Shifting the Frame on Choice.

We live in a society that caters to our desire to make choices. We are regularly advised to choose what is best for us as individuals—to pick the right food, brand, political candidate, romantic partner, career, etc. By contrast, public health is sometimes accused of trying to limit choice, a perception that can serve us poorly in the public conversation, sometimes prompting charges of paternalism. It is true that public health does aim to widen the distance between populations and the substances that could harm them, by limiting, for example, smoking in bars and restaurants, and reducing the accessibility of alcohol. But is public health really fundamentally geared towards limiting choice? Or are our choices already constrained by the context in which we live, and public health is doing what it can to nudge that context in a healthier direction? A note on how public health can shift the frame on choice, to create a world where people can be healthy within the context of both their own choices and the external conditions that shape their well-being.

That our entanglement with choice occasions challenges should not come as a surprise. The US is characterized by a very specific reading of the notion of freedom, one that is centered around the primacy of individual choices. Arguments against cigarette bans, for example, are typically framed as arguments for an individual’s right not to have the choice of whether or not to smoke made for her. Arguments against portion controls for sugar-sweetened beverages are framed as arguments against ceding to the government the right of individual decision-making. But do these arguments take into account the true range of choices available to us, and how these choices are often constrained by our circumstances? At one level, it is true that we have a choice whether to smoke or not. But that choice exists because cigarettes are produced to begin with. This reality is itself a product of choices that were made to allow companies to manufacture and sell cigarettes. Similarly, while the argument against portion controls for soda maintains that individuals should have a choice to drink large quantities of nutrient-poor, calorie-dense beverages, there is another level of choice that precedes this: the choice to allow these beverages to be widely available in our society. Therefore, though the public debate engages with the scope of individual choices, we frequently forget that more “upstream” choices have already been made that reduce the scope of what an individual can, or cannot, choose on her own.

Let us take a recent example that illustrates how choices are made on behalf of populations all the time that have direct, demonstrable consequences for health: the water crisis in Flint, Michigan. In Flint, a political choice to cut costs resulted in highly corrosive water from the Flint River being pumped into the city through lead pipes that would eventually deteriorate and poison the water supply. This contamination had health ramifications for the entire city, undermining the power of residents to protect their well-being through their own choices. After all, there is only so much an individual can do to stay healthy when her water source is tainted by lead. Similar examples abound of how the choices of policymakers constrain the healthy options available to the public. From building major roadways near residential spaces, to allowing the conditions of inequality and poverty to flourish in our society, the decisions of those in power can shape the health of populations in ways that individual choice can do little to counteract.

Therefore, “higher-level” choices are frequently made that narrow the range of choices available to the public. These choices are typically decided by entities that have a clear economic interest in a particular choice set. When the Trump administration, for example, pursues a policy of lifting environmental protections, this policy maximizes the choices available to a broad array of private interests, who, now freed from government oversight, can explore even more paths towards enhancing profit. This higher-level choice stands to benefit particular narrow, but powerful, interests, even if they come at the expense of the broader population.

I submit that this is the level of choice at which public health should engage. While we have historically done much to suggest individual choices that may improve individual health (i.e., do not smoke, drink in moderation), this engagement addresses lower-level choice constraints that do not tackle the decisions that are already made that have the power to circumscribe the individual choice set to begin with. Public health needs to choose carefully which level of choice it tangles with. In particular, this argument suggests a need for public health’s continued engagement with improving the social, economic, and environmental determinants of health as a means of both building a healthier world and transcending, to a degree, the charge that we are trying to manipulate choice. This is not to say that efforts that aim to help us pick the right food or consume fewer harmful products do not represent important opportunities to improve the health of populations. They do. But, ultimately, they do not tackle the causes of the context within which individual choices are made. It is a focus on approaches that constrain the availability of harmful products to begin with that is consonant with the core mission of public health. By maintaining this focus, we can create the conditions within which we can live healthier lives, with a range of options to choose from, all of which are health-promoting.

I hope everyone has a terrific week. Until next week.

Warm regards,

Sandro

Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor
Boston University School of Public Health
Twitter: @sandrogalea

Acknowledgement: I am grateful to Professor Leonard Glantz for sharpening my thinking on this subject, even as he may not agree with my take on it, and to Eric DelGizzo for his contributions to this Dean’s Note.

Previous Dean’s Notes are archived at: https://www.bu.edu/sph/tag/deans-note/