Public Health Law

Government’s principal obligation is to ensure the health and welfare of its population. It does so through the enactment and enforcement of laws designed to create the conditions necessary for citizens to lead healthy, safe lives. This article explores the ways in which law can be used as a tool for improving the health of a society by creating public health authorities, defining their powers, and denoting the mean s by which those powers can be used. However, before we begin, we first offer a definition of public health law, focusing on the characteristics that make it different from other areas of law.

Definition and Characteristics of Public Health Law

Public health has to do with the safety and well-being of populations. Contrast this to the field of medicine, which is primarily concerned with the health of individual patients. In medicine, doctors must do what is best for their individual patient. Public health takes a wider perspective, focusing on what must be done to improve and maintain the health of a collective group. Inherent in this approach is the reality that sometimes the government will require that individual rights be sacrificed for the greater good; people must forgo individual freedom, privacy, and autonomy in order to benefit their community. With this in mind, we define public health law as follows:

Public health law is the study of the legal power s and duties of the state, in collaboration with its partners (e.g., health care, business, the community, the media, and academe), to assure the conditions for people to be healthy (e.g., to identify, prevent, and ameliorate risks to health in the population) and the limitations on the power of the state to constrain the autonomy, privacy, liberty, proprietary, or other legally protected interests of individuals for the common good. The prime objective of public health law is to pursue the highest possible level of physical and mental health in the population, consistent with the values of social justice. (Gostin, 2007)

This multifaceted definition focuses on five essential characteristics of public health law.

  1. Government – The primary responsibility of safeguarding the public’s health falls to government, as it is best situated to act in the interest of the populace (Institute of Medicine, 2002).
  2. Populations – Public health’s goal is to improve the health and well-being of a group rather than individual patients.
  3. Relationships – Public health is concerned with the relationship between the state and the population. Sometimes this relationship justifies the government’s imposition of burdens on individuals in order to promote the population’s greater good.
  4. Services – Public health improves the welfare of a group by providing population-based services grounded in the scientific methodologies of public health (e.g., biostatistics and epidemiology).
  5. Power – In order to promote the public’s health, the government must possess certain powers to regulate and control individuals and businesses. Since public health often requires individual sacrifice, the government cannot rely on requests for voluntary cooperation; an ample, yet clearly delineated power to coerce is required.

Law is the mechanism through which government can fulfill its obligation to protect the public’s health. In the next section, we outline seven models of legal intervention. In each model, the law (through constitutions, legislation, regulation, or the courts) gives government the power to influence human behavior. Of course, although law creates the governmental power to safeguard the public’s health, this same law can serve as a restraint on that power, ensuring that government acts appropriately and maintaining an appropriate balance between individual rights and the population’s health. The third section discusses the ways in which law can limit government action. The fourth section explores the challenges associated with reforming public health law in the face of evolving conceptions of the powers, duties, and restraints necessary for government to protect the public’s health.

Law as a Tool to Protect the Public’s Health

The Power to Tax and Spend

One of the fundamental governmental powers, often contained in a constitution, is the ability to tax and spend. In its simplest form, the power to spend is relevant because it allows government to devote resources toward vital public health infrastructure. Government must hire and train a public health workforce, create information and communication systems, conduct disease surveillance, maintain laboratory facilities, and establish the capacity to respond to public health emergencies (Centers for Disease Control and Prevention, 2002). This direct spending can also have an indirect effect on health through the government’s placement of health-related restriction or conditions on the receipt of public funds. For example, the receipt of local road construction money could be conditioned on the implementation of safety requirements, such as a lower speed limit.

The power to tax can also be used as a tool to indirectly influence the behavior of individuals and businesses. Taxes on unhealthy or harmful behaviors serve as a disincentive to engage in those activities. Many governments tax risky behaviors, such as smoking, in an effort to make it less attractive. This type of monetary disincentive can be a powerful means of influencing unhealthy behaviors, especially among young people. Tax relief can also be used as a positive incentive for engaging in healthful behaviors. For example, a tax rebate or deduction can be offered for purchasing health insurance or for income devoted toward medical expenses.

