The Morality of Public Health and its Consequences

May 24, 2020

Written by: Jenna McHugh

Something that has become increasingly apparent to me over the last 3 years has been the political ideology of the public health sector. As I moved through the completion of my Master’s of Public Health at McMaster University in Canada, I couldn’t help but feel like there was a stark need for diversity of thought. Many of the ideas presented throughout this program were rooted in creating equality of outcomes, disguised by the term equity, rather than encouraging equality of opportunity. These themes seem to move away from establishing directives for enacting measurable success in health outcomes and promote an ideological approach for creating equality by favouring some groups over others in a murky hierarchy. Many of my instructors and classmates wanted to move the lines of fairness because they cared deeply about improving health outcomes for all, without truly considering what these ideologies perpetuated in our society.

These political ideologies became more evident when a friend recommended the works of Jonathan Haidt and his research on morality. As a social psychologist and professor at New York University, Haidt and his team have been conducting research to understand morality and why it varies across cultures, but also has similarities and recurrent themes universally. They discovered 5 foundations of morality that create connections and divisions amongst groups. These foundations are: 1) Care/harm, 2) Fairness/cheating, 3) Loyalty/betrayal, 4) Authority/subversion and 5) Sanctity/degradation. Some of his team’s application of this important work includes applying these foundations to develop understanding about the differences between the polarized right-wing conservatives and left-wing liberal political parties. Haidt’s TED Talk has been viewed over 500,000 times on YouTube where he outlines the moral roots of liberals and conservatives.

According to Haidt’s research, left-leaning liberals are much more likely to value the first two foundations, Care/harm and Fairness/cheating, over the others. Conservatives are more likely to value all 5 foundations equally. Care is the cherishing and protecting others; the opposite of harm. Haidt states, “The moral matrix of liberals, in America and elsewhere, rests more heavily on the Care foundation than do the matrices of conservatives”. Fairness is the rendering of justice according to shared rules; the opposite of cheating. Moreover, Haidt claims that conservatives and liberals view fairness differently, “Everyone cares about fairness, but there are two major kinds. On the left, fairness often implies equality, but on the right it means proportionality—people should be rewarded in proportion to what they contribute, even if that guarantees unequal outcomes.” iberals want complete fairness across the board and conservatives want people to “get what they give”. It is for these reasons, I believe, my teachers and classmates seek equality of outcomes rather than opportunity, which is how we were taught to define equity in the public health realm.

Quickly, Loyalty/betrayal relates to virtues of patriotism and self-sacrifice for the group. It is active anytime people feel that it’s “one for all, and all for one.” Authority/subversion are rooted in leadership and followership, including deference to legitimate authority and respect for traditions. Lastly, Sanctity/degradation means the widespread idea that the body is a temple, which can be desecrated by immoral activities and contaminants (an idea not unique to religious traditions). All this is not to say that one political leaning group is better than the other, but it is important to understand these differences as individuals and governments work through disagreements and make decisions that affect large groups of people. A left-leaning individual has their morals more firmly rooted in Care and Fairness, more than Loyalty, Authority and Sanctity. The importance of these moral foundations cannot be understated. In fact, it is so important that Jonathan Haidt publicly posts Chapter 7 of his book, The Righteous Mind (I highly recommend everyone read the entire thing) online so people can read and understand these 5 foundations and the moralities of populations.

We know that political beliefs have previously spilled over into non-political domains, insofar as consumer spending, romantic partnerships and job hiring. Research about political beliefs in health care has previously been done, revealing some enlightening results. In 2016, Hersh and Goldenberg published an article that highlighted the political differences of physicians and healthcare professionals. To do this, the researchers identified United States voter registration records and conducted a survey from a stratified sample of these physicians. The researchers restricted unaffiliated and third-party registrants to focus on partisans, suspecting that if differences were to emerge they would be pronounced in a comparison of Republicans to Democrats; the right-wing and left-wing political parties in the US, respectively. They found there is a connection between provider political orientation and patient care and suggest that patients need to be aware of their physicians political worldview, especially if they need counsel on a politically sensitive issue.

