Public health often offers directives. You should wear seat belts. You should get vaccinated. You shouldn’t smoke. This command language, with its moral tinge, is at odds with the language of shared decision-making that has become central in the medical world and in some ways may marginalize the message of public health.
Why does public health seem to revel in an approach that is at odds both with notions of individual freedom and with norms in medicine? In the shared decision-making world of modern medicine, doctors are meant to discuss options with patients, the final health decision is made by the patient, who may in the end, make an unhealthy choice. But public health persists in suggesting courses of actions for the entire population.
Why? And is this ok?
The answer is astonishingly simple. Public health professionals know best for populations; individuals know best for themselves.
Let’s use smoking cigarettes as an example. As public health professionals we are delighted that the prevalence of smoking has decreased from 50% to 16% in the past five decades. A future elimination of all tobacco use would please us even more—the end of smoking would save millions of more lives.
Shared decision-making is necessary at medical visits; clinical providers may be experts, but the best data about treatment may not apply to the patient in the office, and so outcomes are always in doubt. Hence, the patient can reasonably choose for herself among a number of uncertain options.
Fortunately, we can be much more certain about the outcome when we are looking at populations. By any reasonable measure—longevity, cost to the health system, quality of life—smokers do worse than non-smokers. We say this with certainty. After we assemble incontrovertible evidence, as public health providers we try to universalize its application for the good of others. We tax cigarettes, we institute anti-smoking advertising campaigns, and we increase insurance premiums to smokers to create a healthier population.
Society entrusts public health to understand what is in the public good and to act on it. Therefore, when we know the healthiest answer, we should be relentless in seeking its implementation. It is up to society to decide if public health should or should not be in a position to flex our muscles. But, when we see opportunity to improve the public’s health, which derives from the combination of evidence and public agreement, we should act. And we should admit that such flexing is at odds with shared decision-making ideals. That is nothing to be ashamed of.
Warmly,
Michael Stein & Sandro Galea