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Edited by
Paul R. Ward
Torrens University Australia, Australia
Reviewed by
Le Jian
Government of Western Australia Department of Health, Australia
Julia Stafford
Cancer Council Western Australia, Australia
Table of contents

 * Abstract
 * Key Messages
 * Introduction
 * Methodology for Analyzing the Ethics of SSBs Taxation
 * Libertarian Ethics and SSBs Taxation
 * Conclusions
 * Author Contributions
 * Conflict of Interest
 * Acknowledgments
 * References


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PERSPECTIVE ARTICLE

Front. Public Health, 16 April 2020
Sec. Public Health Policy
Volume 8 - 2020 | https://doi.org/10.3389/fpubh.2020.00110


THE ETHICS OF TAXING SUGAR-SWEETENED BEVERAGES TO IMPROVE PUBLIC HEALTH

Francisco Goiana-da-Silva1,2*†David Cruz-e-Silva3Oliver Bartlett4Joana
Vasconcelos5Alexandre Morais Nunes6Hutan Ashrafian1Marisa Miraldo7Maria do Céu
Machado8Fernando Araújo9Ara Darzi10
 * 1Centre for Health Policy, Institute of Global Health Innovation, Imperial
   College London, London, United Kingdom
 * 2Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã,
   Portugal
 * 3Centre for Innovation, Technology and Policy Research, IN+, Instituto
   Superior Técnico, Universidade de Lisboa, Lisbon, Portugal
 * 4Department of Law, Maynooth University, Maynooth, Ireland
 * 5Centro Hospitalar Universitário São João, Serviço Nacional de Saúde, Oporto,
   Portugal
 * 6Centro de Administração e Políticas Públicas, Instituto Superior de Ciências
   Sociais e Políticas, Universidade de Lisboa, Lisbon, Portugal
 * 7Department of Economics and Public Policy & Centre for Economics and Policy
   Innovation, Imperial College Business School, London, United Kingdom
 * 8Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
 * 9Centro Hospitalar Universitário São João, Faculty of Medicine, Universidade
   do Porto, Oporto, Portugal
 * 10Department of Surgery and Cancer, Faculty of Medicine, Imperial College
   London, London, United Kingdom

The World Health Organization highlights fiscal policies as priority
interventions for the promotion of healthy eating in its Action Plan for the
Prevention and Control of Non-communicable Diseases. The taxation of sugar
sweetened beverages (SSBs) in particular is noted to be an effective measure,
and SSBs taxes have already been implemented in several countries worldwide.
However, although the evidence base suggests that this will be effective in
helping to combat rising obesity rates, opponents of SSBs taxation argue that it
is illiberal and paternalistic, and therefore should be avoided. Bioethical
analysis may play an essential role in clarifying whether policymakers should
adopt SSBs taxes as part of wider obesity strategy. In this article we argue
that no single ethical theory can account for the complexities inherent in
obesity prevention strategy, especially the liberal theories relied upon by
opponents of SSBs taxation. We contend that a pluralist approach to the ethics
of SSBs taxation must be adopted as the only suitable way of accounting for the
multiple overlapping, and sometimes, conflicting factors that are relevant to
determining the moral acceptability of such an intervention.




KEY MESSAGES

- Evidence shows that appropriately designed fiscal policies have the potential
to impact diets and must be implemented through a concerted approach with other
policy actions.

- The WHO identifies levying taxes on sugar-sweetened beverages as an effective
measure to tackle NCDs.

- Bioethics may play an essential role in clarifying the acceptability of
levying taxes on sugar-sweetened beverages.

- Arguments on the ethicality of levying taxes on sugar-sweetened beverages that
are based solely on one ethical theory should be rejected.

- Use of a pluralist, principled account of public health ethics would better
reflect the complexity of the policy decision at stake, and would produce more
helpful conclusions on whether these novel public health interventions are
ethical.


INTRODUCTION

Bioethics is a multifaceted field of study. Even though it has evolved over
recent decades, it is often mistaken as only representing medical ethics (1).
Bioethics is not solely concerned with genetics, euthanasia and doctor-patient
relationship, and must be transversal to all daily health related operations and
sectors. Bioethics therefore has a role to play in the design and implementation
of public health interventions to address key societal issues. One such issue is
the design of interventions to prevent non-communicable diseases (NCDs), in
particular fiscal policies (2).

