of  public  health  also  highlights  the   importance  of  public  health  methods,  not  merely  ends,  in  marking  it  as  distinct  from  other  forms   of  medicine,  or  other  public  activities.                                                                                                                               210  Institute  of  Medicine,  “The  Future  of  Public  Health”  (Washington,  D.C.:  National  Academy   Press,  1988),  accessed  September  5,  2012,   http://www.nap.edu/openbook.php?record_id=1091.   211  See  for  example,  Nancy  Kass,  “An  Ethics  Framework  for  Public  Health,”  American  Journal  of   Public  Health  91,  no.  11  (2001):  1776.   212  Verweij  and  Dawson,  "The  Meaning  of  'Public'  in  'Public  Health.'"       155     In  this  way,  it  might  be  argued  that  both  the  collective  action  and  prevention  approaches   to  delimiting  public  health  mistakenly  identify  the  means  of  public  health  as  ends.    However,  a   virtue  ethics  approach  to  public  health  suggests  a  reply  to  this  criticism.    Aristotle’s  function   argument  establishes  that  what  is  characteristic  of  a  practice  is  not  merely  the  good  toward   which  is  directed  (the  telos),  but  also  the  activities  central  to  the  practice.    Indeed,  as  virtue  itself   is  considered  activity  (NE  I.7  1098a7),  the  function,  or  ergon,  of  public  health  entails  a  necessary   connection  between  means  and  ends.    The  function  of  public  health,  therefore,  is  not  merely   what  it  achieves  (e.g.,  lowering  morbidity  and  mortality)  but  simultaneously  the  means  by  which   it  achieves  them  (i.e.,  the  actions  of  lowering  morbidity  and  mortality).    Additionally,  once  the   function(s)  of  public  health  have  been  identified,  evaluative  criteria  can  be  developed  to  assess   whether  particular  departments,  institutions,  or  countries  can  be  said  to  perform  said  functions   poorly,  or  excellently. 213   The  collective  action  approach  can  misfire  by  encouraging  public  health  professionals  to   include  problems  merely  because  they  require  a  collective  response.  Civil  rights  movements,   labor  struggles,  and  social  work  –  as  collective  activities  –  become  indistinguishable  from  public   health.    The  collective  action  approach  to  public  health  in  the  United  States  in  part  results  from  a   strong  tendency  for  the  public  to  be  skeptical  of  government  intervention.    And  yet  health,   especially  population  health,  is  still  considered  by  many  to  be  a  legitimate  aspect  of  government   responsibility.  Unlike  many  other  values,  health  is  often  one  that  is  seen  to  have  (near)  universal   appeal.    Thus,  while  a  culture  that  values  individualism  and  self-­‐reliance  can  often  miss  the  ways                                                                                                                           213  Christine  M.  Korsgaard,  “Aristotle  on  Function  and  Virtue,”  History  of  Philosophy  Quarterly   3,  no.  3  (July  1,  1986):  259–79.       156     in  which  individual  health  derives  from  wider  social  determinants,  this  tendency  is  arguably  offset   by  a  similar  cultural  emphasis  on  the  importance  of  human  health.    As  a  result,  because  collective   action  is  tolerated  in  the  arena  of  public  health,  it  is  tempting  to  categorize  social  problems  as   public  health  problems  precisely  because  such  a  move  can  harness  both  political  will,  and  public   resources,  that  may  be  otherwise  unattainable.    Nevertheless,  critics  of  the  broad  approach  are   correct  to  assert  that  the  collective  action  approach,  when  misused  for  such  pragmatic  reasons,  is   likely  to  do  a  disservice  to  public  health  by  assigning  problems  that  squarely  fall  on  the  shoulders   of  public  health  professionals  a  lesser  status  and  decreased  attention.    If  public  health   professionals  commit  to  the  kinds  of  activities  required  to  redress  complex  social  problems,   valuable  resources,  including  time,  may  not  be  available  to  address  traditional  public  health   problems.    In  addition,  identifying  public  health  alone  with  collective  action  is  also  unwise   because  it  reinforces  the  notion  that  human  interdependency  is  an  exception,  rather  than  the   rule.    I  have  argued  elsewhere  that  the  tendency  to  focus  on  patient  and  physician  interpersonal   relationships  erases  the  much  larger  context  of  collective  cooperation  necessary  to  create  and   sustain  such  relationships  in  clinical  medical  practice. 214  Likewise,  the  collective  action  is  also   integral  to  other  important  public  professions,  including  civil  service,  social  work,  environmental   policy,  education,  and  criminal  justice.      Identifying  public  health  with  collective  action  may  do  a   disservice  to  these  other  professions,  what  they  can  and  do  achieve,  and  the  role  of  collaborative   efforts  in  attaining  such  success.                                                                                                                               214  Karen  Meagher,  “Considering  virtue:  public  health  and  clinical  ethics,”  Journal  of  Clinical   Evaluation  and  Practice  17,  no.  5  (2011):  888-­‐93.         157     The  Redefining  Health  Model:    There  are  two  different  ways  public  health  professionals  can  and   do  redefine  ‘health’  in  an  attempt  to  broaden  the  scope  of  public  health.    First,  they  can  simply   adopt  a  more  expansive  definition  of  health  than  the  traditional  biomechanical  model.    Secondly,   they  can  advocate  for  health  as  a  public  good,  transforming  it  from  a  benefit,  not  only  to  the   individuals  with  healthy  lives,  but  also  to  society.     In  the  first  case,  the  adoption  of  a  broad  notion  of  health  follows  those  that  have  lauded  it   as  necessary  to  include  such  challenges  as  mental  health,  or  the  other  aspects  of  suffering  that   can  accompany  disease  and  disability. 215    However,  expansive  definitions  that  equate  health  with   all  of  human  wellbeing  have  been  widely  criticized  for  such  conflation:  “the  World  Health   Organization’s  definition  of  health  as  a  state  of  physical,  mental,  and  social  well-­‐being…is  perhaps   216 the  most  extreme.”  Any  successful  philosophy  of  public  health  will  need  to  engage  in  such   debates,  and  consider  whether  different  conceptions  of  health  might  be  more  appropriate  to   employ  in  public  health  contexts  rather  than  clinical  settings  –  or  whether  such  contextualism   entails  an  unsustainable  form  of  inconsistency.   An  additional  ramification  of  publichealthification  (whether  appropriate  or  not)  is  that  by   characterizing  a  problem  in  terms  of  public  health,  one  also  reconstrues  what  constitutes  success.   One  reason  for  embracing  a  broad  scope  for  public  health  results  from  adopting  broad  definitions   of  health.    Such  definitions  tend  to  conflate  health  with  other  aspects  of  human  wellbeing,   resulting  in  confusion  and  reduction  of  the  harms  of  a  complex  social  problem  to  its  affects  on                                                                                                                           215  Johannes  Bircher,  “Towards  a  Dynamic  Definition.”;  Francesc  Borrell-­‐Carrió,  Anthony  L.   Suchman,  and  Ronald  M.  Epstein,  “The  Biopsychosocial  Model  25  Years  Later:  Principles,   Practice,  and  Scientific  Inquiry,”  The  Annals  of  Family  Medicine  2,  no.  6  (2004):  576–82.   216  Powers  and  Faden,  "Social  Justice,"  83;  See  also  Saracci,  “Definition  of  Health,”  1409.       158     217 human  health.    Alternatively,  a  broad  approach  to  public  health  might  try  to  avoid  an  overly   broad  definition  of  health,  but  in  enveloping  a  problem  like  poverty  under  the  public  health   umbrella,  it  has  a  potential  to  magnify  the  detriments  to  human  health  to  the  exclusion  of   deprivations  in  other  areas  of  human  flourishing.  In  this  way,  a  broad  approach  to  public  health   carries  the  potential  drawback  of  oversimplification,  and  suggests  faulty  metrics  of  progress.    To   reduce  morbidity  associated  with  a  social  problem  like  domestic  violence  may  constitute  a  public   health  success,  but  it  does  not  necessarily  reflect  any  reduction  in  the  incidence  of  the  larger   problem,  any  amelioration  of  its  root  causes,  or  any  resolution  of  its  more  multifaceted  harms.     The  conclusion  of  this  analysis  is  that  any  appeals  broad  model  advocates  might  make  to  greater   efficacy  must  be  tempered  by  such  potential  for  misdirection.     In  the  second  case,  health  is  reconceptualized  in  public  health  as  a  public  good.    While   there  are  many  accounts  of  what  constitutes  a  public  good,  there  are  three  distinctive  features   of  public  goods  that  I  will  consider  here.  They  are  dependence  on  collective  action,  non-­‐ excludability,  and  jointness  in  consumption  or  non-­‐rivalry. 218     1.  