By Daniel Goldberg
Too often throughout the COVID-19 pandemic, policymakers have justified controversial policy choices by stating that the world is not arranged in a way to make certain actions feasible. While practical difficulties matter, permitting such difficulties to exhaust the scope of our ethical obligations is a grave mistake that moves us farther away from a just and equitable world.
For example, last week’s weakened guidelines regarding COVID-19 mitigation from the U.S. Centers for Disease Control and Prevention (CDC) were justified by some public health pundits as “meet[ing] where most Americans are.” Policymakers seem to be arguing that where communities are simply unwilling to take actions (i.e., wear masks, follow quarantine protocols after an exposure, etc.) we should not implement pandemic policy interventions that would challenge that unwillingness.
This is an example of what is called the naturalistic fallacy in moral and political discourse. In essence, the mistake derives normative claims from natural ones. Put less formally, the mistake infers the way the world “ought” to be from the way the world “is.” One major reason this is an error is that it virtually ensures the moral status quo. If the way things are exhaust our sense of the way things ought to be, we will never strive for moral and ethical improvement.
This is not to deny practical and political constraints on policy action, which are real and morally relevant. Nevertheless, it remains an ethical mistake of the worst kind to simply give up on our collective agency and on our ethical responsibilities.
In prior work I termed this tension “the ethics of health policy paradox,” which can be framed roughly as “That which we ought to do may not be what we can do, and that which we can do may not be what we ought to do.” This is a serious problem, but hopefully it is obvious that
choosing to simply do what we can because it is expeditious is no answer at all. The crucial normative question remains unresolved: whether selecting a more practical but inferior approach better satisfies norms of social justice than prioritizing an arguably less pragmatic but almost unquestionably more effective approach that directs public health resources to fundamental causes of disease.
As to our present pandemic moment, it is difficult to claim that there are literally no legal or policy interventions for pandemic response and control that can be implemented; consistent majorities of people in the U.S. support mask mandates during surges, for example. Is there really uniform and widespread opposition to improving ventilation in public buildings? It is, as I have argued, a “high bar to show that action on fundamental causes is literally impossible where there is no shortage of examples of policies and programs across the globe that do so.”
Regarding the significance of “meeting people where they are” in public health, the underlying premise of the argument here is sound. From both an intervention design and an implementation science perspective, it is often good practice to “meet communities where they are.” Sometimes this expression takes on a spatial significance; informants in one 2020 study on community barriers and facilitators of HIV testing emphasized the importance of community-based sites as a means of increasing access. But in the same study, at least one informant affirmed the need to “meet people at their comfort level” which suggests that interventions should be designed and implemented with an eye to generating trustworthiness. Indeed, the literature on non-communicable disease surveillance among marginalized and oppressed communities generally endorses “meeting people where they are” as a means of strengthening screening activities among communities with high disease burdens and often high levels of warranted mistrust.
However, the dangerous move in the argument goes from the premise “public health policymakers should strive to ‘meet people where they are’ in designing and implementing interventions” to the conclusion that “public health policymakers ought never design and implement interventions that fail to meet people where they are.” This argument is invalid in the technical sense – the conclusion does not follow from the premises, at least not in any categorical sense.
While there are likely some interventions which should not be pursued if they cannot ‘meet people where they are,’ it certainly does not follow that public health officials must avoid implementing all interventions for which some percentage of the relevant community is hesitant or unwilling to endorse. Public health interventions are often more popular than is presumed; e.g., at least in pre-pandemic polling, the vast majority of people in the U.S. believe the benefits of childhood vaccines outweigh the risks.
But even where interventions are unpopular, the pursuit of a just world cannot be reduced to a popularity contest in which only the policies and practices that wide majorities support can be implemented. Such a practice perpetuates the naturalistic fallacy and excuses all of us — especially those with the power and privilege to advance social change — from the work needed to help create a more equitable and just social order.
The refusal to endorse any legal and policy interventions that carry even the faintest risk of failing to “meet people where they are” is an abdication of all ethical responsibility to satisfy the “twin aims” of justice: improving overall population health and compressing health inequities. To be sure, meeting these obligations in the face of enormous structural and practical constraints is an incredible challenge. The decimation of public health infrastructure, the exodus of public health into a medicalized enterprise that maintains precious little connection to the structural and social reform traditions in its past, and the outright hostility for public health officials simply trying to do their jobs, are also part of this context. It is hard to ask public health officials to make what in some cases may be unpopular policy decisions when we have, for so long, done so little to support them.
But, ultimately, it is no answer to these problems to simply refuse all efforts to make this deeply imperfect world look like a better one — a world in which we would implement pandemic policies that shelter the whole population and relieve oppressed communities of the devastating impacts of centuries of structural violence. We must not permit the perceived limits of what we can do to exhaust the scope of what we ought to do.