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The Increasing Weight of Regulation: The Role(s) of Law as a Public Health Tool in the Prevention State

Applicant Levy Mélanie
Number 181125
Funding scheme Eccellenza fellowship
Research institution Institut de droit de la santé Faculté de droit Université de Neuchâtel
Institution of higher education University of Neuchatel - NE
Main discipline Legal sciences
Start/End 01.09.2020 - 31.08.2025
Approved amount 1'893'991.00
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Keywords (14)

Nudging; Public health law; Regulatory state; Public-private-partnership; Health promotion; Responsibility for health outcomes; Legal theory; Constitutional law; Social contract; Regulation; Prevention; Health incentives; Individual liberty; Health insurance

Lay Summary (French)

Lead
Le(s) rôle(s) du droit en tant qu’outil de santé publique dans l’Etat de prévention («Prevention State»)La santé publique est au centre des préoccupations médicales et politiques actuelles. Les maladies chroniques dont les origines sont à chercher dans les comportements individuels ayant une incidence sur la santé comme la malnutrition, l’inactivité physique ou encore la consommation de cigarettes et d’alcool sont de plus en plus nombreuses. Ces maladies constituent aujourd’hui la principale cause de décès. Pour la première fois depuis des décennies, l’espérance de vie générale est en baisse dans les pays développés. Les maladies chroniques représentent également un défi économique important des points de vue individuel et sociétal et mettent en cause la solidarité sociale. Un mode de vie sain est ainsi considéré comme une voie prometteuse pour les pays développés afin de contenir l’augmentation exponentielle des coûts des soins de santé.
Lay summary

Le droit est un outil-clé pour protéger et promouvoir la santé publique. Au cours des dernières décennies, le droit de la santé publique a évolué pour passer du domaine de la lutte contre les épidémies et les maladies transmissibles à l’étude des pouvoirs et des devoirs de l’Etat pour assurer les conditions permettant aux individus d’être en bonne santé. Récemment, les législations et politiques publiques encourageant des comportements et modes de vie sains ont ainsi connu une popularité sans précédent (la taxe sur les boissons sucrées, par exemple).

Ce projet s’intéresse tout d’abord à la prévention étatique en matière de santé en tant que chapitre dans l’histoire de la gouvernementalité du corps humain. Il analysera ensuite la théorie juridique sous-jacente au droit et aux politiques de santé publique, avec un accent particulier sur la légitimité, la portée et les outils de l’intervention étatique en santé publique. L’objectif de ces recherches sera de tracer de manière critique l’évolution du contrat social de santé. Le projet examinera ainsi les limites des responsabilités de la collectivité et de l’individu, mais aussi des entreprises, en matière de santé et de maladie, surtout dans cette période actuelle obsédée par le suivi de la santé individuelle («Quantified Self») et supposant l’omniprésence de «l’Etat moralisateur». La balance entre intérêts collectifs et libertés individuelles est fascinante dans ce contexte, car la prévention suscite un désir de surveillance, de contrôle et de dépistage impliquant le domaine public et les individus en bonne santé. Au-delà de ces questions de principe de droit et de théorie politique, le projet se concentrera sur des outils juridiques innovants tels que les «nudges», les «social impact bonds», ainsi que sur les instruments incitatifs dans le contexte de l’assurance-maladie permettant à l’Etat de promouvoir des comportements et modes de vie sains.

L’analyse de ces défis d’une actualité brûlante revêt une importance non seulement en tant que recherche juridique fondamentale, mais également pour la pratique du droit et les politiques publiques en matière de santé. En évaluant de nouveaux outils permettant de promouvoir la santé publique et leurs implications juridiques, ce projet promet un impact pratique significatif.