The Power to Alter the Flow of Information

Information influences the health-related choices that people make. Government can influence the informational environment, thus encouraging healthy behaviors and discouraging harmful ones. The government can engage in direct information dissemination, through the use of educational campaigns. They can impose product labeling rules, requiring the inclusion of important information such as health warnings, nutritional information, or safe use instructions. Government can also impose outright bans on certain forms of advertising, especially for information that is misleading or that promotes unreasonably harmful products (e.g., tobacco, alcohol).

Of course, by regulating or banning certain kinds of commercial speech, government is restricting businesses’ freedom of expression. In many countries, the right to free speech is a core social value. However, there is a difference between expressing one’s social or political views and engaging in commercial speech for profit. Many liberal democracies do not protect commercial speech because it is not vital for the promotion of a vibrant democracy.

The Power to Alter the Built Environment

The environment in which one lives can have an immense impact on health. Public health has long been engaged in interventions designed to improve the health-promoting qualities of our built environment, through the government’s use of laws and regulations. Government has regulated workplace safety to reduce injuries. Cities have required that housing comply with specific fire and building codes. The spread of infectious disease has been impeded through the creation of sanitation systems and the implementation of zoning rules. Government has also restricted the production and use of harmful environmental agents such as lead paint, asbestos, and pollution.

Developed countries are seeing an epidemiological shift away from infectious disease, toward chronic health problems such as cancer, cardiovascular disease, diabetes, asthma, and depression. As the disease distribution changes, government can still use its power to alter the built environment as a tool to promote physical and mental health by reducing the incidence of chronic disease. City planners can include parks and playgrounds that encourage active lifestyles. Government can facilitate access to nutritional foods by encouraging the production of supermarkets in previously underserved areas. Laws can restrict the use of harmful products, such as cigarettes and alcohol; for example, many jurisdictions have banned smoking in all public spaces (Perdue et al., 2003).

The Power to Alter the Socioeconomic Environment

Research indicates a clear correlation between socioeconomic status (SES) and health (Rogot et al., 1992). Populations with the fewest financial, educational, and occupational resources generally are the least healthy. Some have even suggested that countries with the largest gap between the rich and the poor will have lower health status compared to similar countries in which wealth is distributed more evenly. Although we cannot completely explain the complex relationship between SES and health, one can make a strong argument that social justice is good for our health.

Regardless of the specific interrelationship between SES and health, people of low SES are subject to a disproportionate number of harms: reduced access to material goods (food, shelter, and health care), a toxic physical environment, psychosocial stressors (financial, occupational, and social insecurity), and social contexts that promote risky behaviors. Government can work to alleviate these specific determinants of morbidity and premature mortality, keeping in mind that social equality might be the ultimate way to promote the health of an entire population (Lynch et al., 2004).

The Power to Directly Regulate Persons, Professions, and Businesses

Government has the power to regulate individuals, professions, and businesses by creating clear, enforceable rules designed to protect the health and safety of workers, consumers, and the population at large. On the individual level, regulation can reduce injuries and death by controlling individual behavior. For example, in most places, it is illegal to drive without a seatbelt (or helmet) or while under the influence of drugs or alcohol. On the professional level, governments regulate the quality and standards of practice by requiring licenses and permits to enter a field. In the area of health, this power is used to regulate doctors’ licenses, as well as to certify hospitals and nursing homes.

Inspection and regulation of businesses can help create safer work environments, limit toxic emissions, and ensure safer consumer products. For example, the FDA closely regulates the production of influenza vaccines through inspections and testing in order to prevent contaminated products from reaching the market. Of course, the regulation of businesses for public health purposes is controversial. Although there are clear public health benefits achieved through regulation of commercial enterprises, many have argued for the benefits of open competition and unfettered entrepreneurship. Yet effective public health policy requires some level of government restraint on businesses in order to avoid the potential threats that would result from unbridled commercialism.

Indirect Regulation through the Tort System

The tort system aims to hold individuals and businesses civilly accountable for engaging in dangerous or harmful activities. The effects of a tort system are three-fold. First, the threat of being held liable can deter individuals and businesses from engaