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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Alcohol, Liberty, and Societal Change: What Should We Do About Our Drinking Problem? a
Angus Dawson & Kathryn MacKay
a
a
University of Birmingham Published online: 18 Mar 2015.
Click for updates To cite this article: Angus Dawson & Kathryn MacKay (2015) Alcohol, Liberty, and Societal Change: What Should We Do About Our Drinking Problem?, The American Journal of Bioethics, 15:3, 12-14, DOI: 10.1080/15265161.2014.998387 To link to this article: http://dx.doi.org/10.1080/15265161.2014.998387
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 15(3): 12–24, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.998387
Open Peer Commentaries
Alcohol, Liberty, and Societal Change: What Should We Do About Our Drinking Problem?
Downloaded by [Seton Hall University] at 12:07 04 April 2015
Angus Dawson, University of Birmingham Kathryn MacKay, University of Birmingham Alcohol is certainly an important and neglected public health issue. It causes harm directly in relation to health, and also through societal consequences as a result of road accidents, domestic violence, and public order. Alcoholrelated harms have too often been ignored, perhaps because many of us enjoy drinking and the effects it has upon us, and we cannot imagine life without access to our favorite drug. The article by Louise and colleagues (2015) raises a set of important ethical issues that arise in relation to the possible mandating of warning labels on alcoholic beverages. Their focus is on the increased risks of developing cancer from alcohol consumption. These issues certainly require more discussion in the public health and ethics literature. We broadly agree with Louise and colleagues in terms of their recommendations, but suggest that their analysis is not critical enough. We focus on two issues, one empirical and one normative. We begin where we agree. Louise and colleagues are correct to argue that smoking has major limitations as a model for alcohol regulation. Alcohol does not cause harm to others directly in the way we know tobacco smoke does, and low alcohol consumption is likely to be safe, even possibly beneficial. This means that the politics of passing any legislation will be more fraught as both manufacturers and consumers are likely to object. It also means that the information provided at the point of consumption (on the bottle) is going to have to be more subtle and complicated. Messages such as “Alcohol kills” or “drinking alcohol causes cancer” are even more problematic than “smoking kills.” More subtle and truthful labeling may have to be more complex. A message such as “drinking alcohol to excess—defined as x amount of units for y years— increases your relative risk of a particular cancer c by p amount,” even if it fits on a bottle, may generate more questions than answers in the consumer. Information about alcohol-related cancer risk may be welcomed, as this
is not widely known, but are such labels primarily focused on providing information or seeking to persuade the drinker not to have another glass? Louise and colleagues structure their article around the idea that information provision may be laudatory if done well, as it promotes autonomy, but persuasion is problematic as it seeks to push people to make certain choices. It is here that we diverge and suggest that their analysis does not go far enough because it shaped by what we can call a liberty paradigm and this is problematic for two main reasons, one empirical and one normative. First, let’s assume that we have good evidence of increased cancer risk (and other direct health harms) from excessive drinking, and it is a clear public health aim to reduce this risk. Will the provision of information through labeling make a contribution to this aim? This is an empirical question and would have to be explored through research, but we have strong grounds for doubting it. Everyone knows about the risk from smoking, but still some continue to smoke. Relevant information does not always change behavior. Indeed, we know from other areas of health promotion that a focus on information about risks of harm is a very poor way of changing behavior (Dawson 2014). On the model presented by Louise and colleagues it is acceptable to decide against changing one’s drinking behavior as long as this is an informed choice. We come back to this claim later. But for our purposes here we can focus on the assumptions that individuals have complete or at least relevant control over their behavior, that they assess all risks against other things of importance to them (e.g., enjoyment), and that they rationally calculate what is best for them. It also assumes that responsibility for behavior is an individual matter. All of these things can be doubted. Information is an inadequate trigger for behavior change. In a clash between the public health aim of risk reduction and a commitment to a
Address correspondence to Angus Dawson, University of Birmingham, Medicine, Ethics, Society & History (MESH), Birmingham, B15 2TT, United Kingdom. E-mail: [email protected]
12 ajob
Downloaded by [Seton Hall University] at 12:07 04 April 2015
Ethics of Cancer Risk Warnings on Beverages
