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The Value of Unhealthy Eating and the Ethics of Healthy Eating Policies

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Unhealthy eating can have value for individuals and groups, even while it has disvalue in virtue of being unhealthy. In this paper, we discuss some ways in which unhealthy eating has value and draw out implications for the ethics of policies limiting access to unhealthy food. Discussing the value and disvalue of unhealthy eating helps identify opportunities for reducing unhealthy eating that has little value, and helps identify opportunities for eliminating trade-offs between health and other values by making unhealthy food experiences healthier without eliminating their value. It also helps us think through when it is ethically acceptable, and when it might be ethically unacceptable, to limit valuable experience in order to promote health. Our discussion of the value and disvalue of eating is offered here as a necessary supplement to the familiar discussion of paternalism, autonomous choice, and public policy.
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Kennedy Institute of Ethics Journal, Volume 24, Number 3, September
2014, pp. 187-217 (Article)
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DOI: 10.1353/ken.2014.0021
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Barnhill, King, Kass, & Faden • the ethics oF healthy eating Policies
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Kennedy Institute of Ethics Journal Vol. 24, No. 3, 187–217 © 2014 by The Johns Hopkins University Press
Anne Barnhill, Katherine F. King, Nancy Kass, and Ruth Faden
The Value of Unhealthy Eating and the Ethics of
Healthy Eating Policies
ABSTRACT. Unhealthy eating can have value for individuals and groups, even
while it has disvalue in virtue of being unhealthy. In this paper, we discuss some
ways in which unhealthy eating has value and draw out implications for the ethics
of policies limiting access to unhealthy food. Discussing the value and disvalue
of unhealthy eating helps identify opportunities for reducing unhealthy eating
that has little value, and helps identify opportunities for eliminating trade-offs
between health and other values by making unhealthy food experiences healthier
without eliminating their value. It also helps us think through when it is ethi-
cally acceptable, and when it might be ethically unacceptable, to limit valuable
experience in order to promote health. Our discussion of the value and disvalue
of eating is offered here as a necessary supplement to the familiar discussion of
paternalism, autonomous choice, and public policy.
1. INTRODUCTION
As concerns about the negative health effects of unhealthy eating,
overweight and obesity have increased, so too have policy efforts
to promote healthy eating. Federal, state, and local governments
have proposed and implemented a variety of healthy eating policies. Many
of these policies are controversial, facing objections that range from the
practical (e.g., the policy won’t succeed at improving people’s diets) to
the ethical (e.g., the policy is paternalistic or inequitable). Especially con-
troversial have been policies limiting the options offered in the market-
place, limiting access to certain options, or providing disincentives for the
purchase of certain options. Examples of such policies include proposed
taxes on sugary drinks (Brownell and Frieden 2009); bans on trans fat in
restaurants (CSPI 2014); minimal nutritional standards for kids’ meals
in fast food restaurants, a.k.a. the “Happy Meal ban” (Bernstein 2010);
policies limiting the density of fast food restaurants (Severson 2008);
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proposed policies excluding sugary drinks and other unhealthy foods
from SNAP (the Supplemental Nutrition Assistance Program) (Brownell
and Ludwig 2011); and New York City’s failed prohibition on the sale of
sugary drinks larger than 16 ounces (Yee 2013; Reuters 2013).
Policies limiting food options have been criticized on multiple counts
(ten Have et al. 2012). They are claimed to have a negative or unfair
economic impact; for example, opponents of the big soda ban argued that
it would hurt small businesses, and opponents of soda taxes argue that
they are regressive and therefore unfair (Huget 2013). Another concern
raised for some such policies is that they will encourage the stigmatization
of people who are overweight and obese, and, in the case of the proposed
SNAP sugary drink ban, the stigmatization or blaming of poor people
(Kirkland 2011; Barnhill and King 2013). Others challenge the democratic
legitimacy of the policies; for example, opponents argue that the New
York City big soda ban was essentially implemented by mayoral fiat
bypassing altogether the city council, the other relevant elected branch of
government (Farago 2012).
While these criticisms all warrant examination, in this paper we focus
on another line of ethical criticism of these policies, which is found in both
academic work and the popular press: that these policies unduly restrict
consumer choice, limit consumers’ freedom, violate consumers’ right to
choose, and are “nannying” and infantilizing (Lonsberry 2008; Resnik
2010; New York Times 2012; Gostin 2013).1 It is common to identify
paternalism as the central, overarching ethical issue raised by public health
policies limiting individual choice, and to frame concerns with limiting
choice as concerns with paternalism.2 A paternalism-oriented inquiry
often focuses only on whether unhealthy eating reflects the right kind of
choice—such as an autonomous, informed, and voluntary choice—in order
to determine if government interventions are objectionably paternalistic.
We argue here that this discussion of the informed or autonomous nature
of food choices needs to be supplemented with a discussion of the value
and disvalue of food experiences. Policies limiting food options can impinge
on valuable experiences even if they do not interfere with the individual
exercise of autonomy, thus the ethics of such policies must take account
of the value of these experiences as well.
Paternalism is typically understood as making someone do something
she does not want to do, or keeping her from doing something she does
want to do, in order to increase her welfare. But theorists haggle over how
exactly paternalism ought to be understood: some understand paternalism
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more narrowly as interfering with autonomous choice, whereas others
understand paternalism more capaciously as interfering with voluntary
behavior, whether or not this behavior is in some robust sense autonomous
(Dworkin 1972; 2010; Nys 2008; Conly 2013a).3 While some argue
that paternalistic interference with behavior is acceptable only if the
behavior is nonvoluntary, others argue that paternalistic interference
with voluntary behavior can be acceptable, if the behavior is in some
sense not fully autonomous—for example, if it is uninformed or irrational
(Feinberg 1986; Trout 2005; Conly 2013b).4 Policies that interfere with
behavior that is uninformed, irrational, or otherwise nonautonomous do
not violate autonomy, and thus are not a morally objectionable form of
paternalism, on one line of thought. Though theoreticians disagree about
how “autonomous choice” should be defined, and disagree about the exact
relationship between autonomous choice and paternalism, many accept the
central assumption that, all other things being equal, the permissibility of
paternalistic policies hinges on whether these policies interfere with choice
that is in some meaningful sense autonomous (Dworkin 1972; Feinberg
1986; Nys 2008; Sjostrand et al. 2013).5
On this way of laying out the issues, one can defend policies limiting
food options by arguing that food behavior often is not voluntary behavior,
or is voluntary but not an autonomous choice. Such a defense would go
as follows: Because individuals typically do not make autonomous choices
to eat unhealthy food, but instead engage in unhealthy eating that is
nonvoluntary, uninformed, and does not express stable preferences, many
policies limiting food options merely prevent nonautonomous behavior.
Hence, these policies are not objectionably paternalistic. Other ethical
objections could still be lodged to the policies (e.g., they are regressive
and thus unfair to lower income people), but the ethical objection that
limiting choice is objectionably paternalistic would have been refuted.
This argument provides a “win–win” justification of public health policies
limiting choice: some choice-restricting policies improve health, thereby
benefitting individuals and society, without interfering with the exercise of
individual autonomy, since the restricted behaviors are nonautonomous.
The classic public health view acknowledges a trade-off between individual
autonomy and public health, but this “win–win” argument attempts to
have its cake and eat it, too. Many details would have to be filled in for
this argument to be complete—e.g., What exactly is autonomous choice?
In what ways exactly is unhealthy eating nonautonomous?—but the
general outlines are clear, and the ethical issues so presented are fairly
straightforward.
