• 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 …