No, we don't think our doctors are out to get us: responding to the straw man distortions of disability rights arguments against assisted suicide

The arguments that disability rights advocates present in opposition to legalized assisted suicide are frequently misconstrued in public debate. The goal of this paper is to identify and analyze key "straw man" fallacies about the disability rights opposition in order to clarify this position and the factors that contribute to its distortion. The author adopts a first-person perspective as a disability scholar/activist who has participated in "right to die" debates for over two decades. Three possible barriers that potentially impede comprehension of disability rights arguments are discussed. Prominent fallacies that assisted suicide proponents attribute to disability rights opponents are analyzed in relation to the dynamics of the assisted suicide debate, social views of disability and incurable illness, and available evidence. The author's position is that disability rights arguments against legalized assisted suicide contribute a complex intellectual and experience-based perspective to the debate that can illuminate immediate and distal consequences of altering public policy.     

What's public? What's private? Policy trade-offs and the debate over mandatory annual influenza vaccination for health care workers

Policy decisions about public health services differ from those for personal health services. Both require trade-offs between such policy goals as liberty, security, efficiency, and equity. In public health, however, decisions about who will approve, pay for, and deliver services are often accompanied by decisions on when and how to compel individual behaviour. Policy becomes complex because different stakeholders interpret evidence differently: stakeholders may assign different weights to policy goals and may even define the same goals differently. In the debate over mandatory annual influenza vaccination for health care workers, for example, proponents as well as opponents of mandatory vaccination may convey arguments in security terms. Those in favour of mandatory vaccination emphasize subclinical infections and duty of care (public security) while those opposed emphasize risk of adverse events (personal security). Proponents assert less worker absenteeism (efficiency) while opponents stress coercion and alternate personal infection control measures (liberty and individual rights/responsibilities). Consequently, stakeholders talk past each other. Determining the place of mandatory influenza vaccination for health care workers thus demands reconciling policy trade-offs and clarifying the underlying disputes hidden in the language of the policy debate.     

Guest Commentary: Fat and other taxes,lessons for the implementation of preventive policies

Fat, sugar or sweetened beverage taxes are part of an overall public health nutrition approach to healthy eating. They are not approaches that on their own are likely to bring about change. Policy evidence from existing food tax implementation suggest that taxes need to be paralleled by subsidies and other interventions to encourage healthy eating. Such dual methods help not only contribute to nutrition outcomes but also ensure political support for food taxes. Politicians and policy makers are suspicious of taxes, using subsidies and revenue monies from taxes to support healthy eating is more likely to encourage both political and public support. Building support for policies is never just a matter of academic evidence. Public health advocates need to show more ambition by developing skills in implementing pricing policies to support healthy eating. Key opponents to taxes are the food industry who use a range of arguments to prevent taxation being implemented. Public health advocates are weak in tackling the issues of corporate power and providing evidence to maintain policy and political support.The public health movement needs to continue to develop the political will among politicians and the public for taxes on food. A new way of looking at policy formation is required and this includes addressing the power of corporate interests and the role of professionals in shaping or combating these influences.     

Dietary guidelines for cancer prevention: the etiology of a confused debate

Several organizations in different countries have issued dietary guidelines for the public in order to reduce cancer incidence. Meanwhile, proponents and opponents of dietary guidelines disagree about their justification. Unfortunately, the discussion is confined to the question of whether or not present evidence is a firm enough base for recommendations. However, in addition to health-related aspects, other arguments, such as economic, sociological, psychological, ethical, philosophical, and education aspects, also play a role in the decision about dietary guidelines. It is argued that the present debate has resulted in much confusion, because the latter arguments have rarely come up for consideration in the discussion. This paper addresses the various arguments that are involved in the decision-making process. Thus, insight is gained into the causes of the present controversy with regard to dietary guidelines.     

Big Soda’s long shadow: news coverage of local proposals to tax sugar-sweetened beverages in Richmond,El Monte and Telluride

In 2012 and 2013, Richmond and El Monte, CA, and Telluride, CO, became the first communities in the country to vote on citywide sugary drink taxes. In the face of massive spending from the soda industry, all three proposals failed at the ballot box, but the vigorous public debates they inspired provide valuable insights for future policy efforts. We analyzed local and national news coverage of the three proposals and found that pro-tax arguments appeared most frequently in the news. Advocates for the taxes focused primarily on the potential community health benefits the taxes could produce and the health harms caused by sodas. Tax opponents capitalized on the existing political tensions in each community, including racial and ethnic divisions in Richmond, anti-government attitudes in El Monte, and a culture of individualism in Telluride. Pro-tax arguments came mainly from city officials and public health advocates, while anti-tax forces recruited a wide range of people to speak against the tax. The soda industry itself was conspicuously absent from news coverage. Instead, in each community, the industry funded anti-tax coalition groups, whose affiliation with industry was often not acknowledged in the news. Our analysis of this coverage exposes how soda tax opponents used strategies established by the tobacco industry to fight regulation. Despite these defeats, tax advocates can take inspiration from more mature public health campaigns, which indicate that such policies may take many years to gain traction.     

Framing Federal School Nutrition Policy: The Healthy,Hunger-Free Kids Act in the Nation’s News

The 2010 Healthy, Hunger-Free Kids Act (HHFKA) represented a major and controversial overhaul of national nutrition standards for foods served in the United States’ nearly 100,000 public schools. To unpack how debate over this far-reaching policy was presented to the public, we examined 152 national print; network, network affiliate, and cable television; and public radio news stories about the policy, all appearing during the window surrounding its scheduled reauthorization (9/1/14–1/31/16). We found that HHFKA opponents were more likely to argue from a smaller set of frames that comprised a concise, clear narrative they frequently repeated, while proponents drew from a broader range of frames, each used less frequently, to present their position. In addition, key voices expected to be prominent in a debate over child health—children and parents—were relatively deemphasized. Overall, the primary frames on either side of this debate argued past one another, leaving largely unanswered critical charges about the role of government in assuring the public’s health. This debate reflects deeper arguments at the root of many public health policy decisions, and as such, is an illustrative case example for those planning how to enter and help shape national debate over public health policy.     

News Coverage of Sugar-Sweetened Beverage Taxes: Pro- and Antitax Arguments in Public Discourse

Objectives. We examined news coverage of public debates about large taxes on sugar-sweetened beverages (SSBs) to illuminate how the news media frames the debate and to inform future efforts to promote obesity-related public policy.Methods. We conducted a quantitative content analysis in which we assessed how frequently 30 arguments supporting or opposing SSB taxes appeared in national news media and in news outlets serving jurisdictions where SSB taxes were proposed between January 2009 and June 2011.Results. News coverage included more discrete protax than antitax arguments on average. Supportive arguments about the health consequences and financial benefits of SSB taxes appeared most often. The most frequent opposing arguments focused on how SSB taxes would hurt the economy and how they constituted inappropriate governmental intrusion.Conclusions. News outlets that covered the debate on SSB taxes in their jurisdictions framed the issue in largely favorable ways. However, because these proposals have not gained passage, it is critical for SSB tax advocates to reach audiences not yet persuaded about the merits of this obesity prevention policy.A growing body of evidence indicates that consuming sugar-sweetened beverages (SSBs), which include nondiet sodas, energy drinks, and fruit drinks, is associated with higher obesity rates.1–3 Some researchers argue that SSBs are the single largest driver of increasing obesity rates in the United States.4 This evidence has led public health advocates and researchers to search for effective solutions to reduce SSB consumption.Recent research suggests that large (e.g., penny per ounce) taxes on SSBs would reduce consumption and obesity rates.5,6 Although most US states already collect some form of tax on SSBs, these taxes are small relative to the price of these products.7 Many US states and cities (e.g., California, Mississippi, Philadelphia, PA) have considered larger taxes.8 To date, efforts to collect larger SSB taxes have been unsuccessful. Public opinion polls provide mixed evidence about public support for these taxes.9–11 One recent, national survey found substantially higher public agreement with anti-SSB tax than pro-SSB tax arguments.12Understanding how the news media has framed SSB tax debates can shed light on how the political process has played out in various communities. Framing involves emphasizing some aspects of an issue to the exclusion of others.13 Advocates and opponents of specific policies seek to shape policy debates by framing the policy issue in ways that they see as favorable to their positions and by advocating media coverage that employs these frames.14–16 The news media, in turn, help to shape the policy agenda by selecting issues to cover and framing them in ways that invite particular policy interpretations.13,17,18 For example, an interest group might frame a policy issue by highlighting its economic consequences, whereas another group might make an explicit link between the issue and broader values, such as social justice. The news media choose to highlight these or other frames in their coverage, which in turn can influence how the public thinks about these issues.19 A systematic analysis of arguments used in support of and arguments used in opposition to a policy issue, as well as the types of advocates and opponents who participated in the debate, thus provides valuable political context about the issue in question.Such contextual information is particularly important for policies on SSB taxes, characterized by politically polarized views among the public.10,20,21 SSB tax advocates are more likely to succeed at attracting large coalitions of support if they employ frames that resonate across the political spectrum.22 Identifying message frames that SSB tax proponents (typically leaning liberal) and opponents (typically leaning conservative) use and the news media cover can illuminate how various interest groups cast the terms of the debate to resonate with their constituents. Collecting data about the information environment can be helpful for designing future campaigns to increase support for SSB taxes and other obesity-related policies.23     