Hersh and Goldenberg then shared their data with The Upshot (a newsletter for the New York Times), where the data was considered further. It was found that health care professionals may be sorting themselves into particular specialties based on their political affiliation. Firstly, The Upshot found that more than half of all doctors are registered as Democrats. Secondly, there is not an even distribution of political affiliations across medical practice fields. They put together an excellent diagram highlighting the political affiliations of doctoral medical professions in the US, as seen here:

What is worth noting in particular is the last row of the graph. Infectious disease experts are the least right-wing affiliated of all medical specialities with only 23% having registered as Republican. Infectious disease experts are the doctors who study and inform on pathogenic microorganisms, such as bacteria, viruses, parasites or fungi, including the diseases that can be spread, directly or indirectly, from one person to another. When we look at this data through Haidt’s morality-coloured glasses we can infer that infectious disease experts are morally inclined to care more about Care and Fairness than any other medical profession. In its essence, infectious disease is the backbone of public health, as mitigating the spread of infectious disease has historically been its priority. John Snow was acting particularly altruistic when he sought to determine the cause of a cholera outbreak in 1854, perhaps motivated by his Care foundation of morality. Since then, public health has become established in governments and public domains to inform and provide evidence-based population recommendations in hopes of improving health at the community, municipal and national levels.

Across the Western world we have seen public health practices inform policy makers through the dominating lenses of Care and Fairness. Harm reduction approaches have made their way into almost all methods of population health management. What started off as an approach to work with adults struggling with substance abuse issues has bled into other public health priorities such as homelessness, supervised-injection sites, adolescent drinking behaviours, and perhaps most famously, marijuana use. Harm reduction is considered an evidence-based, client-centred approach that seeks to reduce negative health habits without necessarily requiring people to abstain or stopping the behaviour, emphasizing a non-judgemental attitude towards detrimental health behaviours. The approach seeks to empower people to make healthier choices on their own, while eliminating as many dangers as possible.

For example, a supervised injection site allows those who use illicit substances to do so in a health professional supervised setting (usually by nurses) that provides clean needles and resuscitation if an overdose occurs. The needles are provided to reduce the harm associated with using dirty needles, like the spread of HIV, while the nurse is there to educate safe injection practices and prevent death from overdose. These locations can also provide information and resources to those who are intrinsically motivated to stop using, but education is by no means a requirement to use the site. This strategy is measured by the number of overdose deaths prevented. Supervised injection sites do indeed save lives, but the research framework, by necessity, is entirely observational. One of these sites is no picnic for a nurse on duty. It’s scary. Someone could overdose on their watch. Pulling someone out of a euphoric overdose can induce violence on the part of the user. Public health advocates have since moved even further towards judgement free settings, advocating and establishing peer-led injection sites, and are pushing to demedicalize injection drug use. This compassionate approach stemming from the left-leaning morality of Care, and treating everyone Fairly allows public health to maneuver the landscape to support their ideals.

Another harrowing public health issue is the state of homelessness in North America, with seemingly ineffective solutions counteracting the increasing rates. In thinking about moralities and the political ideologies of public health, I remembered a piece published last August in The City Journal by Heather MacDonald, describing the ghastly situation in San Francisco, claiming the city has become a hostage to homelessness. This article kept me up at night. At the time, I couldn’t stop thinking about what was going on in this city and would talk incessantly to anyone I could about it. San Francisco is experiencing some of the worst homelessness in history, which can undoubtedly be viewed as a crisis. In this same article, the author argues the city has stopped enforcing behaviour norms in attempts to establish a compassionate manner towards the homeless. The population living on the streets are facing extremely serious mental health and addiction issues, but according to harm reduction practices health officials have encouraged governments to move away from policing those living in encampments and instead provide food, clean needles and the public space they need to act out these behaviours. This approach is at the price of other residents of San Francisco who have found homeless individuals in their backyards and scare seniors from leaving their communal residence. Throughout my entire education I was told that harm reduction, understanding, compassion and providing resources are the best ways to curb homelessness. None of those strategies are working in San Francisco. MacDonald states the homeless population in San Francisco openly refuses services, dispose of their used needles freely, and generate up to six tons of trash daily.