Fiscal policies are outlined as a priority intervention in the promotion of
healthy eating on the Action Plan for the Prevention and Control of NCDs in the
WHO European Region 2016–2025, with taxes on sweetened beverages highlighted as
an effective measure (3). Both taxes and subsidies are proven to influence
purchasing behaviors, particularly in relation to sweetened beverages (4).
Currently, taxation policies targeting the consumption of sugar-sweetened
beverages (SSBs) are already implemented in several countries worldwide (Table
1).


TABLE 1

Table 1. List of countries where taxation policies targeting the consumption of
sweetened beverages have been implemented.





METHODOLOGY FOR ANALYZING THE ETHICS OF SSBS TAXATION

Bioethical analysis can make an important contribution to the public health
policymaking process by establishing a coherent moral framework for why
governments should or should not intervene in public health in certain ways.
This perspective article seeks to demonstrate how we can ensure that the ethical
analysis we perform is as sound as possible.

Prior to analyzing the ethicality of particular public health interventions,
analysts must establish why a particular health issue should be a matter of
public concern and require government intervention. Several approaches to
address this query are possible—some have answered it using social contract
theory (5), some with political science (6). Ruger has developed a particularly
powerful argument for government intervention in health that combines virtue
ethics and capability theory (7). Whichever approach is taken, high prevalence
of obesity in a population is generally accepted as an issue that governments
should take responsibility for addressing.

In such context, analysts must evaluate whether a particular form of government
intervention should be used to address a public health issue. In this paper we
focus on the question of whether taxes on SSBs should be used to contribute to
obesity prevention policy. The analysis we employ is doctrinal in nature. This
involves looking at ethical arguments as syllogisms—a type of reasoning in which
conclusions are drawn from premises—and testing whether the conclusions drawn in
these arguments are logically sound. Premises are usually statements drawn from
ethical doctrine—for example, interfering with autonomy is always wrong (first
premise), and sugar taxes interfere with consumer autonomy (second premise). A
conclusion must be based on factually accurate premises to be considered valid.
The factual accuracy of premises will be assessed by examining whether they are
supported by epidemiological evidence.

We first focus on the common claims that SSBs taxation is wrong because drinking
SSBs does not harm others, and because taxation restricts consumer choice, which
are grounded in deontological ethical theory (under which ethicality is judged
according to rules or duties relating to the nature of actions). By applying the
findings of behavioral science to the generalized premises on which this
reasoning is based, we will show that they cannot be considered factually
accurate, and therefore valid ethical conclusions cannot be drawn from them.
However, we also find that changing the ethical theory does not change this
outcome—claims grounded solely in other ethical theories, for example
constructivism (under which ethicality is judged not according to the nature of
actions but according to their outcomes), are equally unable to reflect the
complexity of the evidence base surrounding SSBs consumption, and are therefore
equally likely to produce unsound ethical conclusions.

We will use this brief analysis to then argue that the only way to arrive at
valid conclusions on the ethicality of SSBs taxation is to ground the premises
of arguments in a plurality of ethical theories. The policy decision to tax SSBs
is based upon a complex evidence base, and an assessment of the ethicality of
this decision must take account of this evidence base. Since basing an ethical
argument on only one ethical theory tends to mean it is based on factually
inaccurate premises, we argue that grounding ethical analysis in several ethical
theories will result in the premises of that analysis better reflecting the
complexity of the evidence base surrounding SSBs taxation (and obesity
prevention generally), thus leading to sounder ethical conclusions.

To locate the information needed to conduct the above analysis, we primarily
used Google Scholar keyword searches (e.g., “ethics” + “theories” + “liberalism”
+ “autonomy” + “sugar sweetened beverages” + “taxation”) to identify academic
papers related to the ethics of SSBs taxation, the ethics of public health
taxes, and the ethics of public health generally. We also used Google Scholar
keyword searches (e.g., “sugar sweetened beverages” + “taxation” + “policy” +
“evidence” + “impact” + “health”) to identify epidemiological literature on the
population health impact of SSBs taxation and health inequality tends related to
SSBs consumption, as well as behavioral science studies relating to consumer
behavior (e.g., “consumer” + “behavior” + “evidence” + “soda”). We also relied
specifically on similar keyword searches of leading public health ethics
journals such as: Public Health Ethics; Ethics, Medicine and Public Health; and
The Journal of Law, Medicine and Ethics. To ensure that our information remained
current, we limited our searches to academic and policy sources dating from 2000
to the present (excepting sources that spoke to historical trends or
viewpoints).


