The values that bind us

On the roots of our guiding principles.

The longer I do what I do, the more it seems to me that values are core to sustaining a vibrant, engaged public health community. From this basis of values, we are able to engage with the challenges of the moment with the feeling that our feet rest on something solid, that we are grounded in a shared understanding of what matters most for health. Values are also at the heart of many of the debates and areas of polarization that shape the issues that matter for health. How do we define freedom? What constitutes a good life? Is health really worth pursuing as a core priority for policymaking? Engaging with these questions means having a clear sense of our own values and the philosophical basis for what we believe. It is for this reason that we often return to the subject of values, as a first principle for all we do.

Given the importance of values, it strikes me as appropriate to take a moment to reflect on the values that bind us. By ”us,” I mean the local public health community, public health more broadly, and, ultimately, the world. Understanding the values that unite us at these levels means first asking: where do our values come from? What can we learn from the intellectual tradition on which they are based? Our values are, fundamentally, an inheritance. They come to us from a longstanding tradition of activism, scientific engagement with issues of consequence for health, and philosophical inquiry into what constitutes a good society and an ethical life. In uniting us as a public health community, they are offshoots of the values that, at their best, unite us as a world—as a human society. Throughout history, ideas have emerged which have formed the basis for a better world. The ideas that form the intellectual grounding for public health are, in large part, a product of the European Enlightenment, although they are, of course, informed by other cultures and traditions. It was the Enlightenment which originated what we now call small-l liberalism. Philosophers like John Locke and Thomas Hobbes expressed a view of society and politics based on reason, free speech, individual rights, and a government that derives its legitimacy from a social contract between rulers and ruled rather than from assertions of divine right. Over time, this vision evolved into an understanding that societies should be organized in support of human rights, with a focus on creating the material and political conditions that sustain these rights. This perspective informs the core principles of public health, focused as we are on improving the health of populations by creating a context that supports health.  

I am well aware that these philosophical roots sit squarely on a western tradition of philosophy, and that there are insights that are worth weaving into an understanding of our values from other moral philosophical traditions. I am also conscious that value sets have been used to justify the creation of structures that exclude many. Both of these observations should always make us wary of any claims to moral absolutism made by any particular value set. My goal in this essay is not to say that this value set cannot be improved upon, but rather to sharpen our focus on the values that underlie what we do as a challenge to ourselves both to do better by these values, and to improve upon them as our thinking evolves. And, this writing—as with all of my writing—is directly in opposition to any efforts to exclude or to support structures that systematically create barriers for any groups based on any axis of identity. I highlight here values that I think create the path for an inclusive, better world, rejecting efforts to mis-use these values, but being conscious always about the potential for such. 

Having said that, how do these values underlie the work of public health? It strikes me that public health in its current form most clearly intersects with the principles of small-l liberalism in our embrace of three key values: freedom, equity, and the pursuit of truth. These principles are foundational to public health—at the roots of our field—in addition to being core concerns of the philosophers whose ideas birthed Enlightenment liberalism. By way of example, two statements by John Locke stand out. The first is “[B]eing all equal and independent, no one ought to harm another in his life, health, liberty, or possessions.” This reflects how a concern for health was present at the birth of our modern understanding of freedom, as was an understanding of freedom as the capacity to live free from preventable harm—not just to do whatever we want. Locke’s ideal of a citizenry that is “all equal and independent” lays the way for the embrace of equality as a central value, which would later evolve into our present-day focus on equity. Locke also wrote “To love truth for truth's sake is the principal part of human perfection in this world, and the seed-plot of all other virtues.” This resonates with public health’s pursuit of truth as a core value. Our values of freedom, equity, and the pursuit of truth are indeed foundational, and well-worth returning to.    

