Kalle Grill

Recently, it has been argued by several scholars that we have moral reasons to limit our procreation due to the harmful environmental consequences it entails. These calls for procreative restraint are typically made in relation to other lifestyle choices, such as minimizing driving and air travel. In such comparisons, it is assumed that the environmental impact of procreation encompasses the lifetime consumption of the child created, and potentially that of further descendants. After an overview of these arguments, I go on to provide an examination of the main benefits of procreation, in relation to those of consumption, i.e., other lifestyle choices. My normative assumption is that benefits hold moral relevance, alongside harms. Procreation may benefit procreators and may provide more collective benefits. Some benefits tend to preempt the environmental impact associated with procreation. I conclude that the benefits of procreation are substantial and typically greater than those of consumption.

Contemporary population ethics is dominated by views that aggregate by summing, whether of well-being or of some construct based on well-being. In contrast, average well-being is generally considered axiologically irrelevant. To many of us, however, the number of future people does not seem important, as long as it is sufficient to enable rich and varied life experiences, and as long as the population continues throughout time. It therefore seems relatively plausible to aggregate future well-being by averaging. In particular, it seems plausible to value high average well-being at any particular time, and to do so for all future times. I present a time-sensitive version of the Average View that underpins such axiological intuitions. I also address a series of issues and objections that confront such a view.

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 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.

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.

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.

The traditional liberal view on conflicts between care for wellbeing and respect for choice and desire is that we should look to degrees of competence and voluntariness to determine which moral imperative should take priority. This view has likely influenced the common view that children’s choices should be considered only to the extent that this promotes their future autonomy and helps us determine their best interests. I reject both the general traditional liberal view and its application to children. Competence and voluntariness, as well as maturity, are at best proxies for what really matters, which is wellbeing, choice and desire. We typically have reason to respect children’s choices, irrespective of any further positive consequences. If we should more often make children do what they do not want to do, this is mainly because, though we should care about respecting their choices, we should care even more about their wellbeing and future autonomy.

In this comment on Kenneth Iserson’s article, ”Do You Believe in Magic? Shove, Don’t Nudge: Advising Patients at the Bedside,” I discuss the definition of and the moral evaluation of nudging. I propose that using persuasive descriptions and intentionally building trust in patients by one’s demeanor is a form of nudging. I argue that nudging is not necessarily morally problematic, but that it can be controlling and can limit liberty, despite proponents’ claims to the contrary. I agree with Iserson that clinicians should give their patients explicit advice, but add that they should ideally also be aware of the more subtle psychological effects of advice giving.

The debate for and against making e-cigarettes available to smokers is to a large extent empirical. We do not know the long-term health effects of vaping and we do not know how smokers will respond to e-cigarettes over time. In addition to these empirical uncertainties, however, there are difficult moral issues to consider. One such issue is that many smokers in some sense choose to smoke. Though smoking is addictive and though many start young, it does not seem impossible to plan for and implement cessation. Yet many choose not to do so and we arguably have some reason to respect this choice. I propose that liberal opposition to strict tobacco control, based on respect for choice, is mitigated when e-cigarettes are available, since they are such a close substitute. Making e-cigarettes available to smokers might therefore not only enable switching in practice, but may make tougher tobacco control more justified. Another moral issue is that making e-cigarettes widely available might induce many people to vape, who would otherwise have neither vaped nor smoked. If this is so, the price of using e-cigarettes to accelerate smoking cessation may be a long-term vaping epidemic. Since vaping is less harmful than smoking, both individuals and society will have less reason to end this epidemic and so it may endure longer than the smoking epidemic would otherwise have done. This raises further questions around the weighing of reduced harm to current smokers against increased harm to future vapers.

In this article, I challenge the widespread presumption that a child should have exactly two parents. I consider the pros and cons of various numbers of parents for the people most directly affected – the children themselves and their parents. The number of parents, as well as the ratio of parents to children, may have an impact on what resources are available, what relationships can develop between parents and children, what level of conflict can be expected in the family, as well as the costs involved in parenting and the experience of parenting a child. Indirectly, there is also an effect on who will have the opportunity to be a parent, as well as on wider social issues that I mention but do not discuss. Having considered all these factors, I conclude that there is some reason to believe that three or more parents is usually better than one or two, especially if children are to have siblings, which is typically beneficial. However, these reasons are not strong enough to support a general presumption in favor of any particular number. We should therefore jettison the two‐parent presumption and make different numbers of parents more socially accepted as well as legally possible.