Collective  action:  I  have  already  discussed  the  collective  action  model  as  a  distinct   way  of  considering  the  boundaries  of  public  health.    This  approach  is  incorporated   into  the  public  goods  model  of  public  health  insofar  as  one  endorses  the  view  that   public  goods  are  those  communal  benefits  that  can  only  be  achieved  by  collective   action.  In  part,  this  is  one  possible  result  of  a  collective  action  problem:  while                                                                                                                           217  Powers  and  Faden,  "Social  Justice,"  83.   218   Dawson   “Herd   Protection   as   a   Public   Good,”   164;   Randall   Holcombe,   “Public   Goods   Theory   and  Public  Policy,”  The  Journal  of  Value  Inquiry  34,  no.  2  (2000):  273–86.       159     everyone  will  benefit  from  a  certain  action,  no  one  person  has  sufficient  reason  to   act  alone. 219   2. Non-­‐excludability:  In  addition,  once  achieved,  a  public  good  provides  benefits  to  all   members  of  the  community.  This  results  in  what  is  known  as  the  “free-­‐rider”   problem:  certain  members  of  the  public  can  benefit  without  having  to  contribute  to   efforts  that  produce  or  maintain  the  good.  Classic  examples  include  environmental   resources  like  clean  air,  or  safe  and  available  drinking  water.  However,  this  feature   also  characterizes  other  goods  highly  relevant  to  other  aspects  of  public  health   policy,  such  as  the  provision  of  herd  immunity  via  vaccination  programs.    Using  this   model,  advocates  of  a  broad  approach  to  public  health  might  try  to  articulate  how   amelioration  of  candidate  public  health  problems  results  not  in  health  benefits  to   individual  members  of  target  populations,  but  to  the  entire  population.   3.  Non-­‐rivalry:  This  aspect  of  public  goods  acknowledges  the  unrestricted  nature  of  a   resource.  Non-­‐rivalry  means  that  use  or  enjoyment  of  the  good  does  not  preclude  its   use  or  enjoyment  for  others.  A  radio  broadcast  is  a  common  example  of  a  non-­‐rival   good  –  a  radio  listener  does  not  “use  up”  or  prevent  others  from  listening  to  the   same  broadcast. 220  It’s  important  to  note  that  this  example  presumes  equal  access   to  radios.  Such  assumptions  reveal  that  rivalry  can  arise  elsewhere  in  the  process  of   production  or  consumption  of  a  good.                                                                                                                           219  Ibid.,  144.   220  Ibid.       160     Some  accounts  of  public  goods  assert  that  all  three  characteristics  be  met  in  order  for  a   benefit  to  qualify  as  a  public  good.  Other  views  emphasize  one  feature  rather  than  others;  thus,  it   is  not  clear  whether  these  attributes  are  necessary  or  sufficient  conditions  for  public  goods,   either  alone  or  as  a  group.    A  philosophy  of  public  health  that  advocates  for  this  model  will  need   to  defend  whether  improvements  in  population  health  must  necessarily  be  public  goods  to  fall   within  the  domain  of  the  public  health  profession,  or  whether  qualifying  as  a  public  good  merely   increases  the  cause  for  inclusion  within  the  public  health  catalogue.   The  Governmental  Model:  Rothstein’s  main  defense  of  a  narrow  approach  to  public  health  stems   from  a  concern  that  broader  approaches  will  outstrip  social  support  and  the  legitimate  reach  of   public  health  authority.    Rothstein  is  especially  interested  in  limiting  the  scope  of  public  to  health   to  problems  that  justify  governmental  use  of  coercive  powers:    “in  the  absence  of  such  legal   authority,  the  participation  of  individuals  in  health  enhancing  activities  ordinarily  must  be   221 voluntary.”    The  difficulty  with  this  view  is  that  it  appears  to  relegate  all  health  promotion   activities  to  outside  the  realm  of  public  health,  or  at  least  governmental  public  health   responsibilities. 222    Under  this  view,  public  health  is  not  what  we,  as  a  society,  do  to  ensure  the   conditions  for  a  health  life,  but  rather  what  we  do  to  ensure  that  some  do  not  impose  an   unhealthy  life  on  others.    One  purported  advantage  of  this  approach,  according  to  Rothstein,  is   that  it  is  more  likely  to  receive  political  support  from  citizens  by  avoiding  highly  politicized   recommendations,  like  income  redistribution  schemes  to  reduce  the  health  effects  of  inequality.                                                                                                                             221  Rothstein,  “Rethinking  the  Meaning  of  Public  Health,”  146.   222  This  is  arguably  a  consequences  of  a  narrow  approach  that  some  might  wish  to  endorse,  at   least  insofar  as  health  promotion  presumes  an  “overarching”  value  of  health  that  had  not  been   supported  –  see  Lubomira  Radoilska,  “Public  Health  Ethics  and  Liberalism”  Public  Health  Ethics     2,  no.  2  (2009):  135–45.       161     223 The  notion  that  the  broad  notion  of  public  health  is  “politicized”  is  a  common  critique.       However,  it  is  often  not  entirely  clear  what  is  meant  by  such  a  claim.    Certainly,  by  virtue  of  being   performed  by  governmental  professionals  on  behalf  of  citizens,  public  health  is  considered   political  activity.    The  concern,  then,  may  be  that  the  broad  approach  is  too  partisan,  which  may   undermine  public  health  efforts  by  provoking  resistance  from  both  political  leaders  and  the   public.     However,  it  is  worth  ensuring  that  the  critique  is  not  the  claim  that  somehow  the  broad   approach  is  political  in  a  way  that  the  narrow  approach  is  not,  at  least  as  far  as  taking  a  stance  on   what  constitutes  the  proper  role  of  government.    If  this  is  the  claim,  then  Rothstein’s  position  is   merely  stipulative:  the  proper  scope  of  public  health  ought  to  be  narrow  because  it  falls  more   within  the  range  of  appropriate  governmental  authority,  and  the  legitimate  purview  of   government  authority  ought  to  be  narrowly  construed.    Clearly  such  a  view  also  requires  a   political  philosophy  regarding  the  role  of  government,  and  such  narrowness  may  also  be,  perhaps   uncharitably,  interpreted  as  highly  partisan  if  equated  with  advocacy  for  “limited  government.”    I   do  not  mean  to  claim  that  this  is  Rothstein’s  intent,  but  I  do  contend  that  no  view  of  the  proper   limits  of  governmental  authority  can  claim  political  neutrality  –  although  it  may  be  able  to  claim   relative  partisan  neutrality  given  the  current  political  climate.       Arguments  against  politicization  are  similarly  flawed  if  they  include  a  claim  that  public   health  somehow  inherits  some  degree  of  objectivity  that  might  be  attributed  to  the  underlying   science  of  epidemiology.    Thus,  some  have  claimed  that  the  broad  approach  to  public  health  is                                                                                                                           223  As  noted  earlier,  Gostin  anticipates  Rothstein's  argument  in,  “Public  health,  ethics,  and   human  rights.”       162     inappropriate  because  it  causes  the  profession  to  “drift  from  its  scientific  and  clinical   224 moorings.”    I  have  critiqued  the  view  of  public  health  practice  as  devoid  of  normative   elements  throughout  my  arguments,  but  it  will  not  hurt  to  summarize  them  here.    Such  a  position   leads  to  two  possibilities,  it  either  (1)  reflects  an  uncritical  understanding  of  the  normative   225 aspects  of  epidemiological  practice,  in  which  case  a  stronger  defense  of  the  objectivity  of  a   narrow  approach  is  required,  or  proponents  of  the  broad  approach  may  muster  epidemiological   evidence  to  bolster  their  claims;  i.e.,  they  may  employ  the  causation  model  of  public  health  and   meet  critics  on  their  own  terms;  or  (2)  it  fails  to  acknowledge  that  all  health  policy  must  be   similarly  political  and  normatively  justified;  all  public  health  interventions  move  from   epidemiology  to  policy,  and  in  doing  so  require  justifications  that  are  inherently  normative,  and   often  political.    In  this  second  case,  proponents  of  a  broader  approach  may  be  able  to  illuminate   the  ways  in  which  all  public  health  practices  require  justification,  and  what  may  be  in  contention   is  not  what  counts  as  a  public  health  problem,  but  what  counts  as  the  justificatory  conditions  that   legitimate  public  health  policy.   To  be  charitable,  defenses  of  the  governmental  model  of  public  health  are  worthy  of   careful  consideration  when  they  express  a  worry  that  broader  approaches  may  entail  a   corresponding  expansion  of  public  health  authority.    In  such  cases,  a  growing  public  health   agenda  arguably  runs  counter  to  a  public  health  “ethics  of  restraint,”  especially  when  it  increases   226 the  potential  for  abuse  of  public  health  powers.      To  make  this  critique  stick,  however,  it  is  not                                                                                                                           224  Sally  Satel,  “The  politicization  of  public  health,”  Wall  Street  Journal,  December  1996.   225  Steve  Wing,  “Whose  Epidemiology,  Whose  Health?,”  International  Journal  of  Health   Services  28,  no.  2  (1998):  241–52.   226  Nancy  Kass,  “An  Ethics  Framework  for  Public  Health,”  1777.       163     enough  to  merely  claim  that  inclusion  of  poverty,  or  obesity,  or  violence  within  public  health   expands  public  health  powers  –  rather  critics  must  explicate  what  powers  are  expanded,  and  why   this  is  inappropriate.   I  believe  that  these  analyses  reveal  that  it  is  extraordinarily  difficult  to  identify  a  single   feature  of  public  health  will  enable  us  to  clearly  differentiate  between  public  health  and  other   social  services.    However,  this  does  not  mean  that  discourse  surrounding  the  distinctive  features   of  public  health  cannot  be  productive.    What  these  considerations  have  indicated  is  that  what   may  be  in  contention  is  not  what  counts  as  a  public  health  problem,  but  what  counts  as  the   justificatory  conditions  that  legitimate  public  health  policy.    It  is  to  addressing  this  complexity  that   I  now  turn.     4.3  A  Virtue  Approach  to  the  Boundary  Problem     What,  then,  would  a  virtue  ethics  approach  suggest  as  a  resolution  to  the  boundary   problem?    The  boundary  problem  involves  both  conceptual  and  normative  challenges  –  questions   of  what  are  and  ought  to  be  the  limits  of  a  discipline.    However,  concern  over  the  boundary   problem  is  often  expressed  by  public  health  professionals  as  a  pragmatic  concern,  one  regarding   definitive  guidelines  to  help  determine  the  core  of  the  profession,  and  how  to  set  priorities.    The   conceptual  and  normative  challenges  are  related,  but  distinct.    In  this  section,  I  argue  that  a   virtue  ethics  approach  to  the  boundary  problem  suggests  that  the  Aristotelian  notion  of  hamartia   provides  a  metaphor  can  help  to  illustrate  the  differences  between  the  moral  psychology  of   individuals  and  groups.         164     As  I  have  argued,  the  concern  for  the  boundary  problem  is  a  conceptual  matter,  but  also   of  ethical  concern  to  those  engaging  in  the  debate.    The  call  to  articulate  a  shared  set  of  values   for  the  field  involves  a  need  for  a  clearer  picture  of  public  health  practice  to  provide  a  guide  for   action,  i.e.,  the  boundary  problem  is  in  part  a  desire  to  articulate  a  shared  moral  vision  for  public   health  professionals.  I  argue  that  this  notion  of  shared  vision  invokes  an  aspect  of  practical  ethics   familiar  to  virtue  ethics  –  the  connection  between  moral  perception  and  guidelines  for  action.     For  Aristotle,  virtues  lend  agents  a  perceptual  capacity,  “the  eye  of  the  soul  does  not  come  to  be   in  its  proper  condition  without  excellence.”  (EN  VI.12  1144a30)    By  drawing  out  the  saliency  of   features  of  the  moral  landscape,  virtue  enables  the  agent  to  identify  good  ends. 227    While  these   particulars  are  not  what  those  interested  in  an  ethics  of  public  health  have  in  mind,  the  general   idea  is  not  far  off:  by  getting  clearer  on  the  values  of  the  profession,  professionals  will  have  a   better  idea  of  what  to  do.    I  argue  that  a  better  understanding  of  Aristotle’s  picture  of  moral   psychology,  as  expressed  by  his  notion  of  hamartia,  or  missing  the  mark,  can  help  public  health   professionals  distinguish  between  the  clear  vision  of  an  individual,  and  the  clear  vision  of  a  group.   228 While  Aristotle’s  use  of  the  term  hamartia,  “missing  the  mark”  or  “error,”  is  contested, his  employment  of  the  imagery  of  target  practice  can  be  harnessed  to  reconceptualize  the   boundary  problem.    For  Aristotle,  “…being  excellent  is  something  difficult  to  achieve.  For,  in  any   context  getting  hold  of  the  intermediate  is  difficult  –  as  for  example  finding  the  center  of  a  circle   is  not  a  task  for  anyone,  but  for  the  skilled  person…which  explains  why  getting  things  right  is  a                                                                                                                           227  McDowell,  John.    “Virtue  and  Reason.”   228  T.  C.  W.  Stinton,  “Hamartia  in  Aristotle  and  Greek  Tragedy,”  The  Classical  Quarterly  25,  no.   2,  New  Series  (1975):  221–54;  cf.  Isaiah  Smithson,  “The  Moral  View  of  Aristotle’s  Poetics,”   Journal  of  the  History  of  Ideas  44,  no.  1  (1983):  3–17.       165       rare  thing.”  (NE  II.9  1109a24-­‐30)    Excellences  of  character,  virtues,  lend  clarity  about  our  ends  by   distinguishing  good  ends  from  bad  ones,  thereby  correcting  our  aim,  whereas  experience  helps   hone  our  practical  reasoning,  skills,  and  perception  of  particulars  such  that  we  might  achieve  our   ends.  (NE  VI  1144a20ff;  1143b5-­‐15)    This  view  of  the  moral  psychology  of  an  agent  captures  the   instrumental  value  of  virtues:  “an  arête  is  not  merely  one  of  a  thing’s  good  points;  it  is  specifically   a  quality  that  makes  something  good  at  performing  its  function.”    While  the  virtues  are  not  only   instrumental  to  achieving  the  good,  their  utility  is  certainly  an  advantage.    In  public  health,  the   professional  virtues  thereby  speak  to  one  of  the  driving  concerns  for  a  solution  to  the  boundary   problem  –  the  desire  for  greater  public  health  efficacy.  Throughout  this  section  I  examine  the   underlying  concern  for  greater  efficacy  that  drives  advocates  of  both  narrow  and  broad   approaches  to  the  boundary  problem,  and  then  consider  how  the  metaphor  of  “missing  the   mark”  can  shed  light  on  what  this  might  mean  for  efficacy  in  public  health.    In  his  article,  “Rethinking  the  Meaning  of  Public  Health,”  Mark  Rothstein  outlines  some   objections  to  a  broad  approach  to  public  health.      Among  his  concerns  with  a  broader  scope  for   public  health  is  that  “such  an  approach  is  ill-­‐defined,  with  diverse  actors  pursuing  widely   divergent  strategies  to  deal  with  the  same  health  problems,  tackling  health  problems  of  varying   severity,  and  often  pursuing  their  own  agendas  with  little  coordination  or  accountability.”    From   Rothstein’s  perspective,  a  narrow  approach  to  public  health  would  prioritize  threats  to  the  public   health  that  clearly  justify  invocation  of  the  harm  principle,  problems  that  are  solidly  grounded  in   229 public  health  expertise,  and  interventions  that  have  proven  efficacy.      Rothstein  contends  that   such  an  approach  will  provide  greater  efficacy  because  the  resulting  public  health  agenda  will  be                                                                                                                           229  Rothstein,  “Rethinking  the  Meaning  of  Public  Health,”  146.       166     limited  to  problems  supported  by  broad  public  and  professional  consensus,  consist  of  fixed  public   health  priorities,  and  be  firmly  grounded  in  public  health  understanding  of  both  the  problems  and   the  respective  methodologies  needed  for  resolution.   Advocates  for  a  broad  model  share  this  concern  for  efficacy.    There  exists  a  persistent   feeling  among  many  such  professionals  that  public  health  fails  in  its  mission  to  forestall  ill  health,   or  improve  overall  health,  by  abdicating  a  responsibility  to  attend  to  social  determinants  of   230 health  in  favor  of  a  more  limited  focus  on  traditional  goals  and  methods.    However,  when   public  health  professionals  take  on  complex  social  problems  like  poverty  or  domestic  violence,   the  conceptual  and  methodological  resources  required  to  attain  success  may  outstrip  the   expertise  of  public  health  professionals.    For  example,  Meyer  and  Schwartz  identify  problematic   or  counterproductive  forms  of  “publichealthification”  in  public  health  inclusion  of  homelessness   that  illustrate  how  public  health  attention  can  undermine  the  intent  of  advocates  of  the  broad   model  due  to  a  mismatch  between  social  problems  and  epidemiological  concepts  and  methods.     When  public  health  employs  an  aggregative  notion  of  population  health,  this  encourages  a   tendency  to  reduce  cumulative  outcomes  to  individual  behavior.    Thus,  causes  of  homelessness   become  characterized  not  in  terms  of  lack  of  affordable  housing  or  flaws  in  housing  subsidy   structures,  but  individual  “risk  factors,”  such  as  socioeconomic  status  or  mental  health                                                                                                                           230  Link  and  Phelan,  “Social  Conditions  As  Fundamental  Causes  of  Disease”;  David  Evans,  Simon   Cauchemez,  and  Frederick  G  Hayden,  “‘Prepandemic’  Immunization  for  Novel  Influenza  Viruses,   ‘Swine  Flu’  Vaccine,  Guillain-­‐Barré  Syndrome,  and  the  Detection  of  Rare  Severe  Adverse   Events,”  Journal  of  Infectious  Diseases  200,  no.  3  (2009):  321  –8;  Wing,  “Whose  Epidemiology,   Whose  Health?”;  Amy  L.  