We start with freedom—a word which can have different meanings for different people. For some, freedom is simply the capacity to do what we wish to do, unhindered by all but the most basic restrictions. For others, freedom means being able to live free from preventable hazard and disease, which can mean accepting certain necessary constraints. I have long thought it best to pursue a balance between these two definitions of freedom, mindful that one does not overshadow the other. In the US, we have not always been effective at striking this balance. In our politics, we have often seen efforts which would undermine health attempted in the name of “freedom.” These include opposition to commonsense gun control, attempts to dismantle the Affordable Care Act, and a general hostility to the social safety net. Because these efforts tend to come from those on the right, many on the progressive left—a group which is well-represented within the ranks of public health—have come to see freedom as, at least rhetorically, shorthand for a political outlook which is inimical to the policies which support a healthier world. It is important to acknowledge this, and the conditions that have led many to, understandably, regard freedom skeptically. Yet it is also the case that freedom can mean much more—that it can, in fact, align with the mission of public health. Our reflective response to cries of freedom, shaped by years of hearing one particular understanding of the word used to oppose policies we favor, should not lead us to forget that freedom is, fundamentally, the point of all we do in public health. We work to create a context of health in which populations are free to exercise individual autonomy—a word much in use lately. A context of freedom allows us to live healthy, happy lives in which we are able to pursue what makes our time on earth meaningful. In our personal lives, this often means time with friends and family and the travel and leisure activities that enrich our existence. In our professional lives, it means the freedom to conduct scientific inquiry and reasoned debate without concern that the content of our thinking and speaking might jeopardize our efforts. For these reasons, we should not surrender the pursuit of freedom to those who define it differently than we do. Rather, we should embrace and promote an understanding of freedom that aligns with the mission of public health. 

It is important to note that freedom is not without risks—indeed, risk could be said to be the price we pay for freedom. Being free to choose what we wish to do means being free to choose wrong. While public health works to mitigate risk, it is still present and likely always will be to some extent in a free society. In the context of our work, freedom comes with the risk of being exposed to ideas which might strike us as wrongheaded or worse. Or, indeed, we could be the ones promoting ideas we later realize to be wrong. Engaging in productive conversations in a context of freedom means accepting these risks and proceeding with humility and civility, treating those with whom we disagree with the same generosity of spirit we would want extended to us when we find ourselves in the wrong.

Next, we are committed to the value of equity. This reflects our understanding that, even in a context of liberalism which aspires to create equality of opportunity for all, there can still be much unfairness. This unfairness is often structural, emerging from a context of historic injustice which echoes in the present. In the US, for example, the legacy of slavery and racism has created a context where many Black Americans are born into conditions of disadvantage not faced by their white counterparts. Creating equality of opportunity in the US means addressing the structures that create this disadvantage, leveling the playing field for all. A concern for equity helps us to see how, sometimes, what looks like fairness can hide this structural disadvantage. It is up to us to advance opportunities for equal achievement and thriving by first addressing the injustices that can prevent everyone from having an equal start in life.  

Finally, we are called by our values to the pursuit of truth. This is perhaps the most radical of all our values, resting as it does on the belief—in this age of subjective “truths”—that objective truth is real and knowable through a process of reasoned inquiry. This belief helps us support a process of reform that rests on data rather than blind faith or wishful thinking. Creating a better world means first clearly seeing the world as it is, through our pursuit of truth. This pursuit is not always easy. It means being open to facts that may complicate our preferred narratives. It also means subjecting our ideas to the rigorous debate, peer review, and good-faith critique that helps us to see when we are wrong, a necessary but sometimes uncomfortable process. It has been disheartening to see how, in recent years, it has become more common to shy away from this process. It has been particularly unfortunate to see this happening in academia, where forthright engagement with difficult topics can at times be conflated with giving quarter to hate speech. This has arguably had a chilling effect on the public conversation, leading Nadine Strossen, a former president of the American Civil Liberties Union, to recently suggest that speech norms on college campuses are now reminiscent of the McCarthy era. It is, of course, entirely true that hateful rhetoric should find no home in academic communities, and, as I have written previously, such communities are under no obligation to provide a platform to voices that would incite hate. Nor should they shy away from imposing prudent limits on how they engage with topics. But it is also true that academia should not be afraid to engage with hard conversations, and should it feel good-faith exploration of challenging subjects has become taboo, it is a sign that it risks losing its way.

By serving as a unifying influence, these values are core to the work of creating a better world. They provide the cohesion necessary for the collective action that drives positive change. Public health has long emphasized the importance of a collective approach to health. This perspective helps provide a counterweight to the view that health is entirely a matter of individual choices and behaviors. In public health, we engage with health from the perspective of populations, addressing the forces that shape health at the macro-level. This task is too big for any one person; it takes the collective action of many, united around animating values. These values help us to imagine and articulate a vision of the world as we would like it to be—a healthier world characterized by freedom, equity, and the pursuit of truth. The better we understand these values, and the philosophical tradition from which they emerged, the better we can advance the mission of public health.