John Q. Wong, MD, MSc 28 July 2009

 Gostin LO. Public Health Law: Power, Duty, Restraint. University of California Press, Canada: 2000.

 Theory and definition of public health law (PHL)  Systematic evaluation of public health regulations  Evaluation of the Philippine Tobacco Regulation Act

 Medical jurisprudence  Legal aspects of the application of medical and surgical knowledge to individuals

 PHL is the study of  The legal powers and duties of the state To assure the conditions for people to be healthy and  The limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals f or the protection or promotion of community health

 Government  Populations  Relationships  Services  Coercion

 Government  Responsible for PH  Populations  Focus of PH  Relationships  Between the state and the population  Between the state and individuals who place themselves or the community at risk

 Services  Provision of population-based services grounded on the scientific methodologies of PH  Coercion  Power to coerce individuals and businesses for the protection of the community rather than relying on an ethic of voluntarism

 Primacy of government in the constitution  Obligations of government  Governmental health regulation in history and practice

 Medicine  Why did this patient get this disease at this time?  Example Causes of death are cancer, heart disease, CVD, and pulmonary disease  PH  What can we, as a society, do collectively to assure the conditions for people to be healthy?  Example Causes of death are environmental, social, and behavioral factors

 Benefits and burdens placed by government on legally protected interests  Autonomy  Liberty  Privacy  Property

 Mission  Core functions  Essential services  Leading indicators

 Protecting and preserving community health is not possible without constraint of a wide range of private activities  Private actors have incentives to engage in behaviors that are personally profitable or pleasurable but may threaten other individuals or groups  Examples  Individuals with STDs  Polluting industries  Unsafe or unhygienic products

 Paradox  To act affirmatively to promote the health of the people  But cannot unduly invade individuals’ rights in the name of the communal good  Overreaching regulation  Minimal health benefit with disproportionate human burdens  Tension  Voluntarism and coercion  Civil liberties and public health  Discrete (or individual) threats and aggregate health outcomes

 ‘That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others…’

Public health activityPublic benefitsPrivate interests/ rights Prohibition of behavior - smoking in public places Protect health and safety of person or others by restricting risk behaviors Personal autonomy and freedom of action Product design - product (cigarettes) liability under tort law Prevent injuries by regulation or incentives for safer product design, and compensate injured persons Freedom of contract (manufacturer- consumer), business interests, property uses, consumer costs Informational constraints - labeling requirements Restrict content of commercial messages that encourage harmful behavior, provide consumer information to avoid hazards Freedom of speech, freedom of press, business and property interests

Public health activity Public benefitsPrivate interests/ rights Youth access restrictions - cigarettes Reduce health and safety risks among children and adolescents Autonomy of youth, spill-over effects in denying access to adults Taxation - cigarettes Reduce demand for hazardous products by price increases, create disincentives or incentives to promote healthier behavior Consumer costs, business and property interests, and possible fairness problem with regressive taxation

 Risk to others  the ‘harm principle’  Protection of incompetent persons  ‘best interests’  Risk to self  Self-regarding behavior  Motorcycle helmets, gambling prohibitions, fluoridation of drinking water

 Nature of the risk  Duration of the risk  Probability of harm  Severity of harm  Inverse correlation with probability of harm

 Social values  Should popular judgment trump science?  PH should account for traditional values of Voluntarism Personal benefit Fair distribution of risk

 Risk-risk trade-offs  Decreasing one risk increases another  Examples Chemical disinfection reduce risks of water-borne infection but increase risks of cancer Universal precautions in hospitals decrease risks of blood-borne infections but increase costs and reduce access Nuclear power regulation reduces radiation risk but increases hazards due to coal- or oil-based energy

 Government should demonstrate, through scientific data, that the methods of regulation adopted are reasonably likely to achieve public health objective

 Agency resources to devise and implement the regulation  Costs to individuals and businesses subject to the regulation  Lost opportunities to intervene with a different, potentially more effective, technique (opportunity costs)

 Inordinate costs for small health benefits  Low cost-effectiveness  Regulation carried to illogical extremes  Going the last mile  Arbitrary selection of regulatory topics  Random agenda selection

 The least restrictive alternative  Criteria  Invasiveness To what extent does it intrude on rights  Frequency and scope One person, a group, or an entire population  Duration How long is the infringement

 Just distribution of benefits, burdens, and costs  Rule  Provide services to those in need  Impose burdens and costs on those who endanger the PH  Avoid under- and over-inclusiveness

 Systematically evaluate the Philippine Tobacco Regulation Act using Gostin’s criteria  Draw a conclusion as to whether or not it is a ‘fair’ law. Conclusion has to be supported by evidence.

 Mechanics  New groups  3 pages, 1” margin minimum, Times New Roman 12”, single space  Due 5 Aug 2009 by