Preventing disease and promoting health: An argument against the use of interventions that stigmatize

Whether or not it is ethically permissible to use stigma as a tool of disease prevention and health promotion is a contentious question. An anti-stigma approach may now be considered the norm for some illnesses and diseases (e.g., HIV/AIDS), but for others (e.g., smoking) stigmatizing strategies are the norm. The ethical debate turns importantly, though not exclusively, on how one defines stigma. Equally important is a question about the moral foundations of public health. Arguments in favor of using public health interventions that stigmatize unhealthy behavior have been made on grounds that doing so can improve overall population health, an argument animated by the utilitarian principle to maximize health benefits. Yet, many argue that commitments to social justice, not maximization, constitute the moral bedrock of public health. In this presentation, I will argue that that the use of stigmatizing interventions violates two commitments central to contemporary notions of social justice—the pursuit of a fair distribution of important social goods, including health (a “distributional” demand of justice), and the right to be treated as a peer in public life (a “recognitional” demand of justice). I will draw on empirical data about the distribution of smoking and obesity—both major public health challenges—to support my position, showing that stigmatizing interventions are (1) likely to result in the concentration of unhealthy behavior in minority and marginalized populations,  thus violating the distributional demand of justice and (2) likely to exclude and isolate members of these groups, undermining their ability to participate as equals in public life and thus violating the recognitional demand of justice. In an era of stark and growing social inequalities in health, public health needs more than ever to treat people not as “targets” of change but rather as agents of change with insights that can help to map health challenges and whose energies can be recruited to help address them.