• Ethics

Tyler Paetkau, in his paper ‘Ladders and Stairs: how the intervention ladder focuses blame on individuals and obscures systemic failings and interventions’, adds to the growing body of academic literature raising questions about the appropriateness and usefulness of the Nuffield Council on Bioethics (NCB)’s intervention ladder (2007) as a tool for policymakers.1 2 Paetkau is critical of the intervention ladder because he holds that it focuses on individual choice and personal responsibility and pays insufficient attention to ‘systemic interventions’. He suggests substituting the new metaphor of an ‘intervention stairway’ for that of the intervention ladder. I argue that his diagnosis of the problems does not go far enough and that his suggested alternative metaphor is more confusing than helpful.

Paetkau’s critical analysis of the intervention ladder makes some good points. It is true that this metaphor assumes a narrow range of policy options, with a focus on changing individual behaviour, and a consequent emphasis on personal responsibility. This is the flip-side of the NCB’s focus on liberty as always being a positive value and restriction seen as intrinsically wrong. Paetkau points out that this means that much routine public health action directed at changing the more structural features that impact on health is missing from the story. I set this out in earlier work and emphasised how other values, such as justice, efficiency, effectiveness, in addition to liberty were important and provided grounds for thinking that there were often good reasons to focus on actions ‘higher’ up the intervention ladder than if liberty was the sole relevant value.3 The only justification for a tool such as the intervention ladder is if liberty is, implausibly, given some privileged status over other values. The NCB report provides no such thing, quite the contrary, given its official ‘pluralism’.3 Despite this, it does seem to have an individualistic conception of public health and this is why it has been a popular tool for neo-liberal governments.3 An alternative view grounded in the practice of public health would emphasise the importance of both the health of populations and the need for collective actions to deliver the desired public health ends.4 However, a weakness in Paetkau’s approach is that it says little about how values map onto his critique of the NCB report. He seems to embrace the up/down liberty focus of the ladder despite his criticisms and, confusingly, seems to endorse the continuing use of the intervention ladder.

I now want to move to a discussion of Paetkau’s alternative metaphor of the intervention stairs and explain why I think it is confusing and unhelpful. It retains some of the problems of the intervention ladder and adds some new ones. First, the good point. Stairs are wider than ladders, meaning that it is easier to see how solidarity and community action from those on the same stair can be directed at collective endeavours to secure public health ends. In theory more ‘systemic interventions’ can be included. However, the metaphor does not ultimately work because stairs are still focused on going up and down, and on Paetkau’s account it is not clear which value is the one that we use to evaluate proposed actions. It must be a single value because of the up/down nature of the metaphor. In this respect, stairs are the same as a ladder. In addition, he suggests that individuals on the ladder or stairs can go up or down relative to other individuals, even in relation to the same policy. This is a bizarre idea as the intervention ladder is designed as a test for the supposed justification of proposed policies not individual actions relating to individual citizens. I still think that a better metaphor than that of a ladder or stairs is that of the sound mixing desk as it allows us to see that there are a range of values involved and that changes to one value impact on others.3 The way that the stairs metaphor is presented is confusing because the systemic and the individual are presented next to each other in eight separate steps in the diagram. It is unclear how these two lists relate to each other. Paetkau says that the same intervention might be at different levels in relation to these two lists. I do not see how this can possibly work or be helpful to any policymaker. The justification of the proposed policy should take into account all of the relevant ethical considerations and on that basis an all-things-considered judgement about the best outcome should be made.3 It is not a good idea to play twister on the stairs, with a hand on one level (for individuals) and feet on another (for the systemic).

In my previous paper, I offered a far more radical critique of the intervention ladder, arguing that it provides a way of thinking about policy that lacks coherence with the NCB’s overall political philosophy (a variant of liberalism, not libertarianism).3 The tension between philosophy and metaphor exists because the idea of a ladder focuses our attention on going up or down the rungs. Where we are on the ladder relates to the degree of restriction. It is built into the metaphor that the lower we are on the ladder the better. This makes clear that it is liberty that is the primary value that does the work within the ladder metaphor. If we hold other values such as justice to be important, as we should, it is unclear how they fit into the ladder metaphor. The NCB holds distributive outcomes to be important and it is for this reason that there is a tension between their philosophy and their metaphor.3 The danger is that the intervention ladder as a policy tool encourages interventions that, for example, result in greater inequality because of the focus solely on liberty. The tool might therefore result in worse, all-things-considered, population-level outcomes. Metaphors can, potentially, harm our health. Ladders and stairs should only play a role in promoting public health where they are used for active movement not policy justification.