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The intervention ladder and the ethical appraisal of systemic public health interventions
  1. Maxwell J Smith,
  2. Kayla Gauthier
  1. Faculty of Health Sciences, Western University, London, Ontario, Canada
  1. Correspondence to Dr Maxwell J Smith, Faculty of Health Sciences, Western University, London, Canada; maxwell.smith{at}

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The intervention ladder, developed by the Nuffield Council on Bioethics, is a framework intended to help evaluate the ethical acceptability and justification of public health interventions according to their intrusion on liberty.1 In their recent article, Paetkau2 argues ‘the ladder obscures potential interventions that operate on a systemic rather than individual level’ (p. 1) and that ‘it is crucial that systemic interventions not be left off the table when considering potential concrete interventions’ (p. 3), leading them to propose instead the ‘intervention stairway’. Yet, in this commentary we argue the intervention ladder does not delimit the sorts of public health interventions that may be considered to address a public health issue, although it may speak to their putative justification. Hence, despite its other considerable shortcomings,3 4 there is no need, as Paetkau argues, to broaden the intervention ladder to include systemic factors.

Contrary to Paetkau’s claim, the intervention ladder does not preclude policymakers from considering systemic factors’ impact on health outcomes or the public health interventions and strategies that could be implemented to address them. Paetkau adduces the example of measures to protect patients, healthcare workers and healthcare capacity from the threat of infectious diseases. They argue that certain …

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  • X @maxwellsmith

  • Contributors Both authors contributed equally to the conception and writing of this manuscript.

  • Funding Maxwell J. Smith is supported by a Canadian Institutes of Health Research Applied Public Health Chair.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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