method (information provision) that we know probably won’t achieve that aim, it is, according to Louise and colleagues, apparently the public health aim we should abandon. This is an argument that uses a particular normative view, as we show later, for ignoring empirical factors. We suggest that, on the contrary, where the public health goal is justifiable, we should look at all relevant methods that help in attaining that end. Information may help, but it is unlikely to be the silver bullet in achieving behavior change. Change happens, gradually, and, mainly, at the social or societal level, not just that of the individual. As a result, we can also question ideas of individual responsibility, and point out that choices are not made in a social vacuum. Individual choice is shaped by economic and social forces, such as the role of alcohol manufacturers’ and retailers’ decisions in fixing their prices and special offers, the law in relation to how easy it is to access alcohol, peer behavior and the wider culture of alcohol consumption, and so on. What we can learn from the smoking case is that what causes lots of change at the individual level is major attitudinal change within the relevant culture. Once the need for such change is widely accepted, as happened in relation to smoking, you can change behavior, but this may involve pressure, persuasion and coercion. Louise and colleagues seem to suggest that we should avoid all such methods. Why? Our second point is that Louise and colleagues invoke an extremely narrow set of values in their discussion and this is problematic. Their basic approach is one normally labeled liberal, popular in policy discussion, and largely deriving from a particular interpretation of the work of John Stuart Mill’s On Liberty (1859). The focus is on individual autonomous choice, and it is this view of the value of autonomy that shapes their whole approach. As we saw earlier, their view is that information provision is legitimate as long as it seeks to provide the basis for an informed consent, but they hold persuasion to be problematic. This could actually be described as more of a libertarian position, one that accords the value of liberty preeminence over all other values. Liberalism is roughly the view that liberty is important, and may therefore often be according priority, but other values (e.g., justice) can sometimes be even more important. To be fair, Louise and colleagues do mention equity towards the end of their article, but it is unclear how that value is to be weighed against that of liberty in their account. Given the place that they have given to autonomy, it seems hard to see why we might choose to prioritize equity over autonomy in some cases, or why we might think harm reduction should be more important than individual choice. Public health activity is surely not just about autonomy maximization, but has a number of different goals to pursue (Munthe 2008). The narrow range of Louise and colleagues’ interest in values in structuring their position allows them to appeal to views about the illegitimate role of the Nanny state, committed to paternalistically interfering in other people’s lives. However, can public health activity where it seeks to
March, Volume 15, Number 3, 2015
promote population health be fairly seen as paternalistic (Nys 2008)? Let’s assume that it can. Louise and colleagues make much of the intention behind a public health intervention. Their argument suggests that government activity such as legislation only has one aim behind it, which can be labeled “paternalistic.” However, virtually all policies have a number of motives behind them. If the aim of labeling is to provide information then it is okay according to Louise and colleagues’ account, but if it also aims to improve the health of drinkers it is paternalistic and therefore wrong, and if it also aims to reduce health care costs is it acceptable or not? Louise and colleagues use the idea of the prevention paradox to suggest that there is something problematic about situations where individuals seemingly don’t benefit directly from public health measures. However, this view can be challenged. It is too easy to see individuals as atoms, opposed to populations, with different cost/ benefit calculations at the different levels of the individual and the population. Any individual is also part of the larger population, and therefore derives benefit from being part of that society. Anyone not already committed to a libertarian individualism may therefore doubt this kind of analysis—especially in the case of alcohol, where costs have been found at individual, family, community, and system levels, and a focus on benefits to individuals may miss important populationlevel gains in public safety from a decrease in alcoholrelated assaults (Miller et al. 2007), say, or from a decrease in fractured families (Centers for Disease Control and Prevention [CDC] 2014). Certainly Rose (1992) is interested in such population effects. Public health policy is a vital part of a broader project to promote the best possible lives we can live. Part of the good life undoubtedly involves having the freedom to make personal choices, but it also involves other things, including perhaps the enjoyment of alcohol, the reduction of harms, the maintenance of a public space that is safe to enjoy. Governments play a vital role in trying to meet these wider aims. Attitudes toward alcohol will change when we all accept that there are important health effects beyond those typically associated with alcohol addiction. Warning labels may be part of a strategy to get a discussion going about the place that alcohol should have in our society but they are not the answer to the problem. The problem is a social one, so it’s no surprise that the answer is too. We need a public health ethics that not only gives a clear place to autonomy, but also seeks to promote other values such as equity, solidarity, and trust. We may well have a drinking problem, but it is only together that we can truly face the issue. & REFERENCES Centers for Disease Control and Prevention. 2014 Alcohol use and your health. Available at: http://www.cdc.gov/alcohol/factsheets/alcohol-use.htm (accessed December 7, 2014)
ajob 13
American Journal of Bioethics
Dawson, A. 2014 Information, Choice and the Ends of Health Promotion. Monash Bioethics Review 32: 106–120. Available at: http:// dx.doi.org/10.1007/s40592-014-0009-4
Downloaded by [Seton Hall University] at 12:07 04 April 2015
Louise, J., J. Eliott, I. Olver, and A. Braunack-Mayer. 2015. Mandatory cancer risk warnings on alcoholic beverages: What are the ethical issues? American Journal of Bioethics 15(3): 3–11.