Debates on the nature and justifiability of paternalism typically focus only on adults, sometimes presuming without argument that paternalism towards children is a non-issue or obviously justified. Debates on the moral and political status of children, in turn, rarely connect with the rich literature on paternalism. This chapter attempts to bridge this gap by exploring how issues that arise in the general debate on paternalism are relevant also for the benevolent interference with children. I survey and discuss various views and argue for my own: that paternalism towards children is in most respects like paternalism towards adults and stands in the same need of justification, though such justification is more often forthcoming both because children are typically less prudent than adults and so benefit more from interference, and because, in some respects, interference is less harmful to them.

In many or most instances of paternalism, more than one person acts paternalistically, or more than one person is treated paternalistically. This chapter discusses some complications that arise in such group cases, which are largely ignored in the conceptual debate. First, a group of people who together perform an action may do so for different reasons, which makes it more challenging to determine whether the action is paternalistic. This gives us some reason not to pin the property of being paternalistic on actions, since we may alternatively pin it on reasons for actions and allow that these differ between members in the group. Second, the prevention of harmful consensual interactions is sometimes paternalism towards both or all involved, but only if all benefit from interference with themselves rather than with other members in the group, or if all want the harm or risk (more or less) for its own sake. Third, interrelations between three components of paternalism - interference, benevolence and consent - gives us reason to allow that an action can be paternalistic towards some but not others of those affected. This makes it even more difficult, and less relevant, to determine whether or not actions are paternalistic.

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being.

Receiving information about threats to one’s health can contribute to anxiety and depression. In contemporary medical ethics there is considerable consensus that patient autonomy, or the patient’s right to know, in most cases outweighs these negative effects of information. Worry about the detrimental effects of information has, however, been voiced in relation to public health more generally. In particular, information about uncertain threats to public health, from—for example, chemicals—are said to entail social costs that have not been given due consideration. This criticism implies a consequentialist argument for withholding such information from the public in their own best interest. In evaluating the argument for this kind of epistemic paternalism, the consequences of making information available must be compared to the consequences of withholding it. Consequences that should be considered include epistemic effects, psychological effects, effects on private decisions, and effects on political decisions. After giving due consideration to the possible uses of uncertain information and rebutting the claims that uncertainties imply small risks and that they are especially prone to entail misunderstandings and anxiety, it is concluded that there is a strong case against withholding of information about uncertain threats to public health.

While paternalism has been a long-standing philosophical issue, it has recently received renewed attention among scholars and the general public. Comprising twenty-seven chapters by a team of international contributors, this handbook is divided into five parts: (i) What is Paternalism; (ii) Paternalism and Ethical Theory; (iii) Paternalism and Political Philosophy; (iv) Paternalism without Coercion; (v) Paternalism in Practice. Within these sections central debates, issues, and questions are examined, including: how should paternalism be defined or characterized? How is paternalism related to such moral notions as rights, well-being, and autonomy? When is paternalism morally objectionable? What are the legitimate limits of government benevolence? To what extent should medical practice be paternalistic?

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.

As liberals, we would like each person to direct her own life in accordance with her will. However, because of the complexities of the human mind, it is very often not clear what a person wills. She may choose one thing though she prefers another, while having false beliefs the correction of which would cause her to prefer some third thing. I propose, against this background, that to respect a person’s will or self-direction is to respect both her choices and her preferences, with some priority given to those preferences that are informed and coherent. This is a pluralist answer to the neglected question, “respect for what?”

