Depending on the specifics of the public health policy, any number ofthese justifications may be applicable, and they are generally used tobest effect in combination. Section 2 closes with a look at the limitsof frameworks that focus disproportionately on liberty considerationsof the sort addressed in 2.4 and 2.5 and on the importance ofconsidering the range of possible moral justifications in analyzingpublic health policies.
Some of the initiatives are contentious. For example, taxes on non-nutritious foods or "snack taxes" have been levied in seventeen states. Some public health officials use the parallel of the positive impact of tobacco taxes in reducing smoking as a model for taxing snack foods and sodas to promote healthier behavior. But these taxes are quite controversial and untested as to whether they make a significant impact on obesity prevention and control. Any evaluation of the potential positive effects on reducing the prevalence of obesity must be balanced against what opponents argue is the regressive nature of junk food, i.e., taxes are unlikely to encourage the substitution of healthier foods. The level of disagreement about the issue demonstrates the need for further study and a significant gap in our understanding of this legal strategy as a best practice.
Public health involves the organised response by society to improve and promote health of populations (Duckett & Wilcox 2011; McMurry & Clendon 2011). Public health initiatives are based on population-level data and typically involve measurement and surveillance, and development of evidence-based strategies to either prevent or overcome disease. The aim is to protect health, prevent illness, injury and disability and promote health including encouraging healthy behaviours and building healthier communities (Duckett & Willcox 2011). Therefore, all of the above policies and actions are public health initiatives as they are society’s response to improve and promote health of populations through managing and preventing dementia.
In August 2013, prior to the September Federal Election, the Coalition released their policy to Boost Dementia Research. To accompany the policy was the promise of a further $200 million over five years to Australian scientists and medical researchers working on ways to prevent or cure dementia (Loughnane 2013). The boost to funding dementia research will endeavour to: expand capacity in dementia research by supporting new researches to commence work on key challenges; prioritise additional funding for dementia research projects; translate research into better care for dementia patients; and invest in vital dementia research infrastructure. The coalition will work with the National Health and Medical Research Council (NHMRC) and the Australian Research Council to boost the number of Early Career Research Fellowships, Postgraduate Scholarships, Career Development Scholarships and Future Fellowships for dementia research (Loughnane 2013). The $200 million provided will be quarantined for dementia-related research and coordinated through the NHMRC. It’s important to note, this funding is in addition to the Government’s commitments to dementia through the Living Longer Living Better reforms (Loughnane 2013).
In 2012 WHO and Alzheimer’s Disease International developed the report Dementia: a public health priority. The purpose of this report is to raise awareness of dementia as a public health priority, to articulate a public health approach and to advocate for action at international and national levels (WHO 2012). Currently, there is lack of awareness and understanding of dementia in most countries, resulting in stigmatisation, barriers to diagnosis and care, and impacting caregivers, families and societies physically, psychologically and economically (WHO 2012). The report identifies priority areas of action required within policy and planning in order to address these concerns. They include raising awareness, timely diagnosis, commitment to good-quality continuing care and services, caregiver support, workforce training, prevention and research (Alzheimer’s Australia 2013). The report is expected to facilitate governments, policy-makers and other stakeholders to address the impact of dementia as an increasing threat to global health. It is hoped that the report will promote dementia as a public health and social care priority worldwide (WHO 2012).
As with all such principles, questions remain about itsspecification. How significant must the threat of harm be, with regardto both its likelihood and magnitude? Arephysical harms to the health of others to be weighted more thaneconomic harms or other setbacks to interests? Whether interpretednarrowly or broadly, there are limits to the public health cases thatcan plausibly be addressed by the harm principle. Moreover, in thecontext of commitments to social justice and general welfare, and theother justifications described above, too exclusive a focus on theharm principle can undermine otherwise justifiable government mandatesand regulation. It is undeniable that individuals have much broaderand more multi-dimensional interests than narrowly self-directedphysical ones, and in that sense, it is not unreasonable to have afairly expansive understanding of “harm” in a publichealth context. However, adherence to the—admittedly somewhatartificial—heuristic of construing individuals' interests asexclusively their self-regarding ones for purposes of determining whatsacrifices they may be asked to make is an important way of ensuringchecks on potential abuses.
To determine whether overuse of medical care was really the problem in McAllen, I turned to Jonathan Skinner, an economist at Dartmouth’s Institute for Health Policy and Clinical Practice, which has three decades of expertise in examining regional patterns in Medicare payment data. I also turned to two private firms—D2Hawkeye, an independent company, and Ingenix, UnitedHealthcare’s data-analysis company—to analyze commercial insurance data for McAllen. The answer was yes. Compared with patients in El Paso and nationwide, patients in McAllen got more of pretty much everything—more diagnostic testing, more hospital treatment, more surgery, more home care.
This paper has identified the challenges associated with the care and management of dementia within Australia and internationally. It has demonstrated the Australian policy struggle from 2005 to current which has been complicated by limited funding, change in priorities and change in government. It highlighted the Australian Government’s achievement in being the first nation to make dementia a national health priority and the advancement of integrated state and federal policy to address dementia.
In many public health contexts, the only feasible or acceptablyefficient way to implement a policy affects the entire population,leaving no or only very burdensome options open to individualnon-cooperation. Perhaps the most celebrated such example is waterfluoridation, but all safety regulations affecting food and drugsupply and consumer products share this character, as do manyenvironmental and occupational health standards. Here collectiveefficiency considerations loom large. Although we want healthyenvironments and products, individuals are simply not positioned tomake independent decisions about the impact on health and safety oftheir environment and of the hundreds of thousands of productsavailable in the modern market place. Ceding this function togovernment institutions staffed with health experts is prudent andessential to general welfare and social justice in the same respect asceding protection of our interests in personal physical security togovernment institutions staffed with law enforcement and nationaldefense experts is prudent and essential to general welfare (Mill1869).
In a 2003 study, another Dartmouth team, led by the internist Elliott Fisher, examined the treatment received by a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse.
It is important to note that in all these cases, justifiedinterference would be based on a finding of significant compromise of autonomy or rationality in the formation or continued holding ofparticular preferences. This should not be confused with interferencebased on the content of the preferences. Only the former would bejustifiable under soft or weak paternalism, whereas the latter wouldconstitute true or strong paternalism. As always, the demarcations arenot as clear in practice as they are in theory - the content ofpreferences is often precisely what is appealed to in illustratingthat a particular preference is compromised - but by and large, whatdistinguishes soft paternalism from strong paternalism is therequirement that the decision or preference be fundamentallycompromised, and not simply that it be mistaken or ignorant. Thisprincipled distinction remains important not least because it reflectsa difference in approach or attitude: in the case of strongpaternalism, the interference is based on the content of a preferencenot reflecting what is ostensibly in the preference holder'sinterest. Inthe case of soft or weak paternalism, persons might hold all manner ofpreferences not in their best interest that are nonetheless notjustifiably interfered with because the relevant compromisingconditions do not obtain. In public health policy, soft paternalismhas been evoked to justify interventions that limit the ability ofadolescents to act on preferences for alcohol, drugs, sexual activityand driving.