Ethics, Individualism and the Medicalization of Public Health

The central claim of this paper is that dominant practices in U.S. public health are highly individualized and medicalized, and that this state of affairs is ethically problematic.  The paper extends the author’s body of work regarding the influence and deficiencies of what can be termed ‘methodological individualism’ in U.S. public health to a larger discussion about the medicalization of public health practice and policy in the 20^th c. U.S.  The paper begins with an historical argument regarding the shift from the early U.S. public health leaders’ emphasis on social reform to a model of public health that emphasized medical services and interventions (i.e., laboratory techniques, clinical screening, etc.).  The next section of the paper introduces the ethical framework used to evaluate that shift, which is Powers and Faden’s health sufficiency model of social justice.  Powers and Faden’s “twin aims theory” suggests that ethically optimal public health policy should maximize two consequences: improvement in absolute population health and compression of health inequities.  Unfortunately, robust epidemiologic evidence demonstrates that public health interventions targeted at changing individual health behaviors are unlikely to improve substantially overall population health.  Worse yet, the same evidence suggests that individualized and medicalized interventions may actually expand health inequities.  In both respects, such interventions thereby contravene Powers and Faden’s model of social justice.  The paper concludes with a positive argument regarding what model of public health ought to replace the individualized and medicalized version: one that prioritizes collective action on upstream, macrosocial determinants of health.  In its emphasis on collective action and structural remedies, such a model eschews pathways of both individualism and medicalization.  This section of the paper provides practical examples of interventions that embody such an approach and are likely to advance the twin aims theory, including intensive investment in early childhood development and stigma reduction policies and programs.  Ultimately, the historical argument illustrates that this broader model of public health is hardly novel, but rather reflects a return to the true roots of U.S. public health policy, a practice grounded in broad-based social reform.