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7KH 9DOXH RI 8QKHDOWK\ (DWLQJ DQG WKH (WKLFV RI +HDOWK\ (DWLQJ 3ROLFLHV $QQH %DUQKLOO .DWKHULQH ) .LQJ 1DQF\ .DVV 5XWK )DGHQ Kennedy Institute of Ethics Journal, Volume 24, Number 3, September 2014, pp. 187-217 (Article) 3XEOLVKHG E\ 7KH -RKQV +RSNLQV 8QLYHUVLW\ 3UHVV DOI: 10.1353/ken.2014.0021 For additional information about this article Access provided by Johns Hopkins University (20 Nov 2014 10:06 GMT) http://muse.jhu.edu/journals/ken/summary/v024/24.3.barnhill.html
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The Value of Unhealthy Eating and the Ethics of Healthy Eating Policies

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Page 1: The Value of Unhealthy Eating and the Ethics of Healthy Eating Policies

Th V l f nh lth t n nd th th f H ltht n P l

nn B rnh ll, th r n F. n , N n , R th F d n

Kennedy Institute of Ethics Journal, Volume 24, Number 3, September2014, pp. 187-217 (Article)

P bl h d b Th J hn H p n n v r t PrDOI: 10.1353/ken.2014.0021

For additional information about this article

Access provided by Johns Hopkins University (20 Nov 2014 10:06 GMT)

http://muse.jhu.edu/journals/ken/summary/v024/24.3.barnhill.html

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Barnhill, King, Kass, & Faden • the ethics oF healthy eating Policies

[ 187 ]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 find 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

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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,

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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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