The Chief Medical Officer for England, Professor Sally Davies, and colleagues argue that it is time for a ‘fifth wave’ of public health, and influential organisations are seeking to advance this agenda. The fifth wave would progress from earlier shifts in public health, through structural, biomedical, clinical, and, most recently, social waves, towards a wave wherein the public’s health is recognised as a common good to be actively promoted through participation of the public as a whole. Davies and colleagues categorise this fifth wave as cultural, emphasising the cultivation through institutional, social, and physical environments of shared beliefs, values, and behaviours in which pro-health attitudes—individually and at a societal level—are normalised. They advocate for their agenda within a political context that has undermined the highest attainable standards of health through an individualism that defies what is shown by epidemiological studies on the social determinants of health. Focusing on the practical case study of the ‘tobacco endgame’, my paper examines the fifth wave agenda through a public health ethics and law perspective. It critically explores the viability of political justifications for a public health policy strategy that works through a long-game, cross-sector approach of progressive achievement of change. This requires a study both of the justification of the goal that is aimed at and, crucially, the means of achieving it. Given the dominant political context, it is unsurprising that efforts are made to find ‘neutral’ normative framings, such as those promoted by reference to ‘libertarian paternalism’. It is argued, however, that these are inherently deficient as coherent sources of legitimacy: there may be strategic or ‘real politics’ reasons to frame justifications in this way, but the philosophical foundations of efforts to promote the public’s health require a greater—and more contestable—critical depth.
John Coggon is Professor of Law, and Co-Director of the Centre for Health, Law, and Society, at the University of Bristol School of Law. He has published widely on questions concerning the roles of law and governance, and the place of ethics, in public health. This includes his books What Makes Health Public? (Cambridge University Press, 2012) and, with Keith Syrett and A.M. Viens, Public Health Law: Ethics, Governance, and Regulation (Routledge, 2017). Professor Coggon is editor of the journal Health Care Analysis, and is on the editorial board of Public Health Ethics. As well as researching in public health ethics and law, he has pioneered education in the field, leading the development of University teaching on the subject, and developing and delivering training in ethics and law for the public health workforce. He also co-authored, with A.M. Viens, Public Health Ethics in Practice: An overview of public health ethics for the UK Public Health Skills and Knowledge Framework (Public Health England, 2017). In 2016, Professor Coggon was made an Honorary Member of the UK Faculty of Public Health, and is a member of the Faculty’s ethics committee.
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