Two related asymmetries have been discussed in relation to the ethics of creating new lives: First, we seem to have strong moral reason to avoid creating lives that are not worth living, but no moral reason to create lives that are worth living. Second, we seem to have strong moral reason to improve the wellbeing of existing lives, but, again, no moral reason to create lives that are worth living. Both asymmetries have proven very difficult to account for in any coherent moral framework. I propose an impersonal population axiology to underpin the asymmetries, which sidesteps the problematic issue of whether or not people can be harmed or benefited by creation or non-creation. This axiology yields perfect asymmetry from a deliberative perspective, in terms of expected value. The axiology also yields substantial asymmetry for large and realistic populations in terms of their actual value, beyond deliberative relevance.

To nudge is to design choice contexts in order to improve choice outcomes. Richard Thaler and Cass Sunstein emphatically endorse nudging but reject more restrictive means. In contrast, I argue that the behavioral psychology that motivates nudging also motivates what may be called jolting — i.e. the design of choice content. I defend nudging and jolting by distinguishing them from the sometimes oppressive means with which they can be implemented, by responding to some common arguments against nudging, and by showing how respect for preferences over option sets and their aggregate properties may require the trimming of option sets, as well as helpful choice contexts.

This article first describes a dilemma for liberalism: On the one hand restricting their own options is an important means for groups of people to shape their lives. On the other hand, group members are typically divided over whether or not to accept option-restricting solutions or policies. Should we restrict the options of all members of a group even though some consent and some do not? This dilemma is particularly relevant to public health policy, which typically target groups of people with no possibility for individuals to opt out. The article then goes on to propose and discuss a series of aggregation rules for individual into group consent. Consideration of a number of scenarios shows that such rules cannot be formulated only in terms of fractions of consenters and non-consenters, but must incorporate their motives and how much they stand to win or lose. This raises further questions, including what is the appropriate impact of altruistic consenters and non-consenters, what should be the impact of costs and benefits and whether these should be understood as gross or net. All these issues are dealt with in a liberal, anti-paternalistic spirit, in order to explore whether group consent can contribute to the justification of option-restricting public health policy.

There is a large literature exploring the concept of ‘health promotion’. However, the meaning of the term remains unclear and contested. This is for at least two reasons. First, any definition of ‘health promotion’ is going to have to outline and defend an account of the notoriously controversial concept of ‘health’, and then suggest how (and why) we should promote it. Second, health promotion clearly has some overlap with ‘public health’, but it is far from clear how they are related. Is health promotion part of public health or is health promotion a radically different type of activity from public health? Answering this question requires engaging with tricky professional as well as contentious conceptual issues. Some advocates of health promotion talk as though public health is problematic: seen as medical, physiological in focus and reductionist in approach, whereas health promotion, on this view, is focused on the whole person in a social environment. However, to an outsider this looks more like an attempt to artificially (and rather crudely) define and protect professional boundaries, rather than a contribution to conceptual analysis. There seems no good reason why public health cannot take into account the role of social, political, economic and cultural factors and their impact on health. Indeed, much work in public health does precisely this, and uses a wide range of methodologies drawn from non-medical disciplines such as geography, sociology and psychology, not just epidemiology. It seems much more sensible to see health promotion as being one vitally important aspect of the work of public health, rather than something markedly distinct. We will assume here that this is the case and focus instead on the first issue: what is health promotion?

Drink driving causes great suffering and material destruction. The alcohol interlock promises to eradicate this problem by technological design. Traditional counter-measures to drink driving such as policing and punishment and information campaigns have proven insufficient. Extensive policing is expensive and intrusive. Severe punishment is disproportionate to the risks created in most single cases. If the interlock becomes inexpensive and convenient enough, and if there are no convincing moral objections to the device, it may prove the only feasible as well as the only justifiable solution to the problem of drink driving. A policy of universal alcohol interlocks, in all cars, has been proposed by several political parties in Sweden and is supported by the National Road Administration and the 2006 Alcohol Interlock Commission. This article assesses two possible moral objections to a policy of universal interlocks: (i) that it displaces the responsibility of individual drivers and (ii) that it constitutes a paternalistic interference with drivers. The first objection is found unconvincing, while the second has only limited bite and may be neutralized if paternalism is accepted for the sake of greater net liberty. Given the expected technological development, the proposed policy seems a commendable health promotion measure for the near future

Decisions in medical contexts have immediate and obvious consequences in terms of health and sometimes death or survival. Medical decisions also have less obvious and less immediate consequences, including effects on the long-term physical and mental well-being of patients, their families and of care-givers, as well as on the distribution of scarce medical resources. Some of these consequences are hard to measure and estimate. Even harder, perhaps, is the determination of the relative value of different consequences. How should consequences be evaluated? How do uncertainties and biases affect our evaluations of consequences? What influence should our evaluations of consequences have on our actions? These questions are all philosophical in nature.