LIBERTARIAN ETHICS AND SSBS TAXATION

Opponents of SSBs taxes make the general argument that they are illiberal and
paternalistic, and thus wrong (8). Libertarians, in the context of public
health, believe that government intervention can only be ethical when it enables
individual freedom and sustains the conditions for autonomous agency, (9) and
this generally means limiting government intervention to non-coercive measures,
or at least those coercive measures that are absolutely necessary to prevent an
individual being harmed by another. This view is a form of deontological ethical
theory, which broadly holds that actions should be judged by whether the nature
of the action itself can be considered morally worthy. Individuals establish the
rules governing whether an action is morally worthy though critical and rational
self-reflection. Thus, the autonomy of human thought, and the freedom to reason
critically are essential to moral conduct—anything that limits this autonomy and
freedom should itself be considered unethical.

Evidently, fostering every individual's agency to make healthy decisions is
important to population sustainability, however as is clear from the seminal
work by Geoffrey Rose (10) and continued by others (11), promoting good health
within a society requires greater attention to be devoted to how factors
affecting health impact upon groups of individuals, rather than individuals in
isolation. Public health interventions must therefore be designed primarily with
the collective as the beneficiary of the intervention, not the individual. This
means that judging the ethicality of a public health intervention, such as a tax
on SSBs consumption, purely on the basis of the extent to which it interferes
with individual autonomy and freedom means that we are only judging part of the
motivation to adopt that intervention, and even then not the most important
motivation (12). In the paragraphs below, we show how this impacts the validity
of the ethical conclusions drawn from arguments based on autonomy.

Opponents of SSBs taxation usually deploy JS Mills' harm principle, stating that
public health interventions should only be made to prevent harm to others, and
since SSBs consumption only directly harms the individual, taxing SSBs is
unethical. However, the evidence base demonstrates that population SSBs
consumption clearly does have negative effects on others—higher rates of
population SSBs consumption are linked to higher rates of obesity which place
greater pressure on health care resources (13). This affects resource allocation
decisions, which necessarily have negative implications for some areas of health
and social care and impact the experiences of other individuals. Moreover, the
harm principle as originally articulated by Mill does not insist that
externalities must be proximate to individuals to any specific degree—in fact
Mill himself insisted that government intervention in certain areas, such as
consumer product regulation, should not be governed by his ideas on liberty at
all, but by his doctrine on free trade in which he sets out how governments
should balance economic efficiency with public welfare protection (14).

Thus, both premises in the libertarian argument are factually inaccurate—liberal
ethical doctrine does not insist that public health interventions can only
prevent direct harm to others, and SSBs consumption does generate significant
social burdens in addition to the harms suffered by individual consumers. The
reasoning of this argument does not sufficiently account for the complex
relationship between high population levels of SSBs consumption, rates of
obesity, and healthcare resource allocation, and government responsibility for
social protection. Thus, evaluated on the strength of its reasoning, the
libertarian argument that SSBs taxation is unethical should be seen as unsound.

Opponents also usually deploy ideas of autonomy and free choice, arguing that
consumer autonomy holds a privileged status in moral considerations, and should
be given the highest priority in the formation of public health interventions.
Since taxing SSBs substantially interferes with consumers' abilities to make
autonomous and free choices, taxing SSBs is unethical. However, the evidence
base tells us that factors such as the availability of healthy compared to
unhealthy foods and beverages (15) and pricing strategies for SSBs (16) heavily
shape the choices available to individuals before they even arrive in a
consumption choice situation. It is clear that when an individual makes a
consumption choice, that choice is not a pure translation of individual
preferences, but the outcome of a complex mix of individual preferences,
marketing messages, environmental conditions and psychological pressures. Some
of these influences on consumers' choices occur simply because the consumer is a
certain gender, or because they were born in a particular neighborhood, meaning
that different consumers will make choices about consuming healthy or unhealthy
products from vastly different starting points. This is unfair, and according to
the weight of evidence on the effect that health inequalities have on burdens of
disease (17), combatting health inequality should be an important consideration
for governments when choosing public health interventions—perhaps more important
even than protecting consumer autonomy in every situation.

