Political myth versus anthropological reality: Rethinking individualism in public health ethics

Compared to the individual focus of clinical practice, public health practice emphasizes a population or community orientation. This orientation sometimes runs up against the individualism American culture celebrates. Prioritizing individual liberty, however, can make us forget that the cornerstone of social contract theory, the political basis that guarantees our liberty, depends on limiting its full expression. The precedent-setting case, Jacobson vs Massachusetts, reaffirmed this cornerstone for public health interventions. Thus, it is unclear why regulation of liberty is often viewed negatively. Did the “social” in social contract theory, the “grand bargain” knitting society together, suddenly disappear? We need to remind ourselves that the social justice movement began as a counterpoint to the ethos of market individualism. Proponents of this ethos view the opportunity for individuals to participate in the market as a panacea to all social problems, but they tend to ignore the social problems that unbridled market activities create. To explain the reluctance to invoke the social to limit the individual, my presentation will examine a key presupposition of social contract theorists, namely, that the social realm is something artificial or unnatural. For these theorists, humanity’s natural state is that of isolated individuals, requiring a social contract between individuals to create a functioning society.   Despite Jacobson, this presupposition makes individualism the presumptive position that public health practitioners must address in attempting to justify interventions.  Fully appreciating the idiosyncrasy of this presupposition might serve to neutralize some of the resistance to public health interventions that limit individual choice and could provide a rationale for addressing the social determinants of health. I will discuss lessons from the field of anthropology, including recognizing the naturalness of the socio-political realm, acknowledging that humans have physiologically evolved to inhabit this realm, and distinguishing between physiological disease, psychological illness, and social sickness. I will conclude by indicating how these lessons provide a starting point for examining the unique ethical challenges associated with public health practice.