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In this paper, we offer an additional, and critical, lens on the ethics of
policies limiting food options. We argue that determining whether any
instance of unhealthy eating is an appropriate target for public policy by
focusing on the extent to which it reflects an autonomous choice, while
sometimes critical, can also obscure what is arguably a more foundational
concern—the value of the food experience to those the policy would affect.
Food experiences have multiple kinds of value for individuals and
groups. Food is a source of sustenance, pleasure, and comfort, and is a
primary source of good health (along with bad health). Sharing food is a
central way in which people forge and reinforce social bonds, and specific
foods have cultural significance, religious significance, and a special place
in family and community life. When individuals and groups have these
kinds of valuable food experiences, what people eat does not always
reflect a substantially informed or deliberate choice specific to the food
itself. Although what constitutes informed, voluntary, or deliberate choice
is deeply contested, food experiences can have value for individuals and
groups even though the food consumption would not conform to any
plausible account of these concepts. Food and eating is a domain of human
experiences for which the exercise of individual autonomous choice is a
limited ideal. Thus autonomous choice is an only limitedly useful frame for
capturing what might be ethically problematic about ethical concerns with
policies that limit food choice; similarly, autonomy-focused discussions
of paternalism are also only partially useful.
We propose that ethical discussion of autonomous choice be supplemented
by focusing on the value and disvalue of specific eating experiences. We
are not proposing that discussion of autonomy should disappear from
the ethical discourse around choice-restricting food policies, but that
discussion of the value and disvalue of food experiences should come to the
fore. An autonomy-focused discussion of choice-restricting food policies
asks: in what ways or to what degree is eating a less than fully informed
choice, or a less than fully deliberate choice? Are the food experiences
targeted by a potential policy sufficiently or substantially nonautonomous
to make government intervention less ethically controversial? Does the
policy prevent people from engaging in nonautonomous eating behavior,
or correct for failures of autonomy? A value-focused discussion asks: in
what ways do the food experiences at issue have value and disvalue for
people? How do potential policies preserve or threaten these valuable food
experiences? Can policies be designed that preserve the value of experiences
that include unhealthy food while making the food choices themselves
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healthier? When there are ineliminable conflicts between values, what are
the appropriate trade-offs to make?
An autonomy-focused discussion of food policies misses something
ethically important, namely that nonautonomous eating sometimes
can nevertheless be valuable to people, and eating that is substantially
autonomous, in some instances, might not be particularly valuable. By
focusing on whether the food consumption is autonomous—that is, both
an informed and a deliberate choice—we may sometimes forget that food
consumption can be tied up with a larger experience that is valued.
Importantly, our argument in this paper is not a wholesale rejection
of choice-limiting food policies or paternalistic policies. We critique
autonomous choice as an inadequate way of framing discussion of choice-
limiting food policies, and we argue that we should supplement ethical
discussion of choice-limiting policies so that it includes the value and
disvalue of unhealthy eating. However, we are not arguing that unhealthy
eating always has value, nor that when unhealthy eating is valuable, it
is necessarily unethical for policies to target it. Nor are we arguing that
existing policies typically infringe upon valuable food experience in
unethical ways. On the contrary, healthy eating policies by and large target
unhealthy eating that is less valuable, and we support many such policies.
Moreover, we believe that it will often be possible to construct policies
that target valuable unhealthy eating experiences in ways that are ethically
acceptable, by focusing on interventions that respect what is valuable
about the experiences while simultaneously making them more healthy.
As we explain below in “Implications for Policymakers,” discussing the
value of unhealthy eating helps us to identify opportunities for reducing
unhealthy eating that have little or no positive value. Targeting this kind of
unhealthy eating should be a priority for healthy eating policy. A discussion
of the value and disvalue of unhealthy eating also illuminates trade-offs
between health and other values, and helps us identify opportunities
for eliminating these trade-offs by making unhealthy food experiences
healthier without eliminating their value. A discussion of the value of
unhealthy eating also helps us think through when it is ethically acceptable,
and when it might be ethically unacceptable, to limit valuable experience
in order to promote health. As we discuss at greater length below, we
hope that a discussion of the value and disvalue of unhealthy eating can
help to improve the ethical design of policy, and also help policymakers
design more nuanced and effective policies, and bolster the ethical case
for policies targeting low-value unhealthy eating.
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Our discussion of the value and disvalue of eating is meant a supplement
to the familiar discussion of paternalism, autonomous choice, and public
policy. It is an alternative way of exploring the ethical concern that it is
disrespectful towards individuals for the government to limit their food
options for the sake of their health, and thus is an alternative way to talk
about the ethics of limiting consumer choice. Of course, as mentioned
above, there are other ethical objections lodged against healthy eating
policies besides the objection that they unduly restrict choice, and other
arguments in favor of healthy eating policies besides the claim that eating
behavior is substantially nonautonomous and thus fair game for state
intervention to promote health. Our discussion of the value and disvalue
of eating is not meant to address these other objections and arguments,
and thus is not meant to be exhaustive of the ethical considerations that
must be taken into account in assessing the moral acceptability of healthy
eating policies.
Along with giving us an additional and helpful way to talk about choice
and limits on choice, we also hope that our discussion of the value and
disvalue of eating will contribute in other ways to the broader discussion
about unhealthy diet, obesity, and diet-related illness, a topic that many
public health practitioners, academics, and others care about. We need
to find solutions to the problem of diet-related illness collectively, and we
hope to contribute to that discussion by helping to illuminate what’s at
stake in different circumstances with eating, food and health.
We begin in section 2 by reviewing some ways in which unhealthy eating
is viewed as substantially nonvoluntary or nonautonomous. In section 3,
we consider the different ways in which food experiences can be valuable,
even though these food experiences or the food consumption that’s part of
them are not engaged in a result of a deliberate or fully informed choice.
In section 4, we return to paternalism and consider how our focus on
the value of eating relates to theorizing about paternalism and proper
state action. We conclude in section 5 with some specific implications for
policymakers that follow from our claim that we must take account of
the value that attaches to some unhealthy eating.
Before we proceed, a terminological note. We use the phrase “unhealthy
food” to refer to foods that significantly increase the risk of diet-related
illness at current levels of consumption, but do not pose a risk of immediate
harm, and whose risk-attributing components are themselves food
substances (e.g., fat, sugar, or salt). Paradigm cases of unhealthy foods
are certain kinds of fast food (e.g. a McDonald’s Happy Meal), sugary
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drinks (e.g., a Coca-Cola), and processed foods high in sodium, fat, or
sugar (e.g., Cheetos). Unhealthy food should be distinguished from “unsafe
food,” which we define as food that poses a risk of immediate harm (e.g.,
from a toxin), poses a risk of harm at any level of consumption, or whose
risk-attributing properties are not food substances. Examples of unsafe
foods are poisonous foods (e.g., food laced with arsenic), disease-carrying
foods (e.g., food contaminated with E. coli or Mad Cow Disease), and
foods that pose a risk of harm because a nonfood substance is found in
the food (e.g., foods containing mercury).
2. UNHEALTHY EATING AS NONAUTONOMOUS BEHAVIOR
Three paradigms of unhealthy eating are referenced repeatedly in work
on healthy eating policies. First, unhealthy eating is sometimes portrayed
as uninformed choice, as consumers have poor information about the
nutritional content of their food and its impact on their health (Cowburn
and Stockley 2005). Second, unhealthy eating is sometimes described
as not fully voluntary—as automatic behavior, or as resulting from
food addiction, with addicted consumers unable to exert psychological
control over it (Volkow et al. 2013). Third, unhealthy eating is described
as a result of environmental cues that work below the level of conscious
awareness (van Baaren and Wigboldus 2005; Wansink 2004; 2006). While
the first paradigm, unhealthy eating as uninformed choice, is relatively
straightforward in its meaning, the other two paradigms require more
explication.