Fairchild  et  al.,  “The  EXODUS  of  Public  Health,”  American  Journal  of   Public  Health  100,  no.  1  (2010):  54–63.       167     231 diagnosis.    To  provide  another  example,  Sankar  et  al.  argue  that  a  public  health  research   agenda  that  includes  genetic  determinants  of  health  disparities  may  overshadow  social  and   environmental  determinants,  and  reinforce  racial  stereotypes. 232    Such  considerations  reveal   how  a  concern  for  efficacy  often  lies  behind  an  appeal  to  a  broader  causal  model  of  public  health;   merely  being  a  determinant  of  health  is  not  enough  –  what  is  needed  are  guides  for  which  causes   to  focus  on  and  why.    The  examples  provided  here  serve  as  a  warning  as  to  how  classic  concepts   and  methods  in  public  health  can  actually  subvert  the  intent  of  advocates  of  the  broad  approach   by  incorporating  assumptions  that  undermine  actualization  of  the  broad  approach’s  potential  for   improved  efficacy.   Debates  regarding  the  boundary  problem  in  public  health  reveal  how  an  additional   concern  for  unity  of  purpose  gets  mixed  up  with  calls  for  efficacy.    The  demand  that  the  limits  to   public  health  be  firmly  placed  within  public  health  expertise  must  acknowledge  the  dynamic   nature  of  public  health  and  epistemic  authority.    Disparate  goals  in  public  health  may  reflect  a   myriad  set  of  aims,  disagreements  on  their  priority,  as  well  as  varying  on-­‐the-­‐ground  realities   such  as  funding  structures.    But  it  does  not  follow  that  such  apparent  heterogeneity  necessarily   sacrifices  efficacy  for  the  sake  of  plurality.    Advocacy  for  a  broad  model  of  public  health  can  also   be  interpreted  as  a  call  for  understanding  that  efficacy  can  be  evaluated  at  many  levels.    What  is   successful  locally  may  not  be  an  efficacious  state-­‐wide  or  national  policy.    This  is  due  to  local   context,  but  also  to  due  to  variety  in  population  needs.    For  example,  Florida  state,  with  a  large   elderly  population,  may  require  not  only  a  different  set  of  public  health  priorities,  but  perhaps                                                                                                                           231  Meyer  and  Schwartz,  “Social  Issues  as  Public  Health.”   232  P.  Sankar,  “Genetic  Research  and  Health  Disparities,”  The  Journal  of  the  American  Medical   Association  291,  no.  24  (2004):  2985–9.       168     even  unique  public  health  ends.    The  same  might  be  said  for  the  difference  between  urban  and   rural  populations.    With  this  in  mind,  advocacy  for  a  broad  approach  to  public  health  can  also  be   grounded  in  a  concern  for  context.    Thus,  the  same  moral  considerations  needn’t  be  the  guiding   considerations  for  each  and  every  public  health  professional.    Rothstein  believes  that  a  narrow   approach  to  public  health  is  more  likely  to  encounter  public  support,  but  this  again  depends  on   which  public  is  in  question,  and  whether  public  support  is  required,  or  guarantees,  public  health   efficacy.  The  central  claim  of  this  section  is  that  it  is  not  clear  that  professions  are  more   efficacious  when  they  engage  in  a  more  limited  or  even  unified  set  of  goals.    It  is  also  possible  to   envision  that  collectives  can  employ  multiple  methods  to  achieve  the  same  targets,  or  new   means  to  achieve  innovative  ends,  before  deciding  which  methods  to  embrace  on  a  wider  basis  –   or  even  whether  such  homogeneity  is  desirable  in  and  of  itself.      A  virtue  ethics  approach  would   start  by  differentiating  between  the  public  health  calls  for  efficacy  and  unity  in  order  to  clarify   which  values  are  at  play  in  determining  the  boundaries  of  public  health  practice.   Aristotle’s  metaphor  regarding  hamartia,  or  missing  the  mark,  is  a  helpful  metaphor  when   considered  in  terms  of  target-­‐practice.    It  makes  sense  that  clarity  of  purpose,  by  virtue  of   character  excellence,  helps  to  sharpen  the  focus  of  the  moral  agent.    The  image  also  helps  reveal   why  unity  and  efficacy  are  so  easy  to  conflate.    It  is  an  intuitive  notion  that  having  less  to  aim  for   –  a  more  narrow  scope  of  objectives  –  would  make  agents  more  effective  at  attaining  such  goals.     But  the  imagery  of  missing,  or  hitting,  the  mark  must  be  stretched  when  scaled  up  to  the  practical   undertakings  of  an  entire  profession.    Collectives  do  not  pursue  targets  in  the  same  way  as   individuals,  and  as  a  result,  the  features  of  the  efficacious  public  health  professional  may  not  be   the  same  as  the  features  of  an  efficacious  profession.       169     Collectives,  unlike  individual  moral  agents,  can  aim  to  achieve  objectives  that  individuals   alone  cannot  accomplish.    Collaboration  may  require  individual  agents  to  aim  for  intermediate   goals  in  order  to  collectively  obtain  overarching  objectives.  Let  us  call  this  the  matroishka  model   of  public  health  because  smaller  goals  are  nested  under  larger  ones,  like  these  Russian  nesting   dolls.    For  example,  consider  the  traditional  goal  of  reducing  the  incidence  of  hepatitis  within  a   population.    When  considered  in  conjunction  with  the  previous  example,  public  health  advocates   of  a  broader  approach  to  public  health  may  contend  that  it  is  possible  to  understand  some   instances  of  hepatitis  as  a  homelessness-­‐related  morbidity.    Thus,  aiming  to  reduce  the  rate  of   homelessness  might  become  a  minor  objective  in  a  larger  public  health  effort  to  reduce  incidence   of  hepatitis  more  generally.    By  viewing  homelessness  itself  as  a  public  health  objective,  some   public  health  professionals  may  also  be  able  to  address  other  related  co-­‐morbidities  associated   with  homelessness  or  the  mental  illness  that  may  lead  to  them.    Under  this  view,  broader  public   health  goals  and  methods  might  be  subsumed  under  a  more  traditional  public  health  goal,  or   work  in  tandem  with  more  traditional  approaches  that  achieve  related  or  shared  ends.    The  point   here  is  that  because  all  those  engaged  in  discourse  on  the  boundary  problem  share  a  concern  for   seeking  efficacy,  advocates  of  a  broad  approach  might  do  well  to  emphasize  how  newer  goals  and   methods  work  in  conjunction  with,  rather  than  to  the  exclusion  of,  the  pursuit  of  traditional  goals   in  order  to  achieve  wider  shared  ends.     One  objection  to  the  matroishka  model  is  that  there  is  no  guarantee  that  a  more  varied   set  of  sub-­‐goals  in  public  health  will  necessarily  lead  to  greater  efficacy.    In  other  words,  if  we   cannot  assume  that  greater  unity  lends  greater  efficacy,  neither  can  we  assume  that  greater   plurality  of  objectives  does  the  same.  The  reply  that  an  advocate  of  the  matroishka  model  must       170     provide  will  necessarily  need  to  appeal  to  evidence  and  rationale  as  to  why  a  broader  set  of   subgoals  is  more  efficacious.    Thus,  one  revelation  of  the  considerations  so  far  is  that   professionals  cannot  solely  pin  their  hopes  for  greater  professional  efficacy  on  philosophy  of   public  health.    Rather,  while  such  deliberations  can  perhaps  lend  insight  and  greater  clarity,  the   evidentiary  burdens  fall  equally  on  advocates  of  both  approaches  to  supply  reasons  to  support   one  model  over  another  on  the  grounds  of  greater  efficacy.   The  target  metaphor  can  again  be  used  to  envision  how  collective  goal-­‐directed  action   must  be  conceptualized  in  ways  that  distinguish  them  from  the  trappings  of  individual  agency.    In   other  public  health  contexts,  collectives  may  employ  different  strategies  to  achieve  the  same   goals  in  ways  that  individuals  cannot.    Thus,  Rothstein  is  correct  that  constantly  shifting  sands  in   an  overall  public  health  agenda  will  be  counterproductive  –  especially  to  the  long-­‐term   achievements  of  the  profession.    This  is  especially  the  case  when  we  conceive  of  collectives  as   psychologically  akin  to  individuals  –  more  likely  to  succeed  when  focusing  on  a  single  or  discrete   set  of  goals.  Thus,  while  Rothstein  envisions  the  myriad  foci  of  individual  public  health   professionals  as  disorganized  and  ineffective,  employing  disparate  means  to  achieve  the  same   objective  can  also  be  understood  as  an  optimal  strategy  for  success  –  i.e.,  if  one  strategy  fails,   another  might  succeed.  Let  us  call  this  the  fail-­‐safe  method  of  public  health.  