House votes to block funds for needle exchanges

The U.S. House of Representatives voted September 11, 1997 to prohibit the use of Federal funds for needle distribution and exchange programs implementation. AIDS policy advocates denounced this move. Current law would have allowed the Secretary of Health and Human Services, Donna E. Shalala, to lift a ban on Federal funding for needle exchanges. Advocates note that the House's vote directly contradicts the scientific evidence and opinions of experts in the public health community regarding the benefits of needle exchange programs in the prevention of HIV transmission. It is still possible that Senator Arlen Specter, R-PA, will insist that the House amendment be deleted. Experts from both sides of the debate presented evidence about the risks and benefits of needle exchange programs. Representatives from New Haven, CN and Baltimore City, MD, where model needle exchange programs have been operating, report significant declines in the rate of HIV transmission.     

Children's lives or garden aesthetics? A case study in public health advocacy

Abstract: Following a decade of accumulating clinical reports on child drowning in domestic swimming pools, paediatricians began advocating legislation that would require all pools to be ‘isolation' fenced. In 1990, the New South Wales Government introduced and then repealed such legislation following intense lobbying and media advocacy from a group of pool owners. This paper reviews the ways in which isolation fence advocates and opponents framed their public arguments. Five main areas of competing public discourse are identified: why pool drownings occur; the effects of fencing; expert views and community support; the role of the state in prevention; and personalised references to the value systems of those involved in the debate. Two factors seem likely to have contributed most to the overthrow of the legislation: fence opponents inhabiting the same noninterventionist ideological frame of reference as the government; and fence advocates' refusal to compromise on retrospective fencing seems likely to have inspired a commitment in opposition which would have been absent if an incrementalist, prospective fencing policy had been adopted.     

Framing health and foreign policy: lessons for global health diplomacy

Global health financing has increased dramatically in recent years, indicative of a rise in health as a foreign policy issue. Several governments have issued specific foreign policy statements on global health and a new term, global health diplomacy, has been coined to describe the processes by which state and non-state actors engage to position health issues more prominently in foreign policy decision-making. Their ability to do so is important to advancing international cooperation in health. In this paper we review the arguments for health in foreign policy that inform global health diplomacy. These are organized into six policy frames: security, development, global public goods, trade, human rights and ethical/moral reasoning. Each of these frames has implications for how global health as a foreign policy issue is conceptualized. Differing arguments within and between these policy frames, while overlapping, can also be contradictory. This raises an important question about which arguments prevail in actual state decision-making. This question is addressed through an analysis of policy or policy-related documents and academic literature pertinent to each policy framing with some assessment of policy practice. The reference point for this analysis is the explicit goal of improving global health equity. This goal has increasing national traction within national public health discourse and decision-making and, through the Millennium Development Goals and other multilateral reports and declarations, is entering global health policy discussion. Initial findings support conventional international relations theory that most states, even when committed to health as a foreign policy goal, still make decisions primarily on the basis of the 'high politics' of national security and economic material interests. Development, human rights and ethical/moral arguments for global health assistance, the traditional 'low politics' of foreign policy, are present in discourse but do not appear to dominate practice. While political momentum for health as a foreign policy goal persists, the framing of this goal remains a contested issue. The analysis offered in this article may prove helpful to those engaged in global health diplomacy or in efforts to have global governance across a range of sectoral interests pay more attention to health equity impacts.     