Direct link to Lay Summary Last update: 19.07.2020

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Abstract

Background and rationale - The rise of the prevention state raises fascinating questions as to the role(s) of law as a public health tool. This project investigates the legal theory underlying public health law, with an emphasis on the propriety, scope, and tools of state intervention in health promotion and prevention. As such, it restates the somewhat ironic yet profound question raised by Justice Scalia in the historic "Obama care" ruling of the US Supreme Court: can the state force, or rather nudge you, to eat your broccoli?Individual behaviors affecting health outcomes such as malnutrition, physical inactivity, alcohol, and cigarette consumption constitute pressing public health challenges and thus preoccupy current law and policymakers. Poor nutritional choices, for example, lead to significant increases in obesity and overweight. For the first time in decades, general life expectancy in the developed world is declining. The increasing prevalence of non-communicable diseases (e.g., cancer, diabetes, cardiovascular diseases) linked to modern lifestyle places a heavy cost burden on Switzerland’s economic productivity and health care system.In parallel, public health law has evolved from a field concerned primarily with epidemic threats caused by infectious diseases to the study of the legal powers and duties of the state to assure the conditions for people to be healthy. Public health law responses to non-communicable diseases are necessarily different from the traditional regulatory tools designed to fight infectious diseases. Such responses deploy the law to manage individual behaviors and promote healthy choices. Legal mechanisms include, e.g., calorie-labeling mandates for restaurants; taxation of tobacco, alcohol, junk food ("fat tax"), and sweet beverages ("soda tax"); advertisement restrictions; and regulation of sugar content in soft drinks. These mechanisms encourage health-promoting choices, with a view to improve health outcomes and contain health care costs. However, such prevention tools raise challenging questions as to collective and individual responsibility for health and disease. They also imply an intriguing balance of collective interests and individual liberties.Overall objective and specific aims - The project’s objective is to critically analyze the opportunities and constraints of law as a public health tool to address the burden of non-communicable diseases. To meet this objective, the project strives to achieve the following aims:(1) To establish a taxonomy of public health governance instruments in the prevention state;(2) To pursue normative contemplation of the propriety and scope of state intervention to promote healthy behavior in a federal state structure such as in Switzerland;(3) To examine the traditional legal understanding of individual responsibility for health outcomes and evaluate the possibility of integrating a broader concept of social responsibility within a legal framework;(4) To theoretically describe and normatively assess innovative health-promoting legal tools such as nudges, public-private-partnerships, social impact bonds, and health insurance incentives;(5) To advance de lege ferenda proposals for future law reform seeking to improve the design and efficacy of federal and cantonal public health governance instruments.Research questions - To reach its objective and aims, the project will pursue the following working plan by addressing five research questions. While question (A) pursues principled issues of law and political theory, questions (B) to (E) pertain to the design and legal implications of innovative regulatory tools to promote healthy behavior. This working plan is crucial in terms of division of labor, synergies, and research output among the team members.(A) The delicate balance of collective interests in public health versus individual liberty(B) "Judge the nudge", or the choice (architecture) of regulatory instruments to promote public health(C) Overcoming the liberal tradition: a broadened concept of social responsibility for health outcomes(D) The risks and promises of public-private-partnerships in health promotion(E) Health incentives in illness insurance to promote public healthMethods - The legal theory underlying this project is a realist conception of law. The distinction between the descriptive "is" and the normative "ought" plays an important role in legal theory. According to Hume's law, scientific facts cannot serve (directly) as the basis for moral judgments or regulation. Yet being a study that bridges scientific evidence with public health law is one of the distinctive features of this project. Our critical legal analysis will involve both empirical data and normative evaluation. Through the project’s methods, we will make its descriptive and normative aspects explicit.To carry out this project successfully, we will deploy four methods, which will ensure that data collected is relevant, comprehensive, and soundly analyzed. The four methods will be systematically applied to all research questions.The first method is positivist. We will map existing public health initiatives within the Swiss legal framework whose goal is to influence health behavior. For that purpose, we will collect and analyze text-based federal and cantonal legal sources linked to three objects of study: legislation, public policies, and judicial decisions. This existing legal framework will serve as the starting point for our critical analysis.The second method is comparative. As the challenges analyzed are present globally, the project will also refer to legislation, public policies, and judicial decisions in other relevant jurisdictions with a federal state structure (e.g., Canada, USA, Germany). This will lead us to discover regulatory tools promoting health behavior that might be pertinent to the Swiss context.Thirdly, the project will pursue an evaluative and thus normative method. We will critically analyze the research questions from the point of view of constitutional, administrative, and social security law. To nourish our critical assessment, we will consult secondary literature originating in legal scholarship from relevant fields and in non-legal disciplines pertinent to our analysis (behavioral and social sciences).Finally, the project builds on a prospective and thus normative method. Based on the project’s findings, we will articulate de lege ferenda proposals for future law reform in Switzerland.To locate relevant Swiss and foreign legal sources, we will consult official state websites and specialized legal databases. The secondary literature is accessible in the libraries of the University of Neuchâtel and through the Swiss inter-library loan system.Expected results and impact - The project will make a crucial scholarly contribution, pursuing a critical analysis of the evolving social contract of health and the boundaries of collective and individual, but also corporate, responsibility for health and disease, in the current era of self-optimization and the "moralizing state". Beyond this principled question of law and political theory, the project will focus on innovative regulatory tools designed to promote healthy behavior. It will advance public health law scholarship through its original and promising approach, which relies on a realist conception of law and hence goes beyond traditional legal dogmatics. The project’s originality also lies in its rigorous approach weaving important interdisciplinary links with research in social and behavioral sciences. Practically, it will articulate de lege ferenda proposals for future law reform. These recommendations will serve Swiss federal and cantonal law and policymakers, health and legal practitioners in designing and applying legal tools that strive to enhance Switzerland’s public health outcomes.
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