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The Nuffield Council on Bioethics introduced an ‘intervention ladder’ to guide policymakers on public health interventions.1 The ladder’s vertical structure represents an ordering of interventions, from least to most intrusive. In his article, Paetkau acknowledges that this ladder is ‘a useful tool’ (p. 1) for evaluating public health interventions.2 However, he objects that its focus on individual behaviour is too narrow and obscures ‘interventions that operate on the level of systems rather than individuals’ (p. 2).

To be sure, some of the interventions on the original ladder do involve what might ordinarily be seen as ‘system’ or environmental changes. For instance, we might encourage active transport by building dedicated cycle lanes. However, these measures still have their intended effects through altering individual choices. What Paetkau means by a ‘systemic intervention’ is specifically one that improves public health without changing individual behaviour change (pp. 2–3). For example, reducing pollution or improving public health infrastructure. He suggests that, because the Nuffield ladder focuses on individual behaviour, it may lead policymakers to overlook these possibilities.

Paetkau proposes broadening the ladder to include systemic interventions. This results in what he calls a ‘stairway’ (p. 3). It …