The interplay of structure and agency in health promotion: integrating a concept of structural change and the policy dimension into a multi-level model and applying it to health promotion principles and practice

The recent debate in public health about the "inequality paradox" mirrors a long-standing dispute between proponents of structuralist approaches and advocates of action theory. Both views are genuine perspectives of health promotion, but so far they have not been adequately linked by health promotion theory. Using Anthony Giddens's concepts of structure and agency seems promising, but his theory has a number of shortcomings that need to be amended if it is to be applied successfully to health promotion. After briefly assessing Giddens's theory of structuration, this paper proposes to add to it both the concept of structural change as proposed by William Sewell and the policy dimension as described by Elinor Ostrom in her distinction between "operational" and "collective choice" level. On this basis, a multi-level model of the interaction of structure and agency in health promotion is proposed. This model is then connected to central claims of the Ottawa Charter, i.e. "build healthy public policy", "create supportive environments", "strengthen community actions", and "develop personal skills". A case study from a local-level health promotion project in Germany is used to illustrate the explanatory power of the model, showing how interaction between structure and agency on the operational and on the collective choice level led to the establishment of women-only hours at the municipal indoor swimming pool as well as to increased physical activity levels and improved general self-efficacy among members of the target group.     

Social issues in perinatal screening for sickle cell anemia

We are living in a time of fascinating scientific achievement in the biomedical field of genetics. The revolutionary methodologies of this biomedical technology produce new ideas and new options for the quality of our life. While this paper is focused on prenatal testing for sickle cell anemia, it simultaneously illustrates the general complexity of public health issues and points out that some emerging scientific values may be more harmful than beneficial to the public because they are inappropriate priorities and do not deal with problems that truly affect the public's health. Special attention is given to issues of ethical significance demonstrating that scientific objectives have been emphasized and that beneficence and respect for persons are principles that have been neglected in Prenatal Sickle Cell interventions. Lastly, this paper advocates social policy to protect the at risk groups from what may become irresponsible public health paternalism.     

Public Advocacy and Allocation of Federal Funds for Biomedical Research

Members of Congress and officials of the National Institutes of Health face heightened pressure from public advocacy groups seeking more funding for research on specific health conditions. In response, Congress and the Institute of Medicine have urged the NIH to create more opportunities for the public to participate in decision making on allocation of biomedical research resources. The ethical and policy implications of including advocates in the deliberations are explored, leading to the conclusion that public participation could contribute to more defensible decisions under three conditions: public participants are fairly selected and meaningful opinions are solicited; public participants look beyond their narrow constituencies to consider the health needs of the broader public; and NIH officials develop materials to assist participants with their deliberations.     

Evidence-Based Medicine and Power Shifts in Health Care Systems

It is important and urgent to question therelationship between evidence-based medicineand power shifts in health care systems.Although definitions of EBM are phrased as ascientific approach to medicine, EBM is anormative concept: it aims to improve medicineand health care. Both proponents and opponentsuse a normative concept. More particularly,they provide particular views on positions,responsibilities, possibilities, norms andrelationships between professionals, patientgroups, governments and other parties in healthcare and society. From this perspective, wewant to analyse the role of EBM in modernwestern societies. By using citizenshiptheory, we will argue that the role of EBM isnot fixed but depends on the relation betweenstate and society. We will first analyse thefundamental change in western societies duringthe past decades, from modern to post-modernsocieties. Then, we will elaborate a fourfoldmodel of possible relationships between stateand society, and discuss the issue of how EBM mayfit in, by giving some examples of the practiceof EBM in different European countries. On thisbasis, we conclude to consider EBM as a publicforum where proponents and opponents of EBMdiscuss diverse and possibly conflicting waysof changing medicine, health care, and healthpolicy. This requires the incorporation of theperspective of citizens and their socialnetworks, professionals with practical andtacit knowledge, and diverse public views onwhat is regarded as `a good life'. Inasmuch asEBM is expected to be practically relevant, itought to be tied to rather than separated fromthe normative world of emancipated patients anddiverse health care practices. Proponents andopponents of EBM should be prepared to defendthe normative claims and power effects that areinherently tied to any presentation ofevidence.     