For  example,  while   preventive  efforts  may  form  a  central  element  of  forestalling  the  harms  of  an  epidemic,  so,  too,   do  countermeasures  after  an  epidemic  has  begun,  even  if  such  efforts  wade  into  the  murky  area   of  overlap  between  clinical  practice  and  public  health  policy.    Public  health  may  therefore  actually   undermine  efficacy  if  it  equates  it  with  unity  of  vision  and  purpose.    What  to  some  might  appear   as  redundancy  or  confused  heterogeneity  might  in  reality  be  a  system  of  mutually  reinforcing       171     methods  that  ensure  security,  where  one  set  of  public  health  activities  serves  to  achieve  similar   goals  in  case  first-­‐line  efforts  fall  short.   One  advantage  of  the  models  I  have  suggested  here,  that  arise  from  the  target  imagery   invoked  by  the  notion  of  hamartia,  is  that  they  do  not  endorse  one  particular  model  of  delimiting   public  health  problems  discussed  in  Section  1.    Rather,  both  the  matroishka  and  fail-­‐safe  models   of  public  health  accommodate  the  reality  that  no  single  feature  of  public  health  marks  it  as   distinct.    Instead,  each  of  the  models  outlined  in  the  first  section  are  good  reason  to  consider  the   merits  of  incorporating  a  problem  in  the  public  health  lexicon.    In  addition,  by  calling  attention  to   the  underlying  values  that  drive  discourse  concerning  the  boundary  problem,  I  hope  to  have   highlighted  the  ways  in  which  what  counts  as  public  health  activity  will  sometimes  not  be  clear.   Sometimes,  prevention  pushes  public  health  into  the  curative  realm;  at  other  times,  public  health   objectives  may  be  shared  with  other  public  entities  or  even  private  institution.  What  critics  of  the   broad  approach  appropriately  note,  however,  is  that  the  implications  of  shared  responsibility   need  to  be  more  clearly  delineated.    This,  then,  will  also  be  a  criterion  for  a  successful  philosophy   of  public  health.      Another  advantage  of  this  view  is  that  it  accommodates  the  fluid  and  changing  nature  of   professional  knowledge.    We  might  state  simply  that  epidemiology  is  the  study  of  the  processes   that  contribute  to  population  health.    There  is  no  reason  to  think,  however,  that  such  knowledge   will  stay  within  the  bounds  of  preventive  efforts,  be  limited  by  current  understandings  of  what   constitutes  health,  or  even  be  captured  by  the  dominant  understanding  of  causation.  Meyer  and   Schwartz  focus  their  critique  of  the  broad  model  of  public  health  in  the  context  of  public  health   research  because  it  is  precisely  in  this  area  that  “publichealthification”  is  likely  to  take  root,  and       172     perhaps  go  astray.    It  is  our  increasing  understanding  of  the  ways  in  which  our  health  is  wrapped   up  in  the  health  of  others  that  creates  the  potential  for  new  public  health  problems.    The   approach  I  put  forth  here  acknowledges  that  one  source  of  the  movement  for  expanding  the   scope  of  public  health  partially  results  from  expanding  epidemiological  knowledge;  the  more   evidence  and  understanding  professionals  gain  regarding  the  social  determinants  of  health,  the   more  professionals  feel  an  obligation  to  develop  new  methods  of  intervention.    Sometimes  such   professionals  express  that  obligation  in  terms  of  a  professional  duty  to  increase  public  health   efficacy,  other  times  out  of  a  concern  for  fairness  or  justice,  which  I  will  turn  to  shortly.       The  claim  I  wish  to  defend  here  is  that  the  scope  of  public  health  may  never  be  a  fixed  and   determinate  matter:  methodological  expertise  will  need  to  be  developed  to  speak  to  expanding   public  health  expertise  in  disease  etiology,  and  may  sometimes  lag  behind.    In  the  contrary  cases,   public  health  methods  of  intervention  (especially  in  the  form  of  technology)  are  sometimes   developed  and  understanding  of  etiology  follows  in  a  reverse  order.    Advocates  for  a  broader   approach  to  public  health  may  need  to  be  patient  and  respond  to  demands  that  there  be   evidence  of  methodological  efficacy  before  such  public  health  problems  join  the  lexicon   indefinitely.    Narrow  defenders  may  also  need  to  allow  for  greater  flexibility  in  epidemiology  than   in  public  health;  i.e.,  something  may  count  as  a  public  health  problem  before  a  solution  has  been   found.     4.4  Toward  public  health  inquiry  into  the  nature  of  the  profession   The  shared  desire  for  greater  efficacy  reflects  that  one  possible  solution  to  the  boundary   problem  is  to  articulate  the  underlying  values  that  both  camps  share  so  as  to  help  to  develop       173     evaluative  criteria  for  assessing  justifications  for  expanding  or  restricting  public  health   boundaries.    In  other  words,  it  is  one  thing  to  articulate  a  public  health  telos  and  another  thing  to   outline  what  it  means  to  achieve  those  ends  well.    In  discourse  surrounding  the  boundary   problem,  both  aspects  are  at  play  because  there  is  an  overriding  consideration  to  develop  not   just  a  public  health  agenda,  but  also  a  good  public  health  agenda.    As  so  often  happens  in  debates   regarding  what  something  is,  we  are  often  simultaneously  debating  what  something  ought  to  be   –  the  philosophy  of  public  health  and  an  ethics  of  public  health  are  therefore  inextricably  linked,   and  debates  over  the  boundary  problem  often  fail  to  distinguish  these  two  issues.      In  this   section,  I  explore  ways  in  which  recent  discussions  regarding  Aristotle’s  view  of  inquiry  can   provide  some  guidance  for  how  discourse  ought  to  proceed.  In  doing  so,  I  lay  some  of  the   preliminary  groundwork  for  developing  a  fruitful  philosophy  and  ethics  of  public  health  by   considering  the  following  questions:    1)  Is  there  a  distinctive  ethics  of  public  health?  2)  What   shared  assumptions  can  provide  starting  points?  3)  What  are  the  rules  of  engagement?  and  4)   What  are  the  desired  outcomes  of  discourse?       4.4.1  Is  there  a  distinctive  ethics  of  public  health?   As  Salmieri  notes,  “except  in  cases  where  it  is  already  obvious,  it  is  necessary  to  inquire  ‘if   something  is’  before  inquiring  into  ‘what  it  is.’” 233    While  it  may  be  perfectly  obvious  to  some                                                                                                                           233  Gregory  Salmieri,  “Aristotle’s  Non-­‐’Dialectical’  Methodology  in  the  Nicomachean  Ethics,”   Ancient  Philosophy  29,  no.  2  (2009):  320;  Throughout  this  section  I  draw  from  a  variety  of   articles  regarding  the  nature  of  Aristotle’s  position  on  dialectic.  Rather  than  endorse  one   position,  however,  I  draw  more  on  the  implications  of  these  discussions  to  articulate  Aristotle’s   view  how  we  ought  to  inquire,  rather  than  what  category  of  discourse  such  inquiry  ought  to  be   considered.    My  account  owes  a  great  debt,  however,  to  that  of  Salmieri.    For  differing  views  on       174     that  there  is  a  distinct  ethics  of  public  health  to  be  found,  it  is  worth  asking  whether  such  an   ethics  will  be  limited  to  public  health  practice.    This  concern  partly  arises  because  discussions   over  the  distinctiveness  of  public  health  ethics  overlap  with  discussions  regarding  the  future  of   bioethics.    Thus,  the  predominant  concern  for  justice  that  characterizes  much  of  the  recent  work   in  public  health  ethics  also  reflects  a  dearth  of  attention  to  such  matters  in  clinical  organization   contexts. 234    For  example,  at  the  Nuffield  Council’s  Annual  Lecture,  Onora  O’neill  concludes  “that   too  strong  a  focus  on  individual  choice  and  informed  consent  by  patients  and  research  subjects   will  not  only  marginalize  public  health  and  the  ethical  questions  it  raises,  but  hide  much  that  is   fundamental  to  clinical  medicine  and  to  the  conduct  of  biomedical  research.” 235    The  same  might   be  said  for  striking  the  proper  balance  between  group  interests  and  individual  autonomy,  the   236 pertinence  of  organization  ethics,  and  the  social  context  of  clinical  care.    Thus,  as  each  of  the   models  articulated  in  section  one  is  a  common,  but  not  distinctive  feature  of  public  health,  we   ought  also  to  use  similar  caution  in  assuming  that  some  ethical  concepts  are  more  pertinent  to   public  health  than  clinical  medicine.    The  population  level  of  analysis  that  is  characteristic  of   much  of  public  health  does  not  entail  that  public  health  professionals  do  not  address  individuals,                                                                                                                                                                                                                                                                                                                                                                                                 dialectic,  see  D.W.  Hamlyn,  “Aristotle  on  Dialectic,”  Philosophy  65,  no.  254  (1990):  465–76  and   Martha  C.  Nussbaum,  The  Fragility  of  Goodness:  Luck  and  Ethics  in  Greek  Tragedy  and   Philosophy,  2nd  ed.  (Cambridge  University  Press,  2001),  Chapter  8.   234  Norman  Daniels,  “Equity  and  Population  Health:  Toward  a  Broader  Bioethics  Agenda,”  The   Hastings  Center  Report  36,  no.  4  (2006):  22–35.     235  Onora  O’Neill,  “Broadening  Bioethics:  Clinical  Ethics,  Public  Health  and  Global  Health”   (presentation,  The  Nuffield  Council  on  Bioethics  Annual  Lecture,  Royal  Society  of  the  Arts,   London,  UK,  May  19,  2011),  p.  13.  Available  at:   http://www.nuffieldbioethics.org/sites/default/files/files/Broadening_bioethics_clinical_ethics _public_health_&global_health.pdf.   236  Elsewhere  I  have  established  preliminary  arguments  to  this  effect  in  Meagher,  “Considering   Virtue.”;  see  also  Ronald  Bayer  and  Amy  L.  Fairchild,  “The  Genesis  of  Public  Health  Ethics,”   Bioethics  18,  no.  6  (2004):  473–92.       175     but  it  does  indicate  that  what  may  be  distinctive  of  public  health  is  a  division  of  labor  that  lends   greater  salience  to  groups.    The  discourse  within  bioethics  more  broadly,  however,  indicates  that   a  public  health  ethics  would  be  premature  in  assuming  that  this  necessitates  giving  priority  to   groups  over  individuals,  or  incorporating  an  ethics  of  community  exclusive  to  public  health.     Rather  public  health  will  still  need  to  strike  a  balance  between  self-­‐  and  other-­‐regard,  and  this   may  bear  important  implications  for  how  such  balances  ought  to  similarly  be  struck  in  clinical   237 contexts  including  hospital  policy  and  organizational  structure.    The  implication  of  this  analysis   is  that  a  philosophy  of  public  health,  and  its  related  ethics  of  public  health,  is  deeply  tied  to   conversations  about  other  aspects  of  clinical  care;  in  the  end,  they  may  have  more  in  common   than  appears  at  first  blush.     4.4.2  What  shared  assumptions  can  provide  starting  points?     Once  we  have  established  that  the  lessons  of  public  health  ethics  may  not  necessarily  be   limited  to  the  profession,  we  might  return  to  the  arguments  of  the  previous  section  and  examine   the  shared  concern  for  efficacy.    The  notion  that  debate  can  be  beneficial  to  a  community  of   professionals  is  not  new.    And  while  what  may  be  sought  can  be  thought  of  as  a  philosophy  or   ethics  of  public  health,  there  is  good  reason  to  believe  that  it  will  be  a  more  fruitful  discourse  if  it   is  not  limited  to  philosophers,  or  even  those  who  are  concerned  about  the  ethical  implications  of   the  field.    As  Callahan  and  Jennings  observe,  “[ethical]  code  developments  and  revisions…have   often  been  most  successful  when  they  are  accompanied  by  lengthy  and  strenuous  debate                                                                                                                           237For  a  nuance  approached,  see  Sally  Bean,  “Navigating  the  Murkey  Intersection  Between   Clinical  and  Organization  Ethics:  A  Hybrid  Case  Taxonomy,”  Bioethics  25,  no.  6  (2011):  320–5.       176     engaging  the  entire  professional  community  and  not  simply  those  with  a  special  interest  in   ethics.” 238    Recently,  some  authors  have  endeavored  to  articulate  these  underlying  values  that   239 might  be  shared  by  many  of  the  suggested  models  of  public  health.    This  move  may  indicate   greater  unity,  or  consensus,  toward  a  prescriptive  account  of  public  health  so  often  desired  from   discourse  around  the  boundary  problem.    However,  another  way  to  understand  such  shared   values  is  to  view  them  as  starting  points  to  initiate,  rather  than  come  out  of,  inquiry  into  the   nature  of  public  health.       The  nature  of  starting  points  in  the  Nicomachean  Ethics  and  elsewhere  in  Aristotelian   philosophy  is  up  for  debate  –  especially  whether  such  beginnings  are  understood  due  to  insight   (nous),  or  some  other  form  of  epistemic  access.    However,  starting  points  are  commonly   understood  to  be  “mutually  accepted,”  either  due  to  a  common  set  of  beliefs  (endoxa),  a  shared   240 set  of  experiences,  or  the  nature  of  the  subject  matter.  Thus  one  way  to  begin  conversations   around  the  boundary  problem  is  to  propose  candidate  starting  points.    I  have  argued  that   proponents  of  both  the  narrow  and  broad  approaches  share  a  concern  for  efficacy,  and  one   might  also  consider  other  commonly  invoked  values  such  as  efficiency,  community,  utility,  and   justice. 241    From  there,  participants  in  the  conversation  will  need  to  assess  the  assumption  that                                                                                                                           238  Daniel  Callahan  and  Bruce  Jennings,  “Ethics  and  Public  Health:  Forging  a  Strong   Relationship,”  American  Journal  of  Public  Health  92,  no.  2  (2002):  173.   239  Christian  Munthe,  “The  Goals  of  Public  Health:  An  Integrated,  Multidimensional  Model,”   Public  Health  Ethics  1,  no.  1  (2008):  39–52;  Lisa  M.  Lee,  “Public  Health  Ethics  Theory:  Review   and  Path  to  Convergence,”  The  Journal  of  Law,  Medicine  and  Ethics  40,  no.  1  (2012):  85–98.   240  Hamlyn,  “Aristotle  on  Dialectic,”  475;  Salmieri,  “Aristotle’s  Non-­‐’Dialectical’  Methodology,”   319.   241  I  have  said  very  little  up  to  this  point  regarding  justice,  in  part  because  the  relationship  of   the  virtue  of  justice  and  political  justice  is  so  complex,  and  beyond  the  scope  of  this  project.         177     such  values  are  shared,  examine  whether  all  public  health  professionals  mean  the  same  thing  by   the  terms  invoked,  and  consider  whether  such  values  can  coherently  be  endorsed,  amongst  other   considerations  within  the  subsequent  debate.     4.4.3  What  are  the  rules  of  engagement?   In  addition  to  these  considerations,  those  engaging  in  discourse  regarding  the  scope  of  public   health  can  also  look  to  Aristotle  for  guidance  as  to  how  to  conduct  oneself  during  such  an  inquiry.     Thus,  Aristotle  says  of  the  beliefs  of  the  wise  and  experienced  (endoxa),  “it  is  not  reasonable  to   suppose  that  either  set  of  people  are  wholly  wrong,  but  rather  that  they  are  getting  it  right  in  at   least  some  respect,  or  else  in  most  respects.”  (NE  I.8  1098b29)    Here,  again,  the  imagery  of   hamartia  is  at  the  forefront,  and  Aristotle  cautions  those  engaged  in  debate  to  throw  one’s   242 opponents  a  bone,  and  try  to  find  –  and  accommodate  –  the  merits  of  another’s  position.    In   advocating  for  charitability  in  discourse,  Aristotle  endorses  the  value  of  the  intellectual  virtues  –                                                                                                                                                                                                                                                                                                                                                                                                 However,  its  dominance  as  a  topic  in  contemporary  public  health  ethics  indicates  that  any   ethics  of  public  health,  including  a  virtue  ethics  approach,  is  incomplete  without  an   accompanying  theory  of  justice.    For  work  on  social  justice  and  public  health,  see  Ruger,  "Health   and  Social  Justice.";  Powers  and  Faden,  "Social  Justice.";  Dan  Beauchamp,  “Public  Health  as   Social  Justice,”  Inquiry  13,  no.  1  (1976):  3–14;  Nancy  E.  Kass,  “Public  Health  Ethics  From   Foundations  and  Frameworks  to  Justice  and  Global  Public  Health,”  The  Journal  of  Law,  Medicine   and  Ethics  32,  no.  2  (2004):  232–42;  For  an  account  of  justice  as  a  virtue,  see  Bernard  Williams,   “Justice  as  a  Virtue”  in  Essays  on  Aristotle’s  Ethics,  ed.  Rorty,  Amélie  Oksenberg  (Berkeley:   University  of  California  Press,  1980):  189-­‐200.    For  an  initial  discussion  on  the  relationship   between  the  virtue  of  justice  an  Aristotle’s  notion  of  political  justice,  see  Thornton  C.   Lockwood,  “Ethical  Justice  and  Political  Justice,”  Phronesis:  A  Journal  for  Ancient  Philosophy  51,   no.  1  (2006):  29–48.     242  I  owe  this  point  to  Roger  Crisp,  “Aristotle  on  Dialectic,”  Philosophy  66,  no.  258  (1991):  522– 4.       178     243 those  features  of  intellectual  character  that  are  truth-­‐conducive.    We  find  further  evidence  in   Aristotle  to  be  moderately  amiable  when  “sharing  in  discussions”  generally. 244    When  adapted   for  the  context  of  a  profession,  this  virtue  resembles  something  like  collegiality  –  neither  agreeing   too  easily  with  what  others  say,  nor  being  contrary  for  the  sake  of  contrariness.    