students. Pediatrics 119(1): 76–85. Available at: http://dx.doi.org/ 10.1542/peds.2006-1517 Munthe, C. 2008 The goals of public health: An integrated, multidimensional model. Public Health Ethics. 1(1): 39–52. Available at: http://dx.doi.org/10.1093/phe/phn006
Mill, J. S. 1859 [1974]. On liberty. Harmondsworth, UK: Penguin.
Nys, T. 2008. Paternalism in public health care. Public Health Ethics 1(1): 64–72. Available at: http://dx.doi.org/10.1093/phe/phn002
Miller, J. W., T. S. Naimi, R. D. Brewer, and S. E. Jones. 2007 Binge drinking and associated health risk behaviors among high school
Rose, G. 1992 The strategy of preventive medicine. Oxford, UK: Oxford University Press.
Weighing the Ethical Considerations of Autonomy and Efficacy With Respect to Mandatory Warning Labels C. D. Brewer, Central Connecticut State University George N. Himes III, Central Connecticut State University In their article “Mandatory Cancer Risk Warnings on Alcoholic Beverages: What Are the Ethical Issues?,” Louise and colleagues (2015) recognize that the aim of mandatory warning labels could be to reduce the consumption of alcohol, or to allow consumers to make an informed choice. They maintain that the latter may not really be a different rationale (if the labels reduce consumption, it would likely be through informing consumers), and assume that reducing alcohol consumption is the ultimate aim of warning labels. The authors believe that in order to be justifiable as a public health intervention, the labels must change consumer behavior. They write, “If awareness and understanding of risks were the ultimate aim . . . it does not provide a justification for warning labels as a public health intervention, but rather would make it a concern for consumer protection agencies” (5). They assume that public health organizations should only be concerned with ensuring that members of the public make autonomous choices if those choices actually do improve health; providing pertinent health information is not enough. We hold that it is justifiable to mandate warning labels that provide relevant public health information, even if that information does not ultimately lead to a change in behavior. Once it is clear that concerns of autonomy justify mandatory warning labels, we believe that many of the efficacy concerns the authors raise can be dismissed. The authors note that alcohol consumption “significantly increases the risk of certain cancers . . . even at low to moderate levels of consumption” (3). Furthermore, they recognize that public awareness of the link
between alcohol and certain cancers is low. Mandatory warning labels would help ensure that if consumers believe the increased risk of developing certain cancers outweigh any benefits of consuming alcohol, then they have the information to make that choice. Because this decision directly affects consumer health, it ought to be the concern of both public health agencies and consumer protection agencies. We do not have the space to provide a thorough justification for the importance of autonomy, but we will assume that a society concerned with liberty will also be concerned with helping citizens make autonomous choices. The authors clearly acknowledge the importance of autonomy, even though they focus more on concerns of efficacy. In fact, they recognize that the “main argument in favor of mandated warning labels is therefore that it would allow consumers to make an informed choice about their alcohol consumption in light of their own values, concerns, and attitudes to risk” (6). We see no reason why helping to ensure autonomy should be limited to consumer protection agencies. We are not alone in our skepticism; the authors even provide two examples of public safety offices (the Australian Chronic Disease Prevention Alliance and Alcohol Concern UK) that justify mandatory warning labels because they provide consumers with relevant health information. If we turn our attention away from alcohol, there are other examples of public safety offices justifying mandatory warning labels by appealing to consumer autonomy. In reference to California’s Proposition 65, which, among other things, requires businesses to
Address correspondence to C. D. Brewer, Department of Philosophy, Central Connecticut State University, 1615 Stanley Street, New Britain, CT 06050, USA. E-mail: [email protected]
14 ajob
March, Volume 15, Number 3, 2015
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Alcohol, Liberty, and Societal Change: What Should We Do About Our Drinking Problem? a
Angus Dawson & Kathryn MacKay
a
a
University of Birmingham Published online: 18 Mar 2015.