Moreover, this argument presumes that making SSBs more expensive will have an
impact upon consumer autonomy. As recent analysis on the issue points out,
autonomy and freedom should be distinguished, and reducing an individual's
freedom to buy SSBs at low prices does not necessary reduce their ability to
make autonomous decisions on whether to buy SSBs at higher prices (18).
Furthermore, it is not clear from the epidemiological evidence that consumers'
autonomy is affected by SSBs taxes. Evidence from the UK suggests that there is
actually strong support for SSBs taxation, which would unlikely be the case if
consumers felt that their ability to make health decisions for themselves was
being compromised. Perhaps one could argue that consumers' autonomy could be
compromised without them realizing, but then this would seem to support the
argument for SSBs taxation—if the way in which an individual thinks about their
food decisions can be easily manipulated by subtle changes to the
decision-making context without the individual ever realizing this, as
behavioral and marketing evidence shows that it can (19), this would support
affording the protection of autonomy a less privileged position in public health
decision making, and instead privileging how policies can prevent consumer
decisions from being manipulated.

Thus, both premises in the deontological argument based on autonomy are
factually inaccurate—governments have more (and arguably more important) duties
than simply to protect consumer autonomy, and SSBs taxation probably does not
appear to influence consumer autonomy to a very large extent (and testing this
more forensically would constitute an acknowledgment that consumer autonomy is a
frail concept). The reasoning of this argument does not sufficiently account for
the complex influences that environmental conditions and social inequalities
have on SSBs consumption, nor for the fact that an autonomous consumer may
actually welcome public health interventions. Thus, evaluated on the strength of
its reasoning, the argument from autonomy that SSBs taxation is unethical should
also be seen as unsound.


A PLURALIST APPROACH TO THE ETHICS OF SSBS TAXATION

The analysis above demonstrates that basing arguments on the ethics of public
health practice on one ethical theory leads to unsound conclusions. This outcome
is the same no matter what ethical theory is used in place of deontology, even
if it seems more suited to guiding community-oriented action. For example,
utilitarianism, the leading variant of constructivism, holds that an action is
ethical if the consequences maximize utility (often understood as the greatest
happiness experienced by the greatest number of people). These idea influences
the development of obesity policy at the highest levels in the form of
cost-benefit analysis of interventions (20). However, reliance on utilitarian
analysis alone also cannot produce logically sound ethical conclusions where
SSBs taxation is concerned, because the premises of most utilitarian argument do
not account well for complexity either, and therefore are factually inaccurate.
In particular, utilitarian analysis does not account well for hidden
discrimination and inequality (21), which confounds utilitarian calculations of
happiness.

For example, a utilitarian argument might be that the happiness produced by the
health consequences of increasing SSBs prices (decreased population consumption
of SSBs, contributing to reduced rates of population obesity, particularly
childhood obesity) would be greater than the unhappiness produced by the
economic consequences of increasing SSBs prices (somewhat lower profits for the
industry on SSBs, and the inconvenience of having to pay slightly more for
SSBs). However, this does not account for the fact that lower socioeconomic
groups consume proportionately more SSBs, spend a greater proportion of their
income on them, and suffer greater rates of obesity (22). In such circumstances,
it becomes very difficult to accurately calculate the happiness gained or lost
by this population, not to mention the relative weight that should be attributed
to this against the gains or losses of higher socioeconomic groups. Given that
the regressive nature of SSBs taxation is another common objection raised by the
industry, it is particularly important that ethical analysis be capable of
properly accounting for the relationship between inequality, health and fiscal
policy. Utilitarian constructivist arguments are therefore, like deontological
arguments, unable on their own to produce sound ethical conclusions on SSBs
taxation, since they also tend to be founded on factually inaccurate premises.

The ethical analysis of SSBs taxation therefore must be pluralist. Most new
ethical theories tailored to a public health context adopt such a pluralist (or
principled) approach, meaning that they identify a discrete set of different
principles or values that are deemed important for ethical public health policy,
and judge a public health intervention according to all of these principles
simultaneously. Table 2 lists five of the most common principles found in new
accounts of public health ethics, which combine a number of the traditional
ethical ideas surveyed above.


TABLE 2

Table 2. Public health ethics principles.




The potential flaws of principled ethical theories must also be recognized—the
most important is the potential lack of clarity in how principles should be
prioritized if they conflict, and how strong an obligation they should impose
(26). In the authors' opinion, fulfilling one principle does not necessarily
exclude the fulfillment of another. In the case of rights-based ethical
accounts, the enjoyment of one right can exclude the enjoyment of another, and
competing rights must be balanced using additional principles such as
proportionality. However, fulfilling a principle does not necessarily mean that
other principles cannot be simultaneously fulfilled. As long as principles are
selected to be coherent with each other, a process to balance principles is not
a necessity. As long as all principles carry equal weight, the only necessity is
a criterion to decide how many principles an intervention must fulfill to be
ethically acceptable.