This  caution  can   be  interpreted  as  an  indication  that  the  best  way  for  the  boundary  debates  to  avoid  partisanship   is  for  inquirers  to  eschew  ideology  when  engaged  in  debate.     I  will  not  develop  a  comprehensive  account  of  the  intellectual  virtues  (either  generally  or   specific  to  public  health  and  epidemiology),  here.    Rather,  I  merely  wish  to  establish  that  if  some   contentious  aspects  of  the  boundary  are  to  be  resolved,  it  is  those  engaged  in  debate  that  will   need  to  lead  the  way,  in  part  by  building  coalitions  rather  than  solely  seeking  to  find  fault  with   the  opposition’s  view.    Such  a  position  endorses  the  notion  that  virtues  are  not  only  those  traits   that  help  agents  to  achieve  their  goals,  but  also  those  attributes  that  sustain  and  foster  the   communities  and  practices  that  set  the  stage  for  individual  and  collective  goal-­‐directed   endeavors. 245     4.4.4  What  are  the  desired  outcomes  of  discourse?   Lastly,  those  considering  the  boundary  problem  need  to  be  explicit  about  what  they  desire  to   obtain  from  discussion.    Is  the  objective  of  discourse  a  definition  of  public  health  (the  good  and   the  bad),  an  account  of  governmental  public  health  responsibilities,  an  articulation  of  the                                                                                                                           243  James  A.  Montmarquet,  “Epistemic  Virtue,”  Mind  96,  no.  384  (1987):  482–97.   244  Salmieri,  “Aristotle’s  Non-­‐’Dialectical’  Methodology,”  321.   245  I  have  in  mind  here  Montmarquet’s  view  that  virtues  are  sometimes  self-­‐directed,  and   sometimes  other-­‐directed.    Montmarquet,  “Epistemic  Virtue.”       179     common  values  shared  by  the  entire  discipline,  or  a  set  of  values  to  guide  public  health  policies   and  action? 246    Sometimes  what  professionals  seek  from  an  ethics  of  public  health  are  not  only  a   set  of  normative  considerations  characteristic  of  public  health,  but  also  some  way  of  using  these   values  to  shape  allocation  schemes,  or  even  develop  justificatory  conditions  for  initiating   interventions. 247    To  summarize  points  a)  through  c),  Salmieri  observes  that  there  are  “three   fundamental  questions  we  can  ask  about  a  method  of  inquiry:  “What  are  its  starting-­‐points?   What  are  its  goal(s)?  and  What  is  the  process  by  which  we  progress  from  the  starting-­‐points  to   the  goal(s).” 248    Until  those  engaged  in  disputes  around  the  boundary  problem  become  clear   about  the  answers  to  these  questions,  they  are  as  likely  to  speak  past  each  other,  as  to  speak  to   each  others’  legitimate  concerns.     4.5  Professional  flourishing     It  is  noteworthy  that  much  of  the  debate  regarding  the  boundary  problem,  on  both  sides,   stems  from  a  professional  feeling  that  getting  the  answers  wrong  entails  a  moral  failure  on  the   part  of  public  health  professionals.    This  driving  concern  indicates  a  sense  of  professional   dissatisfaction,  even  uneasiness,  with  the  current  state  of  affairs  in  public  health  practice  in  the                                                                                                                           246  Gostin  refers  to  the  distinction  between  the  penultimate  and  ultimate  questions  as  the   difference  between  an  ethics  of  public  health  and  ethics  in  public  health,  “Public  health,  ethics,   and  human  rights,”  125–6.   247  In  addition,  it  is  worth  noting  that  the  results  of  one  inquiry  may  be  that  starting  points  for   further  inquiry,  as  noted  by  Sarah  Broadie  in  Aristotle,  "Nicomachean  Ethics,"  279.  Those   engaged  in  discourse  on  the  boundary  problem  would  also  do  well  to  follow  Aristotle’s  lead  by   recognizing  that  an  inquiry  that  raises  more  questions  is  not  futile  –  the  articulation  of   questions  themselves  may  be  part  of  what  it  means  to  be  a  good  public  health  professional  if   they,  too,  generate  better  understanding.   248  Salmieri,  “Aristotle’s  Non-­‐’Dialectical’  Methodology.”         180     absence  of  adequate  moral  guidance  for  the  profession.    I  claim  that  such  discomfort  illustrates   the  aptness  of  a  virtue  ethics  approach.      For,  it  is  an  advantage  of  a  virtue  ethics  approach  to   public  health  that  it  captures  the  ways  in  which  professional  life  contributes  to  our  assessment  of   a  life  as  a  whole.       Aristotle’s  notion  of  a  good  life  indicates  that  success  or  flourishing  includes  a  temporal   element:  “For  a  single  swallow  does  not  make  spring,  nor  does  a  single  day,  in  the  same  way,   neither  does  a  single  day,  or  a  short  time,  make  a  man  blessed  and  happy.”  (NE  1.7  1098a17-­‐21)   This  aspect  of  completeness  has  its  parallel  in  a  professional  ideal;  a  professional  career  that  ends   in  disgrace  is  one  that  is  perhaps  more  tragic  precisely  because  of  the  good  that  may  have   preceded  a  downfall,  and  our  suspicion  that  such  a  career  had,  until  the  crucial  point,  been   exemplary.    One  might  also  imagine  that  contemporary  public  health  angst  over  the   indeterminate  nature  of  the  profession,  and  its  foundational  values,  indicates  that  the  profession   is  lost,  perhaps  lacking  the  virtues  needed  to  clarify  both  individual  vision  and  sustain  a  coherent   community.    However,  I  think  that  to  the  contrary,  it  is  because  public  health  professionals  have   deeply  personal  moral  commitment  to  serving  that  community  that  advocates  of  both  broad  and   narrow  approaches  are  so  invested  in  engaging  in,  and  determined  to  find  greater  understanding   as  a  result  of,  inquiry  into  the  nature  of  public  health.    Thus,  just  public  health  professionals  (on   both  sides)  are  frustrated  by  the  current  state  of  affairs  in  public  health  precisely  because  they   believe  there  is  more  to  be  done  and  they  feel  unable  to  do  it.  While  gaining  clarity  on  why  such   insights  are  justified  -­‐  and  what  recommendations  for  action  follow  –  will  help,  we  ought  not  to   take  confusion  in  public  health  philosophy  and  ethics  as  a  sign  of  the  absence  of  professional   virtue.  On  the  contrary,  the  concern  with  which  professionals  have  engaged  in  debate  ought  to       181     be  interpreted  as  a  signal  that  virtue  is  present,  and  perhaps  even  accountable  for  both  the   changing  nature  of  public  health,  and  desire  to  preserve  what  is  virtuous  in  traditional  public   health  practice. 249    Virtue  ethics  claims  not  only  that  the  virtues  are  instrumental  to  achieving  one’s  goals,   but  also  constitutive  of  eudaimonia,  or  human  flourishing.  The  professional  equivalent  of  this   implies  that  professional  virtues  are  both  instrumental  to  attaining  professional  goals,  but  also   constitutive  of  professional  flourishing  –  or  professional  satisfaction,  as  we  might  be  more  likely   to  call  it.    This  does  not  mean  that  the  virtues  will  necessarily  grant  professionals  the  capacity  to   achieve  every  promotion  or  recognition  of  good  service  desired.    Rather,  such  achievements  are   as  contingent  upon  the  merits  of  those  who  do  the  valuing  and  promoting.  In  contrast,   professional  flourishing  is  the  satisfaction  that  derives  from  enacting  and  completing  one’s  own   understanding  of  a  job  not  just  well  done,  but  excellently  done.    Only  in  such  a  career  can   professionals  access  what  MacIntyre  calls  these  internal  goods  of  a  practice. 250     Such  goods  are  independent  of  the  outcome  of  public  health  interventions.      Reductions  in   morbidity  and  mortality  achieved  at  the  expense  of  the  virtues  will  give  those  with  the  right   sensibilities  a  sense  of  profound  inadequacy,  despite  the  outcomes.  In  contrast,  when  nothing   else  can  be  done  to  protect  public  vulnerability  to  harm,  virtuous  action  lends  the  professionals   the  inadequate  but  sweet  solace  of  having  done  everything  they  could,  even  if  it  could  not   forestall  tragedy.    Given  the  increasing  connection  between  modern  choices  of  vocation  and                                                                                                                           249  For  a  discussion  of  how  virtues  are  dependent  on  historical  context,  see  Ludwieg  Siep,   “Virtues,  Values,  and  Moral  Objectivity,”  in  Virtue,  Norms,  and  Objectivity:  Issues  in  Ancient  and   Modern  Ethics,  ed.  Christopher  Gill  (Oxford:  Oxford  University  Press,  2005),  Chapter  4.   250  MacIntyre,  "After  Virtue,"  191.         182     personal  identity,  it  is  not  surprising  that  our  professions  are  one  arena  that  prompts  us  to  ask   the  ancient  question  of  what  kind  of  life  we  ought  to  live,  one  remaining  domain  of  life  which   calls  upon  us  to  reflect  on  a  whole  life,  if  not  “from  every  aspect  an  all  the  way  down,”  then  from   251 the  long  and  significant  segment  that  now  constitutes  a  modern  career.                                                                                                                         