Click for updates To cite this article: Angus Dawson & Kathryn MacKay (2015) Alcohol, Liberty, and Societal Change: What Should We Do About Our Drinking Problem?, The American Journal of Bioethics, 15:3, 12-14, DOI: 10.1080/15265161.2014.998387 To link to this article: http://dx.doi.org/10.1080/15265161.2014.998387
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
The American Journal of Bioethics, 15(3): 12–24, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2014.998387
Open Peer Commentaries
Alcohol, Liberty, and Societal Change: What Should We Do About Our Drinking Problem?
Downloaded by [Seton Hall University] at 12:07 04 April 2015
Angus Dawson, University of Birmingham Kathryn MacKay, University of Birmingham Alcohol is certainly an important and neglected public health issue. It causes harm directly in relation to health, and also through societal consequences as a result of road accidents, domestic violence, and public order. Alcoholrelated harms have too often been ignored, perhaps because many of us enjoy drinking and the effects it has upon us, and we cannot imagine life without access to our favorite drug. The article by Louise and colleagues (2015) raises a set of important ethical issues that arise in relation to the possible mandating of warning labels on alcoholic beverages. Their focus is on the increased risks of developing cancer from alcohol consumption. These issues certainly require more discussion in the public health and ethics literature. We broadly agree with Louise and colleagues in terms of their recommendations, but suggest that their analysis is not critical enough. We focus on two issues, one empirical and one normative. We begin where we agree. Louise and colleagues are correct to argue that smoking has major limitations as a model for alcohol regulation. Alcohol does not cause harm to others directly in the way we know tobacco smoke does, and low alcohol consumption is likely to be safe, even possibly beneficial. This means that the politics of passing any legislation will be more fraught as both manufacturers and consumers are likely to object. It also means that the information provided at the point of consumption (on the bottle) is going to have to be more subtle and complicated. Messages such as “Alcohol kills” or “drinking alcohol causes cancer” are even more problematic than “smoking kills.” More subtle and truthful labeling may have to be more complex. A message such as “drinking alcohol to excess—defined as x amount of units for y years— increases your relative risk of a particular cancer c by p amount,” even if it fits on a bottle, may generate more questions than answers in the consumer. Information about alcohol-related cancer risk may be welcomed, as this
is not widely known, but are such labels primarily focused on providing information or seeking to persuade the drinker not to have another glass? Louise and colleagues structure their article around the idea that information provision may be laudatory if done well, as it promotes autonomy, but persuasion is problematic as it seeks to push people to make certain choices. It is here that we diverge and suggest that their analysis does not go far enough because it shaped by what we can call a liberty paradigm and this is problematic for two main reasons, one empirical and one normative. First, let’s assume that we have good evidence of increased cancer risk (and other direct health harms) from excessive drinking, and it is a clear public health aim to reduce this risk. Will the provision of information through labeling make a contribution to this aim? This is an empirical question and would have to be explored through research, but we have strong grounds for doubting it. Everyone knows about the risk from smoking, but still some continue to smoke. Relevant information does not always change behavior. Indeed, we know from other areas of health promotion that a focus on information about risks of harm is a very poor way of changing behavior (Dawson 2014). On the model presented by Louise and colleagues it is acceptable to decide against changing one’s drinking behavior as long as this is an informed choice. We come back to this claim later. But for our purposes here we can focus on the assumptions that individuals have complete or at least relevant control over their behavior, that they assess all risks against other things of importance to them (e.g., enjoyment), and that they rationally calculate what is best for them. It also assumes that responsibility for behavior is an individual matter. All of these things can be doubted. Information is an inadequate trigger for behavior change. In a clash between the public health aim of risk reduction and a commitment to a
Address correspondence to Angus Dawson, University of Birmingham, Medicine, Ethics, Society & History (MESH), Birmingham, B15 2TT, United Kingdom. E-mail: [email protected]
12 ajob
Downloaded by [Seton Hall University] at 12:07 04 April 2015
Ethics of Cancer Risk Warnings on Beverages
