HC 1048-III Health CommitteeWritten evidence from the Nuffield Council on Bioethics (PH 156)

Paragraph numbers refer to paragraphs in the Council’s report Public health: ethical issues: www.nuffieldbioethics.org/public-health

The Stewardship Model

1. Chapter 2 of the Council’s report Public health: ethical issues reviews the role of the state in public health and then outlines a framework for a public health policy, based on a classical liberal conception of the state’s role. While this framework is suitable to address some of the principal issues arising in the context of public health, it also has certain limitations. We therefore propose a revised and extended version of the initial framework, which we call the stewardship model.

2. The report concludes that the state has a duty to help everyone lead a healthy life and reduce inequalities in health. Our “stewardship model” sets out guiding principles for making decisions about public health policies.

Concerning goals, public health programmes should:

aim to reduce the risks of ill health that people might impose on each other;

aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health, such as the provision of clean air and water, safe food and decent housing;

pay special attention to the health of children and other vulnerable people;

promote health not only by providing information and advice, but also with programmes to help people to overcome addictions and other unhealthy behaviours;

aim to ensure that it is easy for people to lead a healthy life, for example by providing convenient and safe opportunities for exercise;

ensure that people have appropriate access to medical services; and

aim to reduce unfair health inequalities.

In terms of constraints, such programmes should:

not attempt to coerce adults to lead healthy lives;

minimise interventions that are introduced without the individual consent of those affected, or without procedural justice arrangements (such as democratic decision-making procedures) which provide adequate mandate; and seek to minimise interventions that are perceived as unduly intrusive and in conflict with important personal values (para 2.44).

3. We were pleased to see many of these characteristics recognised in the Government’s recent White Paper for public health in England, Healthy Lives: Healthy People. However, we have suggested that it would be helpful to see explicit reference to the Government’s programme to reduce health inequalities in England, and how the public health strategy will link with this. We therefore welcome that the Select Committee stresses the reduction of health inequalities as an important aim in its inquiry.

The Intervention Ladder

4. The White Paper includes the Council’s ‘intervention ladder’, as set out in our report on public health, which shows the range of interventions available to policy makers, from the least to the most intrusive.

5. The intervention ladder is not in itself a model or strategy for public health (as suggested in the Government’s press release on the White Paper).

It is the stewardship model that provides the main basis for designing public health programmes and justifying interventions. The function of the intervention ladder is to compare alternative approaches in terms of their intrusiveness and likely acceptability. Different interventions will be appropriate depending on the problem and the context. Any intervention implies value judgements about what is or is not good for people, and requires justification. The higher the rung on the ladder, the stronger the justification has to be in order for the intervention to be proportionate (para 3.37).


Eliminate choice. Regulate in such a way as to entirely eliminate choice, for example through compulsory isolation of patients with infectious diseases.

Restrict choice. Regulate in such a way as to restrict the options available to people with the aim of protecting them, for example removing unhealthy ingredients from foods, or unhealthy foods from shops or restaurants.

Guide choice through disincentives. Fiscal and other disincentives can be put in place to influence people not to pursue certain activities, for example through taxes on cigarettes, or by discouraging the use of cars in inner cities through charging schemes or limitations of parking spaces.

Guide choices through incentives. Regulations can be offered that guide choices by fiscal and other incentives, for example offering tax-breaks for the purchase of bicycles that are used as a means of travelling to work.

Guide choices through changing the default policy. For example, in a restaurant, instead of providing chips as a standard side dish (with healthier options available), menus could be changed to provide a more healthy option as standard (with chips as an option available).

Enable choice. Enable individuals to change their behaviours, for example by offering participation in a NHS ‘stop smoking’ programme, building cycle lanes, or providing free fruit in schools.

Provide information. Inform and educate the public, for example as part of campaigns to encourage people to walk more or eat five portions of fruit and vegetables per day.

Do nothing or simply monitor the current situation.

Role of Third Parties

6. Although the state should be guided in its public health policies by the concept of stewardship, this does not absolve other parties, in particular the corporate sector, from their responsibilities. We discuss the concept of corporate social responsibility, and note that while companies may have different motivations for pursuing social responsibility strategies, they increasingly recognise that they have obligations beyond simply complying with relevant laws and regulations. If industry fails to meet these obligations and the health of the population is significantly at risk, the market fails to act responsibly. In such cases, we argue, it is acceptable for the state to intervene (paragraphs 2.47–2.50, 5.26, 5.16–5.25, 6.18–6.31, 8.24).


7. Evidence about, first, causes of ill health and, secondly, the efficacy and effectiveness of interventions is important to public health policy. Ideally, evidence should be based on peer-reviewed research, and not on preliminary results or unpublished reports. Selective use of evidence or “policy-based evidence” that has been commissioned or interpreted to support existing or planned policies is unhelpful.

8. We support the statement in the Government’s White Paper that “A culture of using the evidence to prioritise what we do and test out innovative ideas needs to be developed, while ensuring that new approaches are rigorously evaluated and that the learning is applied in practice.”

June 2011

Prepared 28th November 2011