Advocating evidence-based health promotion: reflections and a way forward

In the past few years, significant advances have been made in health promotion to generate readily accessible systematic reviews of evidence on the effectiveness of interventions and programs. The influence of this evidence on policy and practice has, however, been unpredictable, and proponents of evidence-based practice are identifying ways to increase the use of research in decisions about health promotion interventions. This paper examines the following questions: (i) is the evidence that is available on the effectiveness of interventions actually relevant and useful to current policy and practice contexts?; and (ii) what is the researcher's or reviewer's role in interpreting the available evidence and advocating action based on their interpretations? The paper concludes by proposing an 'evidence-agenda map' to assist advocates of evidence-based policy and practice to identify the health promotion goals they seek to influence against the required and available evidence.     

Health promotion research and practice require sound policy analysis models: the case of Quebec's Tobacco Act

In this paper we illustrate how policy analysis models can deepen our understanding of the challenges facing health promoters advocating for policy change. Specifically we describe the factors underpinning the adoption of Québec's Tobacco Act (1998) and the role played by actors from governmental public health agencies (GPHAs). Data were collected through interviews (n=39), newspapers articles (n=569) and documents (n > 200) from GPHAs, NGOs, the Québec National Assembly, and opponents to the legislative measures. Data collection and analysis were based on Sabatier and Jenkins-Smith's Advocacy Coalition Framework (1999) and Lemieux's theorization of coalition structuring (1998). We explain the adoption of the Act by: (1) the broad recognition within the policy elite of the main parameters of tobacco use (i.e. lethality, addictive properties, and legitimacy of governmental intervention), (2) the impacts of a series of events (e.g. cigarette contraband crisis) that enabled tobacco control advocates to influence public debates, and the governmental agenda, (3) the critical contribution of a coalition of GPHAs pooling resources to address both the sanitary and economic aspects of the legislation while countering the opposition's strategy, and (4) the failure of the opponents to present an unified voice on the definition of the tobacco policy. This study illustrates the merits of applying a policy-change model to grasp the complexity of the process. Our findings call for the development of permanent policy analysis capabilities within public health agencies and for a broader scrutiny of the non-health-related dimensions of policy debates.     

Fostering deliberations about health innovation: What do we want to know from publics?

As more complex and uncertain forms of health innovation keep emerging, scholars are increasingly voicing arguments in favour of public involvement in health innovation policy. The current conceptualisation of this involvement is, however, somewhat problematic as it tends to assume that scientific facts form a “hard,” indisputable core around which “soft,” relative values can be attached. This paper, by giving precedence to epistemological issues, explores what there is to know from public involvement. We argue that knowledge and normative assumptions are co-constitutive of each other and pivotal to the ways in which both experts and non-experts reason about health innovations. Because knowledge and normative assumptions are different but interrelated ways of reasoning, public involvement initiatives need to emphasise deliberative processes that maximise mutual learning within and across various groups of both experts and non-experts (who, we argue, all belong to the “publics”). Hence, we believe that what researchers might wish to know from publics is how their reasoning is anchored in normative assumptions (what makes a given innovation desirable?) and in knowledge about the plausibility of their effects (are they likely to be realised?). Accordingly, one sensible goal of greater public involvement in health innovation policy would be to refine normative assumptions and make their articulation with scientific observations explicit and openly contestable. The paper concludes that we must differentiate between normative assumptions and knowledge, rather than set up a dichotomy between them or confound them.     

Research, politics, and needle exchange

We now have had 15 years of public discussion of and research on needle exchange programs. The data have shown these programs to be usually, but not always, effective in limiting HIV transmission among injection drug users. Needle exchange programs are conceptualized within a larger framework of providing ready availability of sterile injection equipment for injection drug users. Continuing research is clearly needed regarding how to maximize the availability of sterile injection equipment and how to integrate this with other needed health and social services for drug users. Many initial opponents of needle exchange programs have become supporters of the programs. The number of programs in the United States has been increasing by about 20% per year, and this can be considered substantial progress in reducing HIV infection among injection drug users. Important opposition remains, however, based primarily on the symbolic values expressed in government support for the programs. These value conflicts over needle exchange, which have existed since it was first considered in the United States, cannot be resolved with data. In the late 1980s, the value conflicts greatly hampered the collection of relevant data--there was no federal funding of research on needle exchange programs. Currently, there is considerable research on needle exchange, but many researchers are quite concerned about possible misuse of findings. This may be considered progress to an important but modest degree. Whether current and future research will be used to improve HIV prevention efforts remains to be seen.