What is reasonable?

On defining what is reasonable in pursuit of health, guided by our values, a sensitivity to context, and a pragmatic assessment of human nature and our own capabilities.

Most of us aspire to be reasonable. We do not set out to be irrational, to be easily swayed by emotion and bias. Rather, we try to ground our actions in reasonableness, with the understanding that such a standard is a good basis for living as individuals and as a society. The neuroscientist and philosopher Sam Harris wrote, “There is no society in human history that ever suffered because its people became too reasonable.” This seems to me, well, reasonable. We understand that, when our actions are informed by reason, we tend to make better choices for ourselves and for our world.

This leads naturally to the question: what is reasonable? The Cornell Law School Legal Information Institute defines “reasonable” as “Just, rational, appropriate, ordinary, or usual in the circumstances.” To be reasonable, then, is to be sensitive to context and to aspire to a standard of justice and rationality. I have long felt that, for public health to be most effective, it should rest on a foundation of reason. The problem is that we tend to disagree on how to define what is reasonable. During COVID-19, once we were past the acute pre-vaccine phase of the pandemic, there were some who continued to feel it was reasonable to stick to society-wide mask mandates and that anyone who opposed such sweeping measures was not willing to do what was necessary to save lives. In that heated moment, some even said that those who opposed such mandates had blood on their hands. Yet would such a mandate have been reasonable? Data on masking have cast doubt on the effectiveness of masks at the group level, even as masking has benefits at the individual level. Was it then not reasonable to weigh the pros and cons of mask mandates, factors that could be changing as the pandemic evolved? Or was it not?

Because, sometimes, sweeping, no-exceptions regulations are indeed the most reasonable step we can take to safeguard health. Traffic lights are a good case in point. Anyone arguing that individual choice should determine whether to obey traffic lights would be regarded by most people as unreasonable. For traffic lights to work, they need to be universally obeyed. Without this obedience, lives would be put at risk. In this context, then, the interests of health determine that the reasonable option is the one which minimizes individual autonomy.   

There is a wide range of “asks” we could make of the public which could create a healthier society. Not all of these “asks,” however, could be characterized as reasonable. For example, is it reasonable to say that everyone who rides a motorcycle should wear a helmet? Yes, it is. Motorcycles are dangerous, helmets can help keep drivers safer while imposing minimally on their autonomy, and we have, as a society, already invested much in creating safer roads and drivers through sensible regulation. On the other hand, is it reasonable to ban extreme sports like hang gliding or cliff diving? I would say it is not. Certainly, these activities are dangerous and banning them could ensure less accidental injury and death. But participating in these activities is also highly avoidable and entirely optional. Unlike driving, which most of us do, extreme sports are embraced by a select few thrill seekers who choose to face elevated risk for the sake of an exciting experience. Banning these sports would constitute, arguably, an unreasonable prohibition on activities which only threaten the wellbeing of a small number of people who generally understand the risks involved and choose to live with them for the sake of doing just that—living. What seems more reasonable is to regulate, control, and monitor these sports, as we do other dangerous activities, but to stop short of outright bans.

In determining the difference between what is reasonable and what is not, we should proceed guided by a concern for context and our fundamental values. What is reasonable in one context may be unreasonable in another. For example, under most circumstances, closing much of society for months would seem unreasonable. In the context of a global pandemic, however, reason may support such a measure—at least, for a time. Or perhaps a government ban on certain pesticides may seem unreasonable when the products function as advertised and do not violate any regulatory standards. However, about ten years ago South Korea adopted such a ban when pesticides were linked to suicides in the country, a move which did indeed help cut the suicide rate. There are also certain measures which will always be unreasonable because they fly in the face of our core values. Sealing up every human being in a protective bubble, for example, would help ensure no one will ever get sick. But such an action would be deeply unreasonable and unjust, violating our core values to balance health with a concern for freedom and human rights.

How can we in public health better agree on what is reasonable, to do right by the populations we serve? I suggest the following four observations to help us better define, and do, what is reasonable in pursuit of our work.  