CONCLUSIONS

Extensive evidence shows that implementing taxes on the consumption of SSBs
generates significant health gains and has a positive impact on the reduction of
premature mortality. The WHO has now produced detailed guidance on how to design
fiscal policies relating to diet, responding to the manifest interest of many
countries for more detailed advice on how to implement their international
commitments to adopt effective measures to reduce premature mortality
attributable to obesity (27). However, despite several countries having
implemented such taxes, other countries continue to resist doing so (28). The
rationale for this resistance is primarily economic in nature, however sometimes
the issue of the perceived legitimacy of the measure is also raised.

Further bioethical debate in obesity policy is essential to ensure that
policymakers are equipped with not just sound epidemiological evidence, but
sound moral evidence on which they can base the implementation of polices that
will shape healthier food environments. In this paper we sought to demonstrate
that looking at the ethical legitimacy of interventions such as SSBs taxation
through only one ethical lens is only likely to produce invalid ethical
conclusions, since the premises on which many single-theory ethical arguments
are based are ill-equipped to properly reflect the complexity of factors that
must be considered in policy decisions implement SSBs taxes. A pluralist
approach to the ethics of fiscal policies such as levying taxes on SSBs is
therefore essential to produce a sound explanation of whether they are morally
acceptable in a democratic society. Even though there are also certain issues
inherent to pluralist ethical accounts of public health practice, their use is
more likely to enable progress in ethical debates in the field of
non-communicable disease prevention.


AUTHOR CONTRIBUTIONS

FG: Paper concept, design, drafting, critical analysis, and final approval. DC:
Acquisition of data, Paper drafting, critical analysis, and final approval. OB:
Paper concept, design, drafting, critical analysis and final approval. JV:
Acquisition of data, Data analysis and final approval. AM: Acquisition of data,
data analysis and final approval. HA: Paper concept, critical analysis and final
approval. MM: Paper concept, critical analysis and final approval. MCM: Paper
concept, critical analysis and final approval. FA: Paper concept, critical
analysis and final approval. AD: Paper concept, critical analysis and final
approval.


CONFLICT OF INTEREST

The authors declare that the research was conducted in the absence of any
commercial or financial relationships that could be construed as a potential
conflict of interest.


ACKNOWLEDGMENTS

FG holds an Imperial College London scholarship. After submission, Imperial
College London kindly agreed to fund the open access fees for this paper. We
thank to Imperial College London for funding the open access fees.
Infrastructure support for this research was provided by the NIHR Imperial
Biomedical Research Centre (BRC).


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Keywords: sweetened beverages, taxation, pricing policies, bioethics, health
policy

Citation: Goiana-da-Silva F, Cruz-e-Silva D, Bartlett O, Vasconcelos J, Morais
Nunes A, Ashrafian H, Miraldo M, Machado MC, Araújo F and Darzi A (2020) The
Ethics of Taxing Sugar-Sweetened Beverages to Improve Public Health. Front.
Public Health 8:110. doi: 10.3389/fpubh.2020.00110

Received: 08 August 2019; Accepted: 18 March 2020;
Published: 16 April 2020.

Edited by:

Paul Russell Ward, Flinders University, Australia

Reviewed by:

Julia Stafford, Curtin University, Australia
Le Jian, Curtin University, Australia

Copyright © 2020 Goiana-da-Silva, Cruz-e-Silva, Bartlett, Vasconcelos, Morais
Nunes, Ashrafian, Miraldo, Machado, Araújo and Darzi. This is an open-access
article distributed under the terms of the Creative Commons Attribution License
(CC BY). The use, distribution or reproduction in other forums is permitted,
provided the original author(s) and the copyright owner(s) are credited and that
the original publication in this journal is cited, in accordance with accepted
academic practice. No use, distribution or reproduction is permitted which does
not comply with these terms.

*Correspondence: Francisco Goiana-da-Silva, franciscogoianasilva@gmail.com

†ORCID: Francisco Goiana-da-Silva Orcid.org/0000-0003-2055-6906



Disclaimer: All claims expressed in this article are solely those of the authors
and do not necessarily represent those of their affiliated organizations, or
those of the publisher, the editors and the reviewers. Any product that may be
evaluated in this article or claim that may be made by its manufacturer is not
guaranteed or endorsed by the publisher.




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