Public health policy often limits people’s liberty for their own good. The very point of many types of public health measures is to restrict people’s options in order to stop them from doing unhealthy things, for example use harmful recreational drugs or drive without a seatbelt. While such restrictive public health policies enjoy widespread support, so does the traditional liberal idea that liberty (or autonomy) is a higher value, to be given priority in most, if not all, circumstances. In this text, I will defend the thesis that liberty is an important value, but with no claim to priority.

George Sher’s book Beyond Neutrality: Perfectionism and Politics has, he says, two main purposes. The first is to “defuse the main reasons to deny that the state may seek to promote the good”, the other is to “develop a conception of the good that is worth promoting” (1). In this article, I will not be concerned with either of these aims. Instead, I will focus on Sher’s preliminary discussion of the “scope and meaning” of neutralism (20). I consider Sher’s careful analysis of the structure of neutralism one of the book’s virtues, alongside his original theory of the good and his comprehensive and convincing arguments against neutralism. This careful analysis inspires me to attempt some critique and development. I will defend an account of neutralism according to which this doctrine puts a constraint on what reasons should enter into political reasoning. What I defend is not neutralism per se, but only this account of neutralism relative to competing accounts. I believe this account is an improvement over Sher’s, in terms of conceptual precision and normative plausibility, both in general and from the perspective of the doctrine’s proponents in particular.

This paper presents a framework for discussing issues of ownership in connection to virtual worlds. We explore how divergent interests in virtual property can be mediated by applying a constructivist perspective to the concept ownership. The simple solutions offered today entail that a contract between the game producer and the gamer gives the game developer exclusive rights to all virtual property. This appears to be unsatisfactory. A number of legitimate interests on part of both producers and gamers may be readily distinguished. More complex distributions of rights would allow many of these interests to be consistently respected.

A number of ethical frameworks have been proposed to support decision-making in public health and the evaluation of public health policy and practice. This is encouraging, since ethical considerations are of paramount importance in health policy. However, these frameworks have various deficiencies, in part because they incorporate substantial ethical positions. In this article, we discuss and criticise a framework developed by James Childress and Ruth Bernheim, which we consider to be the state of the art in the field. Their framework distinguishes aims, such as the promotion of public health, from constraints on the pursuit of those aims, such as the requirement to avoid limitations to liberty, or the requirement to be impartial. We show how this structure creates both theoretical and practical problems. We then go on to present and defend a more practical framework, one that is neutral in avoiding precommitment to particular values and how they ought to be weighted. We believe ethics is at the very heart of such weightings and our framework is developed to reflect this belief. It is therefore both pluralist and value-based. We compare our new framework to Childress and Bernheim’s and outline its advantages. It is justified by its impetus to consider a wide range of alternatives and its tendency to direct decisions towards the best alternatives, as well as by the information provided by the ranking of alternatives and transparent explication of the judgements that motivate this ranking. The new framework presented should be useful to decision-makers in public health, as well as being a means to stimulate further reflection on the role of ethics in public health.

This chapter concerns the normativity of the concepts of paternalism and libertarian paternalism. The first concept is central in evaluating public health policy, but its meaning is controversial. The second concept is equally controversial and has received much attention recently. It may or may not shape the future evaluation of public health policy. In order to facilitate honest and fruitful debate, I consider three approaches to these concepts, in terms of their normativity. Concepts, I claim, may be considered nonnormative, normatively charged, or normative in that they involve more complex relationships between values or duties. While the last approach is often best, other approaches may be appropriate depending on the context and purpose of discussion. The chapter’s conceptual investigation is illustrated by application to two public health policies: a tax on the consumption of fat and the encouragement of health-promoting food displays in restaurants and supermarkets.