First, much of our work in public health rests on an assumption that most people will prioritize safeguarding their health under all circumstances. This assumption is false. People will prioritize their health under many circumstances. However, it is a simple fact of human nature that people sometimes take risks. They drive fast cars. They eat unhealthy but delicious foods. For a thrill, they jump off cliffs into the sea. This is just the reality of our collective human experience. Public health can do much, but it cannot change human nature, nor should it try to. What public health can do is provide data about risk and offer advice about how to balance the mitigation of risk with the living of a rich, full life. This seems like a reasonable focus for public health, helping to orient our efforts no matter the context in which we find ourselves.

Second, our work is often shaped by an unreasonable assessment of our own capabilities. To believe we can rid the world of all risk is to believe a fantasy. Yet it is a fantasy we often buy into. We do so because, arguably, we fail to think through the full implications of what eliminating risk would entail. For example, many in public health would likely acknowledge that a world without alcohol would be a much healthier one. Yet alcohol is not just a product subject to taxes and bans. It is a vast industry. This industry is rooted in powerful cultural and market forces which render unreasonable any effort to completely shut it down. In public health, we are sometimes liable to lose sight of these limitations in pursuit of outcomes which are, at core, about the elimination of all risk. We should avoid these diversions, so that we do not make the perfect the enemy of the good.  

Third, people tend to lose trust in institutions which seem to be behaving unreasonably, particularly when this behavior is in service of restrictive policies. I have written previously about the diminishing returns that can set in when public health seems moralistic, heavy handed, unreasonable. We should be judicious about the steps we take, the battles we choose to fight. We live in a society which, at its best, aspires to an ideal of small-l liberalism. Such an ideal prioritizes the autonomy of the individual; measures which seem to limit this autonomy can generate backlash, as we have seen. This does not mean we should stop advocating for sensible steps which support healthy populations—far from it. What it means is that we should maximize the good such measures can do by ensuring that they are indeed reasonable, data-informed, and subject to limits.

Finally, we should pursue our work guided by the assumption that most people are acting in good faith and share our commitment to being reasonable. This means it is on us to give the benefit of the doubt to those with whom we may disagree. When someone suggests an approach which seems to us to be counterproductive, we should not leap to accuse the person suggesting it of malice. Instead, we should ask ourselves how such an approach could seem reasonable to some, and from this basis strive towards a better engagement with differing points of view.

During the pandemic, I became concerned that public health was doing much that was not reasonable. This included refusing to discuss the pros and cons of mandating vaccines for children—instead, framing all nuance on the question as evidence of bad intent—working with special interest groups to shape public health guidance which should have been based on science alone, and meeting conversations about herd immunity—an epidemiologically sound concept—with vitriol. This is not to say that we should not have taken the positions that we did on these issues, only that the refusal to debate, and the willingness to frame attempts at a conversation in the worst possible light, were unreasonable. Had we acted more reasonably, I cannot help but think that the moment might have unfolded differently, and that public health would not face the crisis of trust it now confronts. Unfortunately, we strayed from principles of small-l liberalism that have long kept our work grounded in a basis of reason. This was my motivation for writing my next book, Within Reason: A Liberal Public Health for an Illiberal Time. The book aims to identify where we have strayed from reason and to suggest how we might recover an approach to our work which reengages with the liberalism which was once at its heart. The book is perhaps the most personal I have written, reflecting my effort to address how, in many ways, we may do well to get our collective house in order, post-pandemic, to better pursue our mission. Thank you to all who have pre-ordered the book here. I look forward to discussing its ideas in the months to come, leading up to its December 2023 release.

Public health should not be monolithic. We should be concerned about the health of people and as such should operate as a community of people with diverse perspectives and opinions working to accomplish the goal of better health for all. This diversity of thought means that there will likely always be disagreement about what is reasonable. This disagreement is necessary, healthy, for a robust climate of ideas. My hope is that when we are guided by values, a sensitivity to context, a respect for human nature, a realistic assessment of our own capabilities, and a restoration of small-l liberal values, we can better align ourselves with what is reasonable, to shape a more pragmatic, effective, and trusted public health.

__ __ __

Also this week.

Thoughts with David Velasquez in Medpage Today on the current efforts that can help advance our understanding of the social determinants of health.