2.1. Unhealthy Eating as Nonvoluntary Behavior
Some unhealthy eating results from food addiction or other psychological
mechanisms that make consumers unable to exert psychological control
over it (Volkow et al. 2013). Or if unhealthy eating is not addictive
behavior exactly (Ziauddeen and Fletcher 2013), it is a related form of
behavior that is not fully under the individual’s psychological control.6
For example, Cohen and Farley make the case that eating is an automatic
behavior, where automatic behaviors are those that “occur without
awareness, are initiated without intention, tend to continue without
control, and operate efficiently or with little effort” (Cohen and Farley
2008). If some eating is initiated without intention and tends to continue
without control, as Cohen and Farley suggest, we should question whether
all unhealthy eating is truly a choice.7
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A second and related explanation of unhealthy eating as nonvoluntary
behavior is that certain foods—palatable foods, or those high in sugar,
fat, and salt—stimulate the reward system of the brain. As David Kessler
explains, “Eating foods high in sugar, fat and salt makes us eat more foods
high in sugar, fat, and salt. . . . Rewarding foods tend to be reinforcing,
meaning that they keep us coming back for more. I put an M&M in
my mouth, it tastes good, and I return for another. The sugar and fat in
the candy reinforce my desire to keep eating it” (Kessler 2009, 14–15,
29). Eating certain kinds of unhealthy foods motivates us to eat more of
these foods, even if we are not hungry and would rather not eat them. As
psychologist Kent C. Berridge puts it, we can “want” to eat something
(in the sense that it has increased motivational salience) even if we don’t
want it in other senses—for example, even if we don’t have eating it as a
goal (Berridge 2009).8 Thus some unhealthy eating is behavior that we’re
motivated (often in the very short term) to engage in despite the fact that
we’d rather not engage in it (especially in the longer term).
2.2. Unhealthy Eating as Environmentally Cued Behavior
Some eating results from environmental cues that work below the
level of conscious awareness. Considerable research has been conducted
finding that features of the food environment, such as large serving
sizes, psychologically cue us to eat more, unbeknownst to ourselves
(van Baaren and Wigboldus 2005; Wansink 2004, 2006). As a paradigm
case of environmentally cued unhealthy eating, consider this experiment
described in Wansink (2006): moviegoers were given free tubs of stale,
days-old popcorn, either a large tub or a medium tub. At the end of the
movie, the tubs were collected and the remaining popcorn was weighed
to determine how much had been eaten. Those moviegoers who received
a large tub ate 150 calories more of stale popcorn. Similarly, Wansink’s
other studies have found that people eat more candy if the candy bowl
is clear rather than opaque, they eat more jelly beans if there are more
colors of them, they cook more spaghetti if the spaghetti comes in a larger
box, and they pour a larger drink into a squat glass than a tall and skinny
glass (Wansink 2004). Eating more stale popcorn simply because it comes
in a larger tub is behavior that is externally cued; and importantly, the
increased consumption does not reflect a deliberate choice to eat more,
and thus likely does not reflect a stable preference to eat more.
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2.3. Unhealthy Eating as Nonautonomous Behavior
These three accounts of unhealthy eating—unhealthy eating as
uninformed behavior, nonvoluntary behavior, and environmentally-cued
behavior—together paint a picture of significant amounts of unhealthy
eating as nonautonomous behavior9— that is, behavior that the individual
does not make a fully informed, voluntary, and deliberate choice to
engage in.10 Certain kinds of unhealthy eating are especially likely to be
nonautonomous, such as eating more food because it comes in a large
container, or drinking more soda because it comes in a large bottle.
If specific kinds of unhealthy eating are likely to be nonautonomous
behavior, then it is easier to ethically justify policies meant to limit that
unhealthy eating; or so one might think. What’s objectionable about
paternalism, on some accounts, is that it interferes with the individual’s
informed and voluntary choice, but preventing someone from engaging
in nonautonomous behavior is an acceptable form of paternalism. Thus
limiting access to unhealthy food is an ethically acceptable form of choice
limitation, according to this reasoning, in circumstances where unhealthy
eating is nonautonomous behavior.
Opponents of choice-limiting policies could argue, in reply, that
unhealthy eating is more often autonomous than not. A familiar version
of this argument is that unhealthy foods are cheap, convenient, and taste
good, and thus eating these foods is the rational choice for many people
even if it worsens their health (Finkelstein and Zuckerman 2008). Eric
Finkelstein and Laurie Zuckerman (2008, 82–91), for example, argue
that people overconsume unhealthy food because it is a relatively cheap
source of utility or pleasure, and that people who overconsume and
become overweight are typically making informed choices that maximize
their utility. They argue that these choices maximize people’s utility in
the short-run when they’re eating the delicious food, but also maximize
people’s long-term utility even though the choices increase the risk of
diet-related illness, in part because advances in medical treatments for
diet-related illness have lowered the costs of diet-related illness. Given
the existing costs and benefits of healthy eating, unhealthy eating, and
poor health—costs and benefits that people typically understand—many
people experience more utility from overconsuming than they would from
not overconsuming unhealthy food, Finkelstein and Zuckerman argue.
Notice that, as we’ve laid out this debate, both some proponents and
some opponents of policies limiting food options take for granted that food
behavior is sometimes autonomous (informed, voluntary, and deliberate)
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and sometimes less than fully autonomous, and whether or not unhealthy
eating is an exercise of autonomous choice is ethically important. We
suggest that this way of theorizing food behavior is incomplete. Also
ethically relevant in this context is whether the eating—and its type and
amount—are part of a valuable food experience. Thus the ethics of limiting
food options does not depend solely on whether or not unhealthy eating
is autonomous choice.
3. NONAUTONOMY AND THE VALUE OF FOOD EXPERIENCES
We consider it indisputable that some unhealthy eating is not an informed
choice, a voluntary choice or a deliberate choice. It is helpful to point this
out, and to identify the multiple ways in which the food environment
subverts informed and deliberate choice. Against the background of
our current food environments, exerting vigilant control over our food
behavior might be necessary in order to eat healthfully. But we should
not assume that what makes food experiences valuable or inviolable is
that they are informed, voluntary, or deliberate. While we place value on
being able to make our own choices about food, autonomous choice is not
a proxy for much of what is valuable when it comes to food experience.
Food experience has a dual nature. Food experience, as already
discussed, can be behavior driven both by our neurophysiology and bodily
appetites, and also by environmental cues that may get us to eat when
we are not hungry and do not find significant meaning in the eating (or
additional eating). But in addition, food experience can sometimes be part
of a deeply meaningful and valuable psychological or social experience.
On the one hand, we can be powerfully motivated to engage in some
food behaviors even though they have no meaning or value for us, do
not reflect our stable preferences, are contrary to our goals for our lives,
and are harmful. These considerations are what make it valuable, in some
contexts, to exert vigilant—and arguably sometimes external—control over
what we eat. On the other hand, food experience can be saturated with
meaning and value (Resnik 2010).11 Food provides sustenance, hedonic
pleasure, aesthetic pleasure, and comfort to individuals. Sharing food is
a way to express love, forge relationships, and reinforce bonds. Specific
foods or food traditions have cultural and religious significance, and a
special place in family and community life (Anderson 2005, chaps. 8 and
0; Srinivas 2006; Counihan and Van Esterik 2013; Guptill, Copelton, and
Lucal 2013, chap. 2). What we eat expresses our personal and group
identities (Weiner 1996; Rozin and Siegal 2003; Guptill, Copelton, and
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Lucal 2013, chap. 2; Wilk 2013). Last but not least, food can be a source
of good health, something that virtually everyone values.