method (information provision) that we know probably won’t achieve that aim, it is, according to Louise and colleagues, apparently the public health aim we should abandon. This is an argument that uses a particular normative view, as we show later, for ignoring empirical factors. We suggest that, on the contrary, where the public health goal is justifiable, we should look at all relevant methods that help in attaining that end. Information may help, but it is unlikely to be the silver bullet in achieving behavior change. Change happens, gradually, and, mainly, at the social or societal level, not just that of the individual. As a result, we can also question ideas of individual responsibility, and point out that choices are not made in a social vacuum. Individual choice is shaped by economic and social forces, such as the role of alcohol manufacturers’ and retailers’ decisions in fixing their prices and special offers, the law in relation to how easy it is to access alcohol, peer behavior and the wider culture of alcohol consumption, and so on. What we can learn from the smoking case is that what causes lots of change at the individual level is major attitudinal change within the relevant culture. Once the need for such change is widely accepted, as happened in relation to smoking, you can change behavior, but this may involve pressure, persuasion and coercion. Louise and colleagues seem to suggest that we should avoid all such methods. Why? Our second point is that Louise and colleagues invoke an extremely narrow set of values in their discussion and this is problematic. Their basic approach is one normally labeled liberal, popular in policy discussion, and largely deriving from a particular interpretation of the work of John Stuart Mill’s On Liberty (1859). The focus is on individual autonomous choice, and it is this view of the value of autonomy that shapes their whole approach. As we saw earlier, their view is that information provision is legitimate as long as it seeks to provide the basis for an informed consent, but they hold persuasion to be problematic. This could actually be described as more of a libertarian position, one that accords the value of liberty preeminence over all other values. Liberalism is roughly the view that liberty is important, and may therefore often be according priority, but other values (e.g., justice) can sometimes be even more important. To be fair, Louise and colleagues do mention equity towards the end of their article, but it is unclear how that value is to be weighed against that of liberty in their account. Given the place that they have given to autonomy, it seems hard to see why we might choose to prioritize equity over autonomy in some cases, or why we might think harm reduction should be more important than individual choice. Public health activity is surely not just about autonomy maximization, but has a number of different goals to pursue (Munthe 2008). The narrow range of Louise and colleagues’ interest in values in structuring their position allows them to appeal to views about the illegitimate role of the Nanny state, committed to paternalistically interfering in other people’s lives. However, can public health activity where it seeks to
March, Volume 15, Number 3, 2015
promote population health be fairly seen as paternalistic (Nys 2008)? Let’s assume that it can. Louise and colleagues make much of the intention behind a public health intervention. Their argument suggests that government activity such as legislation only has one aim behind it, which can be labeled “paternalistic.” However, virtually all policies have a number of motives behind them. If the aim of labeling is to provide information then it is okay according to Louise and colleagues’ account, but if it also aims to improve the health of drinkers it is paternalistic and therefore wrong, and if it also aims to reduce health care costs is it acceptable or not? Louise and colleagues use the idea of the prevention paradox to suggest that there is something problematic about situations where individuals seemingly don’t benefit directly from public health measures. However, this view can be challenged. It is too easy to see individuals as atoms, opposed to populations, with different cost/ benefit calculations at the different levels of the individual and the population. Any individual is also part of the larger population, and therefore derives benefit from being part of that society. Anyone not already committed to a libertarian individualism may therefore doubt this kind of analysis—especially in the case of alcohol, where costs have been found at individual, family, community, and system levels, and a focus on benefits to individuals may miss important populationlevel gains in public safety from a decrease in alcoholrelated assaults (Miller et al. 2007), say, or from a decrease in fractured families (Centers for Disease Control and Prevention [CDC] 2014). Certainly Rose (1992) is interested in such population effects. Public health policy is a vital part of a broader project to promote the best possible lives we can live. Part of the good life undoubtedly involves having the freedom to make personal choices, but it also involves other things, including perhaps the enjoyment of alcohol, the reduction of harms, the maintenance of a public space that is safe to enjoy. Governments play a vital role in trying to meet these wider aims. Attitudes toward alcohol will change when we all accept that there are important health effects beyond those typically associated with alcohol addiction. Warning labels may be part of a strategy to get a discussion going about the place that alcohol should have in our society but they are not the answer to the problem. The problem is a social one, so it’s no surprise that the answer is too. We need a public health ethics that not only gives a clear place to autonomy, but also seeks to promote other values such as equity, solidarity, and trust. We may well have a drinking problem, but it is only together that we can truly face the issue. & REFERENCES Centers for Disease Control and Prevention. 2014 Alcohol use and your health. Available at: http://www.cdc.gov/alcohol/factsheets/alcohol-use.htm (accessed December 7, 2014)
ajob 13
American Journal of Bioethics
Dawson, A. 2014 Information, Choice and the Ends of Health Promotion. Monash Bioethics Review 32: 106–120. Available at: http:// dx.doi.org/10.1007/s40592-014-0009-4
Downloaded by [Seton Hall University] at 12:07 04 April 2015
Louise, J., J. Eliott, I. Olver, and A. Braunack-Mayer. 2015. Mandatory cancer risk warnings on alcoholic beverages: What are the ethical issues? American Journal of Bioethics 15(3): 3–11.
