Kalle Grill

Advances in genetic diagnostics lead to more patients being diagnosed with hereditary conditions. These findings are often relevant to patients’ relatives. For example, the success of targeted cancer prevention is dependent on effective disclosure to relatives at risk. Without clear information, individuals cannot take advantage of predictive testing and preventive measures. Against this background, we argue that healthcare professionals have a duty to make actionable genetic information available to their patients’ at-risk relatives. We do not try to settle the difficult question of how this duty should be balanced against other duties, such as the duty of confidentiality and a possible duty not to know one’s genetic predisposition. Instead, we argue for the importance of recognising a general responsibility towards at-risk relatives, to be discharged as well as possible within the limits set by conflicting duties and practical considerations. According to a traditional and still dominant perspective, it is the patient’s duty to inform his or her relatives, while healthcare professionals are only obliged to support their patients in discharging this duty. We argue that this perspective is a mistake and an anomaly. Healthcare professionals do not have a duty to ensure that their patients promote the health of third parties. It is often effective and desirable to engage patients in disseminating information to their relatives. However, healthcare professionals should not thereby deflect their own moral responsibility.

To an ever-greater extent, we spend our lives in an online environment designed by corporations. These corporations have an interest in shaping not only our purchasing behavior, but also our focus of attention and engagement and to some extent our worldview and identity. As a means to this end, they collect and trade in personal information. One important method of behavioral influence employed to advance these purposes is default-setting - the design of a product or a situation such that one option out of several seems natural to accept, because it is the path of least resistance. Default-setting is a non-rational influence, often imperceptible, yet effective. To protect users from defaults that are manipulative and harmful, individually and collectively, societies should require minimal quality standards. Just as some products are overall too harmful or too poor to be legally marketed, other products have default settings that are too harmful or too poor to be acceptable. In particular, defaults should minimize inadvertent consumption, should minimize the collection of personal data, and when providing information should be truthful. In addition, opt-out costs should be minimal in order to empower users who prefer alternative options.

This thesis is an attempt to constructively interpret and critically evaluate the liberal doctrine that we may not limit a person’s liberty for her own good, and to discuss its implications and alternatives in some concrete areas of public health policy. The thesis starts theoretical and goes ever more practical. The first paper is devoted to positive interpretation of anti-paternalism with special focus on the reason component – personal good. A novel generic definition of paternalism is proposed, intended to capture, in a generous fashion, the object of traditional liberal resistance to paternalism – the invocation of personal good reasons for limiting of or interfering with a person’s liberty. In the second paper, the normative aspect of this resistance is given a somewhat technical interpretation in terms of invalidation of reasons – the blocking of reasons from influencing the moral status of actions according to their strength. It is then argued that normative anti-paternalism so understood is unreasonable, on three grounds: 1) Since the doctrine only applies to sufficiently voluntary action, voluntariness determines validity of reasons, which is unwarranted and leads to wrong answers to moral questions. 2) Since voluntariness comes in degrees, a threshold must be set where personal good reasons are invalidated, leading to peculiar jumps in the justifiability of actions. 3) Anti-paternalism imposes an untenable and unhelpful distinction between the value of respecting choices that are sufficiently voluntary and choices that are not. The third paper adds to this critique the fourth argument that none of the action types typically proposed to specify the action component of paternalism is such that performing an action of that type out of benevolence is essentially morally problematic. The fourth paper ignores the critique in the second and third papers and proposes, in an anti-paternalistic spirit, a series of rules for the justification of option-restricting policies aimed at groups where some members consent to the policy and some do not. Such policies present the liberal with a dilemma where the value of not restricting people’s options without their consent conflicts with the value of allowing people to shape their lives according to their own wishes. The fifth paper applies the understanding of anti-paternalism developed in the earlier papers to product safety regulation, as an example of a public health policy area. The sixth paper explores in more detail a specific public health policy, namely that of mandatory alcohol interlocks in all cars, proposed by the former Swedish government and supported by the Swedish National Road Administration. The policy is evaluated for cost-effectiveness, for possible diffusion of individual responsibility, and for paternalistic treatment of drivers. The seventh paper argues for a liberal policy in the area of dissemination of information about uncertain threats to public health. The argument against paternalism is based on common sense consequentialist considerations, avoiding any appeal to the normative anti-paternalism rejected earlier in the thesis.

This is a thesis about anti-paternalism – the liberal doctrine that we may not interfere with a person’s liberty for her own good. Empirical circumstances and moral values may certainly give us reason to avoid benevolent interference. Anti-paternalism as a normative doctrine should, however, be rejected. Essay I concerns the definitions of paternalism and anti-paternalism. It is argued that only a definition of paternalism in terms of compound reason-actions can accommodate its special moral properties. Definitions in terms of actions, common in the literature, cannot. It is argued, furthermore, that in specifying the reason-actions in further detail, the notion of what is self-regarding, as opposed to other-regarding, is irrelevant, contrary to received opinion. Essay II starts out with the definition of paternalism defended in essay I and claims that however this very general definition is specified, anti-paternalism is unreasonable and should be rejected. Anti-paternalism is the position that certain reasons – referring one way or the other to the good of a person, give no valid normative support to certain actions – some kind of interferences with the same person. Since the reasons in question are normally quite legitimate and important reasons for action, a convincing argument for anti-paternalism must explain why they are invalid in cases of interference. A closer look at the reasons and actions in question provides no basis for such an explanation. Essay III considers a concrete case of benevolent interference – the withholding of information concerning uncertain threats to public health in the public’s best interest. Such a policy has been suggested in relation to the European Commission’s proposed new system for the Registration, Evaluation, and Authorisation of Chemicals. Information about uncertain threats to health from chemicals would allegedly spread anxiety and depression and thus do more harm than good. The avoidance of negative health effects is accepted as a legitimate and good reason for withholding of information, thus respecting the conclusion of essay II, that anti-paternalism should be rejected. Other reasons, however, tip the balance in favour of making the information available. These reasons include the net effects on knowledge, psychological effects, effects on private decisions and effects on political decisions.

Health incentive schemes aim to produce healthier behaviors in target populations. They may do so both by making incentivized options more salient and by making them less costly. Changes in costs only result in healthier behavior if the individual rationally assesses the cost change and acts accordingly. Not all people do this well. Those that fail to respond rationally to incentives will typically include those who are least able to make prudent choices more generally. This group will typically include the least advantaged more generally, since disadvantage inhibits one's effective ability to choose well and since poor choices tend to cause or aggravate disadvantage. Therefore, within the target population, health benefits to the better off may come at the cost of aggravated inequity. This is one instance of a problem I name the Able Chooser Problem, previously emphasized by Richard Arneson in relation to coercive paternalism. I describe and discuss this problem by distinguishing between policy options and their effects on the choice situation of individuals. Both positive and negative incentives, as well as mandates that are less than perfectly effective, require some sort of rational deliberation and action and so face the Able Chooser Problem. In contrast, effective restriction of what options are physically available, as well as choice context design that makes some options more salient or appealing, do not demand rational agency. These considerations provide an equity-based argument for preferring smart design of our choice and living environment to incentives and mandates.