In these ways and others, food experiences have social meaning and have
value for individuals and groups. And, importantly, food experiences are
sometimes meaningful and valuable in these ways regardless of whether
individuals make an autonomous choice to participate in them and,
importantly, even when they do not make an autonomous choice. Indeed,
sometimes the fact that we nonautonomously engage in food experiences
might be central to their value. In some cases, that food experience is
habitualized and ritualized, and not a deliberate individual choice, is part
of what makes it a source of comfort for individuals and a powerful glue
for our social lives.
In the next subsection, we discuss the ways in which unhealthy eating is
part of valuable food experiences, and argue that food experiences can be
unhealthy and still valuable, independent of the extent to which engaging
in them is an autonomous choice.
3.1. Valuable and Unhealthy Food Experiences
As a paradigm case of a valuable food experience that involves unhealthy
eating, consider this hypothetical example:
Every Sunday after church, a family attends the weekly potluck supper,
at which a variety of unhealthy but delicious foods is always served. The
parents know the supper is unhealthy and they would like their family to
eat more healthfully, but they attend the church supper because they’re not
willing to miss out on seeing their friends, staying up to date on what’s
happening in the church, and making sure their children feel like part of
the church community. Also, attending the church supper was important
to them growing up and is a tradition that they value and would like to
pass on to their children.
The parents choose to attend the church supper, despite knowing it
is unhealthy, because for them it is a meaningful experience that has
multiple kinds of value: it’s enjoyable, it reinforces social bonds, and it’s
a meaningful tradition that they are transmitting to their children. Other,
similar examples are:
•   Having a family night out at the movies, and eating popcorn, soda, or 
candy;
•   Taking  your  grandchild  out  for  ice  cream  every  Friday,  as  your
grandmother did with you;
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•   Celebrating a child’s birthday by bringing her favorite kind of cupcake 
to school, as you do every year.
In all of these cases, unhealthy eating is part of a valuable social
experience. In some cases, it is tradition—a way to connect with the past,
to reinforce a family identity, and to pass this on to the next generation.
In all of these cases, the unhealthy eating is also a culturally resonant
part of the social experience—that is, an eating practice that is culturally
recognized as an appropriate and valuable part of that social experience.
Cupcakes are the way to celebrate a child’s birthday; popcorn, soda, and
candy make the movie night even more fun; and going out for ice cream
is a way to show love for a child by giving her a special treat.
Food is used to mark special occasions in culturally distinctive, and
socially and personally valuable, ways. Often unhealthy foods are used
to mark special occasions—birthday cupcakes, but also wedding cake,
Halloween candy, and Valentine’s chocolates. Consuming unhealthy foods
on special occasions would not be a health concern were they isolated
events, but these “special occasions” are increasingly commonplace. For
example, including birthdays, holidays, bake sales, and so on, a child might
have “special occasions” at school as frequently as once a week, if not
more. Although having one cupcake each week is not a health concern by
itself, most children are also consuming foods high in sugar at breakfast,
lunch, and snack time, an unhealthy pattern that is arguably reinforced
by the special treats at school and that, of course, makes the special treats
by definition less special.
Along with “special occasion” food experiences, everyday food
experiences also can have meaning and value, and often they, too, involve
unhealthy foods. Everyday food experiences can be comforting rituals.
Sharing food is a foundational experience in virtually all kinds of human
relationships and social groups, including families, groups of friends, and
communities, and often the food is unhealthy. Preparing food for someone
is a way of expressing love. Shared food experiences create and reinforce
social bonds. Ethnic groups, societies, and sub-cultures within societies
often have distinctive patterns of eating, and foods that are assigned special
significance (Anderson 2005; Counihan and Van Esterik 2013). Everyday
food behavior can express affiliation, group membership and cultural
identity (Anderson 2005; Rozin and Siegal 2003; Guptill, Copelton, and
Lucal 2013, chap. 2). Religions prescribe patterns of eating, including
special foods as part of rituals, special foods on holidays, periodic fasting
and abstinence, as well as standing prohibitions of certain foods.
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It’s not just traditional or culturally distinctive food practices that have
meaning and value. As new foods and food practices are introduced to a
society—for example, new products, new restaurants, and new cuisines—
they can take on certain meanings, come to fill social roles, and become
valuable for individuals and groups.
3.2. Valuable Unhealthy Eating That Is Deliberate and Informed
In short, even when we know that the food consumed during a food
experience is unhealthy, we still might consider the experience as a whole
to have value, and make a deliberate and informed choice to engage in it.
Just as a family chooses to participate in the church supper every Sunday,
despite knowing it’s unhealthy, so too individuals might make an informed
and deliberate choice to participate in countless other unhealthy eating
practices on a daily basis, in part because they value the larger experience of
which it is a part. In addition, even when unhealthy eating is substantially
nonautonomous, it can still be valuable and thus there might be ethical
reasons why policymakers ought not interfere with it, or at least be mindful
of this value when debating which public health interventions are best.
3.3. Valuable Unhealthy Eating That Is Not Deliberate or
Fully Informed
Unhealthy eating is not always a robust exercise of informed, deliberate
choice. However, this nonautonomous unhealthy eating can still have
value; and this is where the ethics of limiting food choice becomes complex.
There are multiple ways in which eating can be less than fully informed,
voluntary, and deliberate, while still being valuable:
•   You unquestioningly participate in a ritual or tradition involving food. 
For example, you make oatmeal cookies with your children, using the old
family recipe, without considering how healthful they are even though
you would like to eat more healthfully.
•   You nd an unhealthy eating practice to be valuable, and purposefully 
ignore the fact that it is unhealthy. For example, you know on some level
that the church supper is unhealthy, but you push this out of your mind.
•   You participate in an unhealthy  eating practice, and this  participation 
has multiple kinds of value for you, but you do not recognize or assess
its value to you. For example, you have lunch with your coworkers twice
a week, and everyone is expected to order a decadent dessert to share
with the group. You participate in this lunch ritual, even though you are
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trying to reduce your sugar intake for health reasons. Participating in
this lunch ritual strengthens your relationships with your coworkers, is
a comforting break from a stressful work routine, and is pleasurable. But
you do not explicitly assess the value of participating in a lunch ritual
that reinforces social bonds, is comforting, and is pleasurable; you don’t
really think about it this way, it just feels good to participate. So while it
seems accurate to say that you experience the value of having lunch and
dessert with your coworkers, it does not seem quite accurate to say that
you make an informed and deliberate choice to experience this valuable
experience rather than to experience the value of eating more healthfully.
•   Individual  instances  of  consumption  of  an  unhealthy  food  could  be 
nonautonomously motivated, while the overall practice has meaning and
value for you. For example, you mindlessly devour the potato pancakes
(latkes) that your mother brings, by the dozens, to your family’s Hanukah
celebration. However, the tradition of having your mother make potato
latkes and bring them to share is a practice that has meaning and value for
you, and it has meaning and value for you to participate in this tradition
by eating her latkes.
•   A  more  complicated  kind  of  case  is  when  your  consumption  of  an 
unhealthy food is nonautonomously motivated and has disvalue for
you, but is a side-effect of a social practice that has value. For example,
you eat your kids’ leftover Halloween candy, which you’d rather not do,
simply because you have trouble stopping yourself. Eating the leftover
candy is nonautonomous behavior and has disvalue for you, but is an
environmentally cued side-effect of having your kids go trick-or-treating,
which is a practice that you find meaningful and valuable.
