44 HASTINGS CENTER REPORT July-August 2002 P ublic health has been one of the most important endeavors of the past century, changing the face of the world and enlarging the scope, if not the size, of governments everywhere. Public health’s focus on populations and communities is its most distinctive fea- ture, and promoting the public’s health takes health officials and advocates far beyond their scientific training into the thicket of democratic politics. This em- phasis on politics and political philoso- phy is one reason why bioethics finds public health so difficult to bring into philosophical focus. Public health itself has difficulties bringing its political task into philo- sophical focus. For example, the 1988 report of the Institute of Medicine, The Future of Public Health, defines the mis- sion of public health as “fulfilling soci- ety’s interest in assuring the conditions in which people can be healthy.” How- ever, the report goes on to place the pol- itics of assuring those conditions within a standard interest group model of polit- ical action and conflict. These models could describe the politics of the Na- tional Rifle Association or the tobacco industry as easily as those of public health. We want to know far more than how strong public health groups are po- litically; we want to know what central political goods or purposes lie behind modern public health campaigns and the patterns of conflict that provisioning these goods or purposes elicits. A more useful way to think about the recurring and central conflicts is found in Michael Walzer’s 1983 book, Spheres of Justice: A Defense of Pluralism and Equality. In this major work of political philosophy, Walzer outlines a model of the political community as consisting of key social goods provided in distributive spheres or domains, each operating ac- cording to the historical and social meanings and logics that attach to those goods. For example, commodities are provided to those with money, work to those whose talents are needed, basic lib- erties to all who are citizens and mem- bers, and so forth. The key spheres are those for communal welfare, basic civil liberties (speech, assembly, and other basic rights), privacy, political power, markets and commodities, criminal jus- tice, and membership and alienage. Walzer’s model permits us to pin- point a constant theme in most political conflict: the struggle to resist domina- tion of one or several spheres of provi- sion by a more powerful one. In the United States and for public health poli- cy the central conflicts center around the struggles to resist domination and inva- sion by the more powerful domains of the market and of political power. The chief patterns of domination in the U.S. political system are markets overtaking communal welfare (managed competi- tion in health care provision, workfare, and so forth), or the realm of free speech and discussion (the legal doctrine of commercial speech launched in the 1970s by the Supreme Court), as well as electoral politics arising in the domain of political power and mobilizing majori- ties around a cultural politics based on religious moralism. What religious moralism seeks are new laws threatening the realm of privacy (attacks on abortion and contraceptive rights rooted in a sphere of privacy), limits on democratic discussion (limiting what can be said or discussed in educational campaigns against HIV), and ultimately undermin- ing effective public health policies. Walzer’s approach to political philos- ophy is not the only one that might be employed to assess the political chal- lenges for public health, but it is partic- ularly apt because his “justice of the spheres” so closely parallels U.S. Consti- tutional conflicts centered in privacy, free speech, the regulation of markets, the provision of welfare, and so forth. Walzer’s model serves up this key in- sight: strengthening the health of the cit- izenry and strengthening the health of the civic community are two sides of the same coin. Lawrence O. Gostin’s Public Health Law: Power, Duty, Restraint and Nancy Milio’s Public Health in the Market: Fac- ing Managed Care, Lean Government, and Health Disparities seek in different ways to detail the recent political for- tunes of public health. Milio focuses en- tirely on the last two decades of the twentieth century. While Gostin surveys the long history of the law’s involvement with public health in the U.S., his em- phasis is on the legal clashes of recent decades. Thus both authors discuss decades that have been deeply inhos- pitable, politically, to promoting the public’s health. Public Health Law is a wonderfully comprehensive overview of the field of public health law, important for far The Law, the Market, and the Health of the Body Politic by Dan Beauchamp review essay Public Health Law: Power, Duty, Restraint. By Lawrence O. Gostin. University of California/Milbank Series on Health and the Public, 2000. 489 pp. $24.95, paperback, . Public Health in the Market: Facing Managed Care, Lean Government and Health Disparities. By Nancy Milio. University of Michigan, 2000. 322 pp. $44.50.