students. Pediatrics 119(1): 76–85. Available at: http://dx.doi.org/ 10.1542/peds.2006-1517 Munthe, C. 2008 The goals of public health: An integrated, multidimensional model. Public Health Ethics. 1(1): 39–52. Available at: http://dx.doi.org/10.1093/phe/phn006
Mill, J. S. 1859 [1974]. On liberty. Harmondsworth, UK: Penguin.
Nys, T. 2008. Paternalism in public health care. Public Health Ethics 1(1): 64–72. Available at: http://dx.doi.org/10.1093/phe/phn002
Miller, J. W., T. S. Naimi, R. D. Brewer, and S. E. Jones. 2007 Binge drinking and associated health risk behaviors among high school
Rose, G. 1992 The strategy of preventive medicine. Oxford, UK: Oxford University Press.
Weighing the Ethical Considerations of Autonomy and Efficacy With Respect to Mandatory Warning Labels C. D. Brewer, Central Connecticut State University George N. Himes III, Central Connecticut State University In their article “Mandatory Cancer Risk Warnings on Alcoholic Beverages: What Are the Ethical Issues?,” Louise and colleagues (2015) recognize that the aim of mandatory warning labels could be to reduce the consumption of alcohol, or to allow consumers to make an informed choice. They maintain that the latter may not really be a different rationale (if the labels reduce consumption, it would likely be through informing consumers), and assume that reducing alcohol consumption is the ultimate aim of warning labels. The authors believe that in order to be justifiable as a public health intervention, the labels must change consumer behavior. They write, “If awareness and understanding of risks were the ultimate aim . . . it does not provide a justification for warning labels as a public health intervention, but rather would make it a concern for consumer protection agencies” (5). They assume that public health organizations should only be concerned with ensuring that members of the public make autonomous choices if those choices actually do improve health; providing pertinent health information is not enough. We hold that it is justifiable to mandate warning labels that provide relevant public health information, even if that information does not ultimately lead to a change in behavior. Once it is clear that concerns of autonomy justify mandatory warning labels, we believe that many of the efficacy concerns the authors raise can be dismissed. The authors note that alcohol consumption “significantly increases the risk of certain cancers . . . even at low to moderate levels of consumption” (3). Furthermore, they recognize that public awareness of the link
between alcohol and certain cancers is low. Mandatory warning labels would help ensure that if consumers believe the increased risk of developing certain cancers outweigh any benefits of consuming alcohol, then they have the information to make that choice. Because this decision directly affects consumer health, it ought to be the concern of both public health agencies and consumer protection agencies. We do not have the space to provide a thorough justification for the importance of autonomy, but we will assume that a society concerned with liberty will also be concerned with helping citizens make autonomous choices. The authors clearly acknowledge the importance of autonomy, even though they focus more on concerns of efficacy. In fact, they recognize that the “main argument in favor of mandated warning labels is therefore that it would allow consumers to make an informed choice about their alcohol consumption in light of their own values, concerns, and attitudes to risk” (6). We see no reason why helping to ensure autonomy should be limited to consumer protection agencies. We are not alone in our skepticism; the authors even provide two examples of public safety offices (the Australian Chronic Disease Prevention Alliance and Alcohol Concern UK) that justify mandatory warning labels because they provide consumers with relevant health information. If we turn our attention away from alcohol, there are other examples of public safety offices justifying mandatory warning labels by appealing to consumer autonomy. In reference to California’s Proposition 65, which, among other things, requires businesses to
Address correspondence to C. D. Brewer, Department of Philosophy, Central Connecticut State University, 1615 Stanley Street, New Britain, CT 06050, USA. E-mail: [email protected]
14 ajob
March, Volume 15, Number 3, 2015