•   Your participation  in unhealthy eating is deliberate and informed,  and 
thus is autonomous; but it’s also halfhearted and performed with some
ambivalence and regret. For example, you want to celebrate your child’s
birthday at school, and recognize that bringing cupcakes is the socially
appropriate way to mark this occasion that all the children, including your
own, look forward to. Although you wish there was a healthier way to
celebrate, you don’t want to disappoint your child on her birthday. You
embrace the experience that involves unhealthy eating, without embracing
the unhealthy eating itself.
As these cases demonstrate, some types of meaningful and valuable
food behavior are not a robust exercise of an individual’s informed
and deliberate choice. Indeed, what seems valuable about some food
experiences is that they are the devoted enactment of tradition, or they
are comforting habits done without a second thought. In the words of
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philosopher Bernard Williams (taken out of context), weighing the pros
and cons of some food experiences seems to be “one thought too many”
(Williams 1981, chap. 1). The goods at stake in some food experiences
are goods that, perhaps, ought to preempt certain calculations. Or at
least, they are goods that are diminished by engaging in these calculations.
You make oatmeal cookies with your children, using the same recipe that
your mother made with you; that you unquestioningly follow tradition,
connecting the love you share with your mother with your children, may
be a large part of what makes baking the cookies valuable for you. This
is not to say that baking cookies involves no choice whatsoever: you
choose to bake these oatmeal cookies with your children, rather than,
say, making fruit salad. This choice might be based upon a recognition
of some of the ways in which it has value for you and them, but without
necessarily appreciating or taking into account other considerations that
also matter to you such as shaping your children’s eating preferences and
habits in healthful ways.
Offering these instances of valuable but less than fully informed and
deliberate eating is not meant to suggest that all such eating has value
(nor that all or even most valued eating is substantially uninformed or
nondeliberate). Some eating is both mindless and valueless. But some
valuable food experiences include consumption that is not itself a fully
informed or deliberate choice.
Michael Pollan has written about the value of traditional cuisines as
repositories of nutritional wisdom; he argues that nutrition science’s efforts
to nutritionally optimize our diets have been relatively unsuccessful, and
that we would be better off following a traditional diet (Pollan 2007).
Indeed, a compelling ideal for a food culture is one in which there are
no significant trade-offs between health and the social goods associated
with eating, health follows automatically from enacting pleasurable food
traditions, and healthful eating need not be a deliberate choice. In other
words, the ideal food culture might be one in which maintaining good
health, and experiencing the other personal and social goods associated
with eating, does not require the individual to exercise deliberate and
fully informed choice vis-à-vis food. We might even say: ideally, healthy
food behavior would be substantially nonautonomous—habitualized,
environmentally cued, nondeliberate behavior. That we must exercise
careful, deliberate choice vis-à-vis food in order to eat healthfully is a sign
that something has gone terribly wrong.
Thus, autonomous choice—understood as informed, voluntary, and
deliberate choice—is not a comprehensive ideal for food behavior. While
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we do place value on being able to make our own choices about food,
informed and deliberate choice is not a proxy for much of what is valuable
when it comes to food experience. This observation complicates efforts
to defend food policies by arguing that unhealthy eating is not informed
choice, or is addictive or automatic behavior not fully under the individual’s
control. The ethical defense of such policies will need to be more complex,
accommodating the fact that some uninformed, nondeliberate food
behavior is nonetheless very valuable.
4. PATERNALISM AND THE VALUE(S) OF UNHEALTHY EATING
Our discussion of the value and disvalue of unhealthy eating has
been presented, thus far, as a supplement to an autonomy-framed
discussion of paternalistic policies. But the two framings are in some ways
complementary, and our discussion can usefully inform an autonomy-
framed discussion and other ethical debates about paternalistic policies.
Though a primary ethical concern with paternalistic policies is that they
violate individual autonomy, two additional ethical concerns are that
they typically backfire and fail to promote individuals’ welfare, and they
impose one set of values or one conception of well-being upon everyone
(i.e., a conception of well-being according to which health has paramount
value) (Dworkin 2010; Noe 2013).
In order to understand how policies limiting unhealthy food options
could fall prey to these three objections, we need to understand the ways
in which having unhealthy options has value for people. How is it valuable
to have unhealthy options, such that paternalistically limiting these options
might not promote an individual’s welfare, all things considered? How
does unhealthy eating express individuals’ and groups’ values, such that
limiting unhealthy options is imposing values upon people that they don’t
share? Similarly, in order to understand how policies limiting unhealthy
food options could evade these objections, we need to understand the
ways in which having unhealthy options has disvalue for people. How
does having unhealthy options make it harder for people to have valuable
experiences, thus diminishing their welfare? How does having unhealthy
options make it harder for people to live in ways consistent with their
own values (for example, living a long and healthy life, which most people
value)? And perhaps most importantly, in what ways do having valuable
experiences and living a life that’s consistent with one’s own values not
require having unhealthy options?
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Thus, our discussion of the value and disvalue of unhealthy eating
can provide substance to the ongoing debate about whether policies
limiting food options are objectionably paternalistic. However, as we’ve
argued, our discussion is also a necessary supplement to an autonomy-
focused discussion of paternalism. As discussed in the previous section,
eating can have value even when it is not fully informed, voluntary, and
deliberate; thus, while interfering with uninformed, nonvoluntary, and
environmentally cued eating will indeed sometimes be both appropriate
and ethically straightforward, it should not be assumed to always be
ethically unproblematic. Conversely, interfering with deliberate, informed
food choice is not always problematic; not every autonomous food choice
we make has significant value (Powers, Faden, and Saghai 2012). To chart
the way forward with healthy eating policy, we need to theorize not only
nonautonomous vs. autonomous choice but also the value and disvalue
of eating. This is not to say that the language of autonomy, choice, and
informed choice should disappear from the conversation. What we’re
suggesting, rather, is that discussing the value and disvalue of eating should
also have important and independent consideration, and that it gives us
a way to capture what we believe is at stake when others have discussed
the importance—in some contexts—about making autonomous choices.
In contexts where unhealthy food options may be worthy of protection,
this is so not primarily because individuals typically make informed and
deliberate choices to eat these foods, or because “choice” should itself
be preserved blanketly, but rather because individuals have valuable
experiences eating these foods and limiting their access would prevent
these valuable experiences. What makes some unhealthy food options
appropriate targets of restriction is not primarily because these foods
are typically consumed in a nondeliberate, environmentally cued, and
uninformed way. Rather, what makes some food options appropriate
targets of restriction is that having these food options is not a source of
value, or of sufficient value, to people, and that having these food options
undermines the achievement of something they do value, namely health.
Of course, there are complications here. Food experiences may be
sources of value and disvalue. For example, a parent may experience a
value conflict around taking cupcakes to school to celebrate his child’s
birthday. He may value his child’s health and consider it to have significant
disvalue that she regularly eats cupcakes at school, while also valuing the
pleasure and joy that birthday celebrations provide, and the way they
make children feel special on their birthdays. A potential way out of this
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value conflict is to try to change the way that birthdays are celebrated
at school: replace the cupcakes with another experience that is fun and
pleasurable, and makes the birthday child feel special, while also being
healthier. For example, the birthday child gets balloons and the child
gets to choose a game to be played by everyone during the time that
would have been devoted to eating cupcakes. The valuable experience
that involves unhealthy eating is transformed into a healthier experience
without compromising the values at stake.
