The Tragedy of the Commons and Population Health: The State’s Intervention in an Individual’s Actions and Choices from a Capability Perspective

Abstract

The discussion of public health ethics usually focuses on public health and relates it to the notion of a public good. In this paper, I explain why we need to focus on population health and why it corresponds to a common good and hence is prone to depletion in the absence of appropriate state regulation. Using the capability approach perspective and Sen’s focus on the value of the opportunity and process aspects of freedom, I show why the state commitment to guarantee each individual the prerequisites for her positive freedom in fact justifies limiting an individual’s freedom of action in order to protect the freedom of others. However, even such infringements might not suffice to maintain population health as a common good. Hence, in the third section, I look at an additional course of intervention by the state, namely the use of nudges which are intended to influence an individual’s choices and to steer her to more health-enhancing behavior. In light of the possible violation of the opportunity and process aspects of individual freedom, I show why and under what circumstances the use of nudges is not only ethical, but actually preserves the two aspects of freedom and at the same time maintains the common good.

Keywords:

• Population health
• Public health
• Common goods
• Sufficiency
• Capabilities
• Nudge

Acknowledgements

The author is grateful to the two anonymous referees for their helpful comments and suggestions.

Disclosure Statement

No potential conflict of interest was reported by the author.

About the Author

Efrat Ram-Tiktin is a lecturer at the Department of Philosophy at Bar-Ilan University. Her work focuses on Sufficiency of Capabilities as just distribution of health care, and on patients’ prioritization under moderate and severe scarcity of resources.

Notes

1. For the different definitions of public health and its scope, see, for example, Nuffield Council on Bioethics (2007, 5–6), Faden and Shebaya (2016), Anomaly (2011, 251–252), and Verweij and Dawson (2007). For the different definitions of population health, see Kindig and Stoddart (2003).

2. This is evident from the various definitions and discussions that can be found in Winslow (1920), Association of Schools of Public Health (cited in Nuffield 2007, p. 6), World Medical Association (1995), Nuffield Council on Bioethics (2007), Institute of Medicine (1988), World Federation of Public Health Association (cited in Nuffield 2007), and Carter, Cribb, and Allegrante (2012). An interesting discussion by Verweij and Dawson (2007) focuses on the two senses of “public” in public health. They state that the first sense is the public’s state of health, that is, the population’s collective health. The second sense is “practice or a set of interventions aiming to protect the health of the public” (21, emphasis added). Verweij and Dawson conclude that the practice of public health should be understood as the “collective interventions that aim to promote and protect the health of the public” (21). That understanding of the term “public health” is in line with other definitions in the literature. In addition, it supports the distinction I am proposing between public health and population health. It is important to note that although Verweij and Dawson do not explicitly discuss the definition of population health, they do use the term when they want to indicate its first sense (22).

3. Dunn and Hayes (1999) focus on health status while Kindig (1997) and Kindig and Stoddart (2003) refer to health outcomes.

4. These mistakes are attributed to the Nuffield Council on Bioethics (2007) and others such as Faden and Shebaya (2016) and Anomaly (2011). In the case of Anomaly, I believe the mistake to be even graver since he identifies health outcomes (i.e., population health) as exhibiting “the two characteristic features of public goods: non-excludability and non-rivalry” (251). In the second section, I will present the widely accepted characterizations of public goods and common goods and explain why population health exhibits the features of a common good (i.e., non-excludable and rival). In contrast, Gostin and Stone (2007) correctly relate to common goods. Although they use the term public health, from the way in which they interpret the term, it is clear that they are referring to a population’s state of health.

5. Deneulin and Townsend make that claim regarding exclusion, and Ostrom and Ostrom refer to both criteria (although they do not use the term “rivalry,” but rather “jointness of use or consumption”).

6. See, for example, Bayer and Fairchild (2004, 474–475). Loose use of the term “common good” can be found in Carter, Cribb, and Allegrante (2012). They relate to the common good (singular) and relate it to “collective goods” (12–13).

7. The rate of vaccinated individuals required to achieve the herd effect varies across contagious diseases (80–95%) and also depends on various other factors.

8. A similar conclusion regarding the need for collective action in order to maintain the common good can be found in Verweij and Dawson (2007, 25–27) and Gostin and Stone (2007).

9. For a more extensive presentation of the account, see Ram-Tiktin (2012, 2017).

10. Ram-Tiktin (2018).

11. Here I adopt Paula Casal’s (2007) distinction between positive and negative theses of sufficiency. For a presentation of an allocation principle above the sufficiency threshold, see Ram-Tiktin (2012).

12. For a detailed presentation of each key system, see Ram-Tiktin (2017, 151–153).

13. Ram-Tiktin (2018).

14. For example, running is a function requiring a combination of the following set of capabilities: blood circulation, respiration, movement, and stability and senses.

15. There is no justification for quarantine in the case of contagious diseases that are spread by direct contact with body fluids, such as AIDS or hepatitis. I will not discuss the issue of quarantine in this paper since I wish to look more closely at other forms of state interventions, but I find it important to stress the following with respect to quarantine and isolation. These procedures are extreme violations of an individual’s freedom and therefore must be limited to the necessary minimum. Quarantine should be limited to the contagious phase only and during that period of time, other aspects of an individual’s freedom should be protected, such as the possibility of communicating with loved ones, freedom of action as long as the safety of other patients and the medical staff is ensured, and so forth.

16. OECD (2010), McKinsey Global Institute (2014), Nuffield Council on Bioethics (2007), and Healthy Diet Committee (2017).

17. Thaler and Sunstein (2003) and Sunstein and Thaler (2003).

18. For further discussion of libertarian paternalism’s endorsement of behavioral economics and rejection of neo-classic economics and rational choice theory, see Ménard (2010).

19. Apparently, the prohibition on smoking in public areas is more costly to a smoker because he has to leave the public area and find a designated smoking area; nonetheless, he is not prohibited from smoking.

20. The use of nudges (or other kinds of interventions) presents a practical problem that might not seem to be a priority concern for Sen and Nussbaum. However, in my opinion, formulating a theory of justice is not enough to guarantee the improvement of peoples’ lives. Questions of implementation must also be addressed in order that statements about justice do not remain mere statements.

21. Ram-Tiktin (2018).