251  Williams,  "Ethics  and  the  Limits  of  Philosophy,"  5.       183       CONCLUSION     I  mentioned  in  the  introduction  that  professional  ethics  are  necessarily  truncated.    One   way  that  philosophers  have  handled  this  with  respect  to  other  professions  is  by  a  drawing   bright  line  between  the  goals  of  a  profession  and  the  more  general  goals  of  a  good  life.    I  have   conducted  my  investigations  here  with  an  eye  toward  the  impossibility  of  such   compartmentalization.    I  contend  that  a  virtue  approach  to  public  health  ethics  cannot  be   isolated  in  this  way  from  virtue  ethics  more  broadly  due  to  two  insufficiencies  that  result:  (1)   inadequate  guidance  for  public  health  practice,  and  (2)  inadequate  guidance  for  public  health   professionals.    I  then  consider  some  avenues  for  further  development  of  a  virtue  approach  to   public  health  ethics.   (1)  In  Chapter  1  I  examined  the  role  of  public  health  professionals  in  cultivating  civic   friendship.    I  have  neglected  until  now  to  note  that  Aristotle  primarily  believed  that  such   alliances  would  be  formed  based  on  shared  understandings  of  the  minimal  requirements  of  a   just  society.  I  did  this  in  part  because  such  friendships  can  be  motivated  by  what  I  have  called   “civility,”  or  a  kind  of  general  amiability  or  concern  for  others  that  can  be  distinguished  from   justice.    However,  that  Aristotle  conceived  of  civic  friendship  as  centrally  connected  to  matters   of  justice  is  a  reflection  of  his  view  that  moral  and  political  matters  both  fall  under  the  umbrella   of  practical  action.    As  such,  for  Aristotle,  the  moral  is  political.    A  virtue  ethics  of  public  health,   then,  will  not  be  complete  without  an  account  of  justice  as  a  virtue,  but  also  in  terms  of  a   political  philosophy.    I  have  made  some  references  to  justice  throughout  the  dissertation,  but   this  more  comprehensive  account  requires  far  more  than  can  be  accomplished  within  the  limits   of  this  project.    My  analysis  here  suggests  that  this  more  complete  virtue  approach  to  public       184     health  ethics  will  see  public  health  professionals  as  fulfilling  two  roles.    The  first  is  educational,   as  exhibited  by  the  process  of  imaginative  engagement  initiated  from  the  synoptic  perspective   characteristic  of  all  public  leaders.    Such  engagement  goes  beyond  the  professional  virtues   because  it  involves  such  professionals  in  the  process  of  articulating  a  societal  understanding  of   the  good  life.    In  this  way,  public  health  practice  will  be  a  generative  force  for  the  civic  virtues   and  their  place  in  individual  and  communal  views  of  the  good  life.    Secondly,  while  part  of  what   public  health  professionals  do  is  create  and  sustain  community,  they  are  also  implementers  of   political  legislation.    Thus,  public  health  professionals  will  need  an  account  of  political   philosophy  in  order  to  attend  to  this  aspect  of  their  work,  which  covers  both  the  virtuous  and   the  non-­‐virtuous  members  of  society.    The  need  for  an  account  of  justice  ought  not  to  come  as   a  surprise  to  those  working  in  public  health  ethics  given  the  way  in  which  social  justice  has   come  to  be  a  prominent  topic  of  discussion  in  recent  years. 252    The  account  I  have  provided   here  is  therefore  consistent  with  the  current  emphasis  public  health  ethics  is  placing  on   developing  ethical  resources  for  just  public  health  practice.   (2)  A  virtue  approach  to  public  health  ethics  is  a  version  of  role  morality,  and  as  such  it   exhibits  the  limitations  of  all  role  morality.  Virtues  and  their  specifications  in  public  health   practice  are  not  the  only  expressions  of  virtue,  and  while  one  can  be  professionally  virtuous,   this  is  not  sufficient  for  providing  individuals  who  happen  to  be  public  health  professionals  with   guidance  for  how  they  should  act  all  things  considered.  What  one  ought  to  do  qua  professional   vs.  qua  person  can  be  a  challenging  determination  for  public  health  professionals  to  make   because  they  cannot  artificially  separate  their  professional  expertise  from  their  public  (or                                                                                                                           252  See  note  241.       185     personal)  personas.    For  example,  as  public  figures,  it  will  be  difficult  for  public  health   professionals  to  speak  out  publicly  and  distinguish  this  act  as  one  not  performed  in  a   professional  capacity.    This  may  be  in  part  what  is  happening  in  public  health  at  the  moment.     Given  the  injustices  public  health  professionals  are  increasingly  aware  of,  the  boundary   problem  is  in  part  an  expression  of  struggles  to  determine  what  is  required  of  them  as   professionals,  and  what  is  required  of  them  as  members  of  a  society  responsible  for  such   injustices,  in  order  to  respond  to  such  injustice  appropriately.    One  way  of  thinking  about  the   relationship  between  public  health  ethics  and  ethics  simipliciter  is  to  assume  that  role  morality   253 is  subject  to  being  overruled  by  more  general  moral  considerations.    Thus,  a  public  health   professional  may  conclude  that  while  her  professional  obligations  do  not  require  her  to  speak   out  about  injustices  she  has  witnessed  in  a  professional  capacity,  other  moral  obligations  do.       Another  way  of  considering  this  relationship,  however,  is  to  consider  whether  a   particular  role  is  in  the  midst  of  being  renegotiated.    On  this  view,  role  morality  is  an  instance  of   ordinary  morality,  and  the  content  of  the  role  is  constantly  negotiated  both  internally  by  those   who  take  on  a  role,  but  also  externally  by  those  whom  are  served  by  the  role. 254    Again,  the   boundary  problem  discussion  is  explained  by  this  view.    In  making  a  professional  commitment   to  society,  different  professionals  may  “hear  different  promises  being  made,”  and  furthermore                                                                                                                           253  Norman  E.  Bowie,  “‘Role’  as  a  Moral  Concept  in  Health  Care,”  The  Journal  of  Medicine  and   Philosophy  7,  no.  1  (1982):  57–63.   254  Judith  Andre,  “Role  Morality  as  a  Complex  Instance  of  Ordinary  Morality,”  American   Philosophical  Quarterly  28,  no.  1  (1991):  77.         186     the  public  may  have  heard  a  different  set  of  promises  as  well.    On  this  view,  the  boundary   problem  is  a  discussion  about  the  content  of  this  professional  promise. 255   In  conclusion,  the  view  I  have  presented  here  provides  an  initial  glimpse  of  what  a  virtue   approach  to  public  health  ethics  has  to  contribute;  as  I  have  noted,  such  discussions  have  no   small  bearing  on  the  future  of  bioethics  more  broadly.    I  would  like  to  highlight  two  features  of   the  arguments  presented  here  that  suggest  some  considerations  for  further  development  of  a   virtue  approach  to  public  health  ethics.       The  first  consideration  is  the  need  to  understand  the  nature  of  the  relationship  between   institutions  and  virtue.    Developing  such  an  account  will  be  important  to  public  health  ethics,   but  also  a  great  deal  else  in  professional  ethics,  suggesting  important  overlap  with   organizational  ethics.      Because  public  health  is  a  collective  and  public  practice,  I  believe  it  more   immediately  suggests  the  need  to  develop  accounts  of  ethics  within  institutions.    Possibilities   include  acknowledging  the  limits  of  the  virtues,  and  exploring  their  capacity  to  complement   principled  approaches,  or  perhaps  an  account  of  the  intellectual  virtues  of  organizational   deliberative  processes.    I  believe  that  such  discussions  will  have  important  bearing  on  public   health  ethics  pedagogy  as  well  as  clinical  ethics,  where  such  matters  have  been  sorely   neglected.   The  arguments  laid  out  here  also  highlight  the  interdependent  nature  of  the  virtues,  and   how  an  understanding  of  them  changes  how  we  can  discuss  what  ought  to  be  done.    I  have   argued  that  an  understanding  of  courage  can  contribute  to  risk  discourse,  including  with  the   public,  which  means  that  such  conversations  are  a  form  of  imaginative  engagement  that  fosters                                                                                                                           255  Andre,  “Role  Morality,”  p.  77         187     civic  friendship  as  well  as  civic  courage.    In  turn,  the 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