As another example of a food experience that involves a conflict of
values, someone might eat a “Value Meal” lunch regularly at McDonald’s
because it is cheap and filling, and she’s on a tight budget, even though it
is unhealthy for her and she would like to eat more healthfully. She values
her health but she also values saving money. A policy that taxed unhealthy
options at McDonald’s and subsidized healthier options would resolve
her conflict of values, and would be better in all respects, as far as she is
concerned. This policy does not fail to respect her values, or impose values
on her; on the contrary, it helps her to achieve what she values.
Notice that our analysis of these cases requires that we go beyond
theorizing unhealthy eating as informed and deliberate choice vs.
uninformed or nondeliberate “mindless” eating. The choice to eat
McDonald’s food because it is cheap and convenient, though unhealthy,
could well be a voluntary, deliberate, informed, and even rational choice.
Similarly, the choice to bring cupcakes to school for your child’s birthday,
even though it’s unhealthy and you value your child eating more healthfully,
could well be an informed and deliberate choice. If we theorize unhealthy
eating as informed and deliberate choice vs. uninformed and nondeliberate
behavior, on the presumption that the latter is a less problematic target for
intervention, then these choices will register either as inappropriate targets
for policy intervention or as targets that require a major showing of public
health benefit to justify the moral cost of interfering with autonomous
choice. But if we theorize unhealthy eating in terms of the extent to which
the eating has value and disvalue, we can more readily see where conflicts
of value are likely to arise, thus allowing for policies to be structured that
are more likely to be effective because they avoid or reduce such conflicts.
While it is sometimes possible, it will not always be possible to transform
an unhealthy experience into a healthier one without compromising the
values at stake. In some cases, the unhealthy food itself is valued, and
the valuable experience cannot be disjoined from the unhealthy food.
Unhealthy foods might provide a kind of hedonic pleasure that healthier
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foods will never provide for some people (though of course there are
many healthy foods that are delicious). Some people eat at McDonald’s
because the taste of the fried and salty foods is intensely pleasurable for
them, not just because the food is cheap. Some people cook with butter
instead of more healthful fats because of the flavor only butter can
impart. In addition, specific unhealthy foods may be irreplaceable parts
of traditions and important religious and cultural practices. We might not
be able to replace Grandma’s cookie recipe with fresh fruit, or replace
Dad’s Hanukah potato latkes with grilled vegetables without some loss of
meaning and value. Some unhealthy experiences cannot be made healthier
without damage to the values at stake. In some cases, unhealthy food
experiences occur so infrequently that they do not pose health concerns,
such as Hanukah latkes or a large Thanksgiving dinner with pies and other
unhealthy foods. But in other cases, unhealthy eating occurs frequently
enough that it can negatively impact health; for example, drinking soda
every day or having cupcakes at school twice a week.
Our view is that, in some such cases of ineliminable trade-offs between
health and other values, promoting health at the expense of other values
can be legitimate. But it depends upon the values at stake. Food experiences
have diverse kinds of value. Some experiences have value that is appreciated
in the moment, such as hedonic pleasure. Other experiences have value that
can be appreciated “on reflection” even when we are not in the middle of
the experiences, such as the value of religious and cultural expression, or
even the mindful decision to try new types of cheeses, pastries, or other
local delicacies while traveling.
While it seems intuitively correct, to us, that certain kinds of valuable
experience ought to be ethically privileged over others—for example,
experiencing family traditions ought to be privileged over experiencing the
hedonic pleasure that comes with high-sodium packaged food—we will not
argue for this conclusion here, and we recognize that people hold a range
of views about the relative importance of different valuable experiences.
The trade-offs between values that it is legitimate for government
policies to impose upon people are, of course, an ethically complex and
fraught issue. May the government implement policies that reduce hedonic
pleasure or convenience, or prevent people from engaging in socially or
culturally valuable experiences, for the sake of improving health? How
much pleasure or convenience, and for what certainty of improved health?
What kind of social and cultural value, and for what certainty of improved
health? What is needed to answer these questions—but is beyond the
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scope of this paper—is a robust account of how and when government
is permitted or obligated to interfere with valued experiences in order to
promote healthier eating, and how the ethics of this interference depends
upon the specific values in question. We don’t develop such an account
here, though we will venture some claims and examples that signal the
kind of view that seems correct to us.12
It can be legitimate for policies to impose trade-offs between health and
other values. In particular, it can be legitimate for policies to reduce the
hedonic pleasure people experience in the short run in order to promote
their long-term health. Part of the reason is that preferences and the
experience of hedonic pleasure are shaped by the environment and by
experience, including by market forces that aim not only to change tastes
or values per se but to increase revenue. To reject any modification of
the foods people currently enjoy, simply because they enjoy them, creates
a vicious cycle in which the development of healthier preferences—so
that people may have experiences that are pleasurable and healthier—is
precluded. It allows for no opportunity to modify environments and allow
people’s preferences to adapt so that they enjoy foods that are healthier.
In addition, the government may have ethical reasons to privilege some
values over others. For example, the government may be ethically entitled
to privilege cultural and religious expression in a way that it does not
privilege the experience of short-term hedonic pleasure, either because
these are values that citizens themselves privilege (or would privilege
upon reflection), or because the government has a particular obligation
to respect religion and culture.
Crucially, in our opinion, the set of food experiences most worthy of
privilege or deference by the state should not be populated only or even
primarily by those experiences that individuals make an informed and
deliberate choice to engage in. There are many food experiences that
people value deeply that are nevertheless engaged in nondeliberately
and without full information. Conversely, some food experiences that
are not “mindless,” but rather are engaged in deliberately and with
full information, nevertheless do not have the kind of value warranting
deference.
While it is ethically relevant whether eating is “mindless,” so too is
it ethically relevant how the eating adds value to the lives of individuals
and groups. Also relevant is the public health burden of the eating in
question; kinds of consumption that are infrequent will not be justifiable
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targets of intervention, simply because they do not pose a significant risk
to public health. The lowest hanging fruit, as it were, is the “mindless”
eating that also has little value to the eater, and is prevalent enough to
place a significant public health burden; this should be the priority for
healthy eating policy. The next priority is the “mindless” eating that does
offer value to the eater, but a kind of value that the state may subordinate
to health.
5. IMPLICATIONS FOR POLICYMAKERS
Our discussion of the varying value and disvalue of unhealthy eating
has several implications for policymakers designing healthy eating policies.
First, the accumulating evidence that some unhealthy eating is uninformed,
environmentally cued, “mindless” behavior does not in and of itself
give the government blanket license to interfere with unhealthy eating.
Policies interfering with unhealthy eating may prevent people from having
experiences that are important to them in ways that matter morally, and
understanding which unhealthy food behaviors do and do not matter to
people will be an important piece of the policy process.
At the same time, recognizing that unhealthy eating can sometimes be
valuable to people does not mean that unhealthy eating always or even
typically has significant value. Nor does it mean that when unhealthy eating
is valuable, policymakers must leave it be. Our discussion here should not
be taken as a blanket condemnation of policies targeting unhealthy eating;
on the contrary, we support many such policies. Engaging with what people
find valuable about food experiences is not intended to undermine public
health policymaking around healthy eating but rather to strengthen it by
helping us design interventions and set priorities within public health that
are likely to be more fully ethically preferable.
First, some policies that limit food options do not impinge on valuable
food experiences. For example, one might argue that a ban on trans fat
in restaurant food does not impinge on the valuable aspects of affected
food experiences, insofar as trans fat can be eliminated from foods
without changing consumers experience of these foods. Food experiences
that are neither healthy nor highly valued will be priority candidates for
intervention (and food experiences that are furthermore not fully informed
or not deliberately chosen will be the best candidates).