Based on my personal experience sifting through public health dogmas and knowledge of Haidt’s research, I am beginning to understand why some governments and health officials are continuing to produce fear and pro-lockdown messaging through the COVID-19 pandemic. Considering the evidence presented by Haidt and his team, and recognizing the political leanings of infectious disease experts, there is cause for concern about the recommendations politicians are receiving in the current climate. The health sector specialty that is curently informing different levels of governments on the direction of the pandemic response is the same discipline using harm reduction approaches to curb the population-level health problems above. Compassion is propelling them to save everyone, but we know as a societiy that seniors, tragically, fall ill and pass away for many reasons. The information is morally biased towards harm prevention (care) and the leftist view of fairness (equity). The lack of moral and political diversity in the public health sector seems to push governments and politicians to make decisions that are focused on a minority population, in this case, seniors, often neglecting the community at large. In an attempt to bring about complete Fairness, with Care, populations have had to sacrifice their businesses, employment and important social engagements, as public health perpetuates a narrative of equity. This thinking is preventing nations from making headway on economic fallouts and reversing lockdown measures. Health professionals are unconsciously informing our politicians from a point of view that is rooted in the principles of “Do No Harm”, seemingly at all costs.

Optimistically, all is not lost. Four infectious disease experts wrote an opinion piece in The National Post recommending a continuation of releasing lockdown measures, as our goal to “flatten the curve” has been successful. As stated in the article, and to my agreement, waiting for a vaccine ignores how complicated and difficult vaccine development can be. They argue that Canada needs a model that uses a hospital capacity-based approach to guide local lifting and reintroduction of more restrictive measures, as necessary. The experts recommend, “In the absence of hospital strain, consider continuing with a swift release of lockdown measures, to include opening of elementary schools, playgrounds, workplaces, stores and restaurants, while following basic physical distancing rules and voluntary limitations to social gatherings, while continuing to ban mass gatherings and protecting the elderly and those at highest risk.” Two of four of the experts in this article were from McMaster University. I wonder what their thoughts would be if they sat through the same public health courses I have over the last 3 years.

In Canada, the individual rate of death from COVID-19 for people under 65 years of age is 6 per million people, 0.0006%. This is equivalent to a motor vehicle accident during the same period. Has public health ever recommended that people don’t ever drive in case someone gets in an accident? Of course not. Public health works to improve the outcomes of driving through safety features like seatbelts, speed limits and age restrictions. The safety features in cars are wonderful and historic examples of harm reduction measures, based on succinct evidence and experimentation. Public health needs to change its tune and embark on the “seatbelts” of COVID-19: masks and recommendations routed in evidence, not compassion-induced paranoia.

More evidence is being presented that indicates the extreme measures were not necessary, but public health is not all to blame as an article in Real Clear Politics points out: “If you are a hammer everything looks like a nail. I blame government leaders for failing to surround themselves with diverse viewpoints and to think critically for themselves.” Public health will admit that their epidemiological models are inaccurate and their projections are based on moving targets. Skewed thinking towards protecting the vulnerable is overshadowing the needs of the majority of the population during the pandemic in a noble attempt to reduce harm. I don’t expect the political ideologies amongst health professionals to change, as the research above indicates there are many right-wing individuals in other specialities of health care. It makes logical sense for someone who highly values Care and Fairness to assist in health outcomes for the population. However, governments need both conservative and liberal ideas to thrive. Even though I believe that compassion, optimism and hope are important contributors to aid our society in improved long-term health outcomes, these can’t be the only morals to inform some of our toughest population-based problems.

Our governments are succumbing to harm reduction ideals in responding to the pandemic. Yes, liberals are right, we need to continue to care deeply about our senior population and their vulnerabilities to COVID-19. But conservatives are also right: we need to care about the majority of the populations who desire to get back to work, restart the economy, and live the life we are all accustomed to. There is now no clear reason for why lockdown measures (or public shaming for visiting parks, for that matter) should continue. Recognizing that infectious disease experts are the most motivated by the moral foundations of Care and Fairness within the health sector and their predominantly left-leaning approach, decision makers need to stop, think and rationalize how the messages they are receiving are slanted. It is up to governments and politicians to take recommendations from health officials and strive to find moderate solutions to problems for everyone.

Jenna McHugh is the Founding Editor of Vigor. Follow her at @jennoratorr

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