Second, some valuable experiences that currently include unhealthy
eating could be modified to include healthier foods, or could be modified
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to center around practices that do not involve food, without compromising
the values at stake. Indeed, it is our view that one aim of healthy eating
policies should be to facilitate this process—to help change norms and
practices, so that unhealthy eating is a less central part of valuable
experiences while still ensuring that those experiences retain their value.
An example would be a policy that aims to incrementally change how
children’s birthdays are celebrated at school, gradually replacing food
as the means of celebration with symbols of joy such as balloons or
ceremonies to celebrate the individual child. Another would be to have
group cooking sessions preparing healthier options such as baked, rather
than fried, chicken for the church supper. If policies are to target the norms
and practices that encourage unhealthy eating, then they should not steer
clear of all valuable experiences involving unhealthy eating—precisely
the opposite. Such policies should understand and engage with the ways
in which unhealthy eating is part of valuable experiences and, in at least
some cases, attempt to make the experiences healthier while preserving
and respecting the value of the experience itself.
Third, as discussed above, it will not always be possible to make
unhealthy food experiences healthier without sacrificing some of their
value. In these cases, what kind of policy intervention is appropriate,
if any, depends upon the values at stake. For example, we believe it is
acceptable for the state to forbid public schools from selling sodas and
other nutritionally void, sugar sweetened beverages to schoolchildren,
not only as part of their lunches, but “anyplace, anytime” (Kass et al.
2014),13 despite the value that children place on the pleasurable taste of
such drinks. Similarly, the fact that children and young people find eating
candy to be distinctively pleasurable, and thus valuable, does not mean
that on balance it is morally wrong to ban candy from vending machines
in schools and dormitories.
A more complicated case is when some people view unhealthy food
as an ineliminable part of a meaningful social practice or tradition. For
example, some people object to policies banning cupcakes from birthday
celebrations at school for just this reason (Holland 2014; Skinner 2014);
to take out the cupcake is to make the birthday celebration not only less
delicious but less fun. There is more at stake, with the school-celebration
cupcake ban, than the experience of hedonic pleasure. The policy would
require modification of a social experience in ways that some people feel
would diminish its value as a social experience. At the same time, however,
a vital case can be made that much of what is valuable about making a
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child feel special on her birthday can still be preserved even if cupcakes
are no longer included. Moreover, we consider the policy to involve a
justifiable trade-off between whatever social value is lost, on the one hand,
and health, which is significantly valued in the long run, on the other hand.
But if an unhealthy food experience has certain, important kinds
of cultural or religious significance, then it might be disrespectful and
inappropriate for the state to attempt to influence or alter that practice.
For example, it might be inappropriate for the state to encourage houses of
worship to change the foods they serve, depending on the kind of meaning
and value these foods have.
When considering policies that limit unhealthy food options,
policymakers should ask at least four questions. First, is the food option
consumed frequently enough that it poses a substantial public health
burden, and are there evidence based interventions available that could be
effective at changing the consumption (Childress et al. 2002; Kass 2001)?
Second, what are the valuable food experiences that include the unhealthy
option? Third, is the food itself essential to these valuable experiences, or
can the valuable experiences be modified so that they do not include the
unhealthy food, or so that the unhealthy food could be prepared in a more
healthful way? Fourth, what kind of value is at stake? For example, is the
food experience pleasurable? Is it convenient? Is it a social experience that
brings a group together? Is it a form of cultural or religious expression?
Is it an experience that, “on reflection,” has important meaning to the
person experiencing it?
Not all healthy eating policy is on a par, morally, because not all
unhealthy eating is equally valuable for individuals and groups. Our
discussion of the value and disvalue of unhealthy eating helps us identify
opportunities for reducing unhealthy eating that has little or no positive
value. Targeting this kind of unhealthy eating should be the priority for
healthy eating policy. Our discussion also illuminates trade-offs between
health and other values. It helps us identify opportunities for eliminating
these trade-offs, and helps us think through which trade-offs are acceptable
and which are unacceptable. Moreover, it bolsters the case for policies
that make acceptable trade-offs: clarifying the significant value of some
unhealthy eating bolsters the case for policies targeting unhealthy eating
that is not valuable. If we value health and we value unhealthy eating that
is very pleasurable, traditional, or has religious and cultural significance,
then it’s all the more important to target and reduce the habitual and often
mindless unhealthy eating that is not valuable in these ways. Thus, on our
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analysis, there is good news for public health. Once we start thinking about
which food experiences are valuable and which are not valuable, we can
identify a space of unhealthy eating that is not valuable, or that could be
made healthier without losing its value, and which is thus the best target
for intervention. Our analysis directs our attention to this “low-hanging
fruit” and bolsters the case for action.
ACKNOWLEDGEMENTS
We would like to acknowledge the Levi Leadership Program for their support for this
research. This paper emerged out of the Levi Leadership Symposium, “Toward Develop-
ing an Ethical Framework for Policy Options in Healthy Eating and Obesity Prevention
in the United States” held at Johns Hopkins Berman Institute of Bioethics of November
28–29, 2012. We would like to thank Symposium participants for their contributions to
the symposium, which were the inspiration for this paper.
NOTES
1. These criticisms are also made by interest groups. See, for example, a series
of advertisements by the Center for Consumer Freedom, including http://
www.consumerfreedom.com/wp-content/uploads/2012/06/Bloomberg-
nanny_final_outlines.pdf and http://www.consumerfreedom.com/2011/12/
you-are-too-stupid/. For a discussion of paternalism and public health, though
not an endorsement of the view that choice-limiting public health policies
are unduly paternalistic, see (Bayer and Moreno 1986; Powers, Faden, and
Saghai 2012; Nys 2008; Gostin 2013).
2. There are a number of interrelated ethical concerns with food policies that fall
under the broad umbrella of ethical concerns with paternalism. One concern
is that limiting food options to improve health is an objectionable limitation
of personal liberty or autonomy (Resnik 2010). A second concern is that
limiting people’s food options is nannying or infantilizing—it treats adults as
if they were still children, incapable of making decisions for themselves (see
Gostin 2013 for a discussion of this concern, though not endorsement of it).
A third concern is that in limiting food options in order to improve health,
policymakers are imposing one set of values on everyone. That is, they are
imposing on everyone a hierarchy of values that privileges health over other
goods and pleasures that come from unhealthy eating (Noe 2013).
3. For a helpful overview of different conceptions of paternalism, see Dworkin
2010. For a classic take on paternalism, see Dworkin (1972). Some recent
works including discussion of how, exactly, paternalism ought to be defined
include Nys (2008), Conly (2013a), and Sunstein (2013). Sunstein and Thaler
(2006) and Sunstein (2013) understand paternalism more broadly than we do
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here: paternalistic policies are those that attempt to change people’s choices
in ways that will make them better off, even if this influence doesn’t interfere
with or override choices (see pp. 1853–1854 of Sunstein 2013).
4. For a classic defense of the view that paternalistic interference with voluntary
behavior is wrong, see Feinberg 1986. For a vigorous defense of extensive
paternalism in cases of irrational action, see Conly (2013b).
5. Powers, Faden, and Saghai (2012) defend a complex and nuanced Millian
framework for public health ethics that rejects the view that all liberties and
choices enjoy an equal presumption in their favor. They argue that what is
of focal importance for Mill in protecting liberty is captured by the essential
role that the value of self-determination plays in human well-being, a position
that is in interesting respects congenial to what we argue here.
6. Ziaudden and Fletcher (2013) argue that the concept of food addiction has
some theoretical problems and is under-supported by the existing evidence.
Rather than food addiction, they argue, it might be more helpful to talk about
a continuum of consumption behavior, from food use to food abuse/misuse
to addiction. Food abuse/misuse would be harmful use that is maladaptive
but doesn’t meet the criteria for addiction. The concept of food addiction has
been used to justify policies, but should not, at this time, guide policymaking,
they assert.
7. This depends, of course, on exactly how we understand intention, control
and choice.
8. Berridge writes: “‘Wanting’ is a shorthand term my colleagues and I use
for the psychological process of incentive salience. Incentive salience is at-
tributed to rewards and their predictive cues, which helps determine their
motivational value. Those cues then become potent triggers of ‘wanting’. In
this way, cravings can be triggered by simply imagining the sight, smell and
taste of palatable foods. . . . According to the incentive salience concept,
‘wanting’ is a mesolimbic generated process that can tag certain stimulus
representations in the brain that have Pavlovian associations with reward.
When incentive salience is attributed to a reward stimulus representation, it
makes that stimulus attractive, attention grabbing, and that stimulus and its
associated reward suddenly become enhanced motivational targets” (2009,
2).
9. An additional layer of this story, as it is sometimes told, is that the food
industry intentionally puts us in this position. The food industry formulates
unhealthy food products to be in some sense irresistible and intentionally
misleads consumers about the nutritional value of foods. In addition, the food
industry engages in aggressive marketing that establishes unhealthy food as
kennedy institute of ethics journal • september 2014
[ 212 ]
desirable and socially normative (Schwartz and Brownell 2007; Nestle and
Ludwig 2010; Moss 2013).
10. There are diverse theories about what counts as an autonomous choice: a
voluntary choice; a rational choice; an informed and rational choice; a choice
that one would endorse, if one had fully information and were perfectly ratio-
nal; a choice that one judges to be coherent with one’s values and long-term
goals; an authentic choice; and so on. For our purposes here, let’s understand
an autonomous choice as an informed choice (one is basically informed about
the important consequences of the choice), and a voluntary (as opposed to a
poorly psychologically controlled choice or a coerced choice) and deliberate
choice. A nonautonomous choice is one that is uninformed, nonvoluntary,
or nondeliberate; though autonomous choice and nonautonomous choice
come in degrees. We define nonautonomous choice in this way—uninformed,
nonvoluntary, or nondeliberate—for the purposes of this paper because these
are features of choice that the empirical evidence described above suggests
some unhealthy eating lacks. We do not mean to imply that this is the ethi-
cally central notion of autonomous choice; we are simply working with this
definition of autonomous choice because it captures features of choice that
are empirically studied and are cited by proponents of healthy eating poli-
cies. Another dimension of choice that we do not examine in this paper, but
which is also empirically studied and cited by proponents of healthy eating
policies, is the rationality of choice. Behavioral economics has identified a
range of cognitive biases that impact judgment and choice, rendering them
systematically irrational; these failures of rationality justify paternalistic
action in certain circumstances, according to some theorists (Conly 2013a,
2013b; Sunstein 2013). For a classic discussion of how autonomous choice
ought to be defined for the purposes of theorizing paternalism, see Feinberg
(1986). See also Nys (2008) and Conly (2013a), especially the Introduction,
pp. 42–44, and pp. 176–79. For a discussion of the multiple notions of au-
tonomy at play in ethical discourse, see Arpaly (2003, 117–48).
11. David Resnik identifies multiple ways in which “food has a significant impact
on one’s quality of life”: eating, preparing and serving food is pleasurable;
food has ethnic, cultural and religious significance; food plays an important
role in family traditions and customs. Resnik concludes: “Thus, the freedom
to decide what one eats is an important freedom that should not be restricted
unnecessarily” (2010, 29).
12. One broader theoretical framework within which we could situate our
view is Faden and Powers’s account of social justice and the role of self-
determination. According to Powers and Faden (2006) and Powers, Faden,
Barnhill, King, Kass, & Faden • the ethics oF healthy eating Policies
[ 213 ]
and Saghai (2012), not all liberties and choices are on a par morally, and do
not enjoy an equal presumption in their favor, because these liberties and
choices are differentially important in securing self-determination which, as
a central component of human well-being, is a condition in which an indi-
vidual shapes the broad contours of a life and has some significant say over
its general course. Similarly, not all valuable experiences are on a par mor-
ally because they are differentially important in securing self-determination
and overall well-being. For example, the experience of eating salty packaged
food and the experience of eating latkes do not play an equivalent role in
self-determination and overall well-being.
13. As already required by the Healthy Hunger Free Kids Act of 2010 (see http://
www.fns.usda.gov/cnd/Governance/Legislation/CNR_2010.htm).
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In this article, we address the relevance of J.S. Mill's political philosophy for a framework of public health ethics. In contrast to some readings of Mill, we reject the view that in the formulation of public policies liberties of all kinds enjoy an equal presumption in their favor. We argue that Mill also rejects this view and discuss the distinction that Mill makes between three kinds of liberty interests: interests that are immune from state interference; interests that enjoy a presumption in favor of liberty; and interests that enjoy no such presumption. We argue that what is of focal importance for Mill in protecting liberty is captured by the essential role that the value of self-determination plays in human well-being. Finally, we make the case for the plausibility of a more complex and nuanced Millian framework for public health ethics that would modify how the balancing of some liberty and public health interests should proceed by taking the thumb off the liberty end of the scale. Mill's arguments and the legacy of liberalism support certain forms of state interference with marketplace liberties for the sake of public health objectives without any presumption in favor of liberty.
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I argue that it can be morally permissible to coerce people into doing what is good for their own health. I discuss recent initiatives in New York City that are designed to take away certain unhealthy options from local citizens, and argue that this does not impose on them in unjustifiable ways. Good paternalistic measures are designed to promote people's long-term goals, and to prevent them from making short-term decisions that interfere with reaching those, and New York's attempts to ban the sale of sugary drinks larger than 16 ounces and the use of trans fats fall within those parameters. Given our tendency to cognitive bias, we need help in making choices that truly instantiate our values.
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Obesity and overweight prevalence soared to unprecedented levels in the United States, with 1 in 3 adults and 1 in 6 children currently categorized as obese. Although many approaches have been taken to encourage individual behavior change, policies increasingly attempt to modify environments to have a more positive influence on individuals' food and drink choices. Several policy proposals target sugar-sweetened beverages (SSBs), consumption of which has become the largest contributor to Americans' caloric intake. Yet proposals have been criticized for unduly inhibiting choice, being overly paternalistic, and stigmatizing low-income populations. We explored the ethical acceptability of 3 approaches to reduce SSB consumption: restricting sale of SSBs in public schools, levying significant taxes on SSBs, and prohibiting the use of Supplemental Nutrition and Assistance Program (formerly food stamps) benefits for SSB purchases. (Am J Public Health. Published online ahead of print March 13, 2014: e1-e9. doi:10.2105/AJPH.2013.301708).
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Since Mill’s seminal work On Liberty, philosophers and political theorists have accepted that we should respect the decisions of individual agents when those decisions affect no one other than themselves. Indeed, to respect autonomy is often understood to be the chief way to bear witness to the intrinsic value of persons. In this book, Sarah Conly rejects the idea of autonomy as inviolable. Drawing on sources from behavioral economics and social psychology, she argues that we are so often irrational in making our decisions that our autonomous choices often undercut the achievement of our own goals. Thus in many cases, it would advance our goals more effectively if government were to prevent us from acting in accordance with our decisions. Her argument challenges widely held views of moral agency, democratic values, and the public/private distinction, and will interest readers in ethics, political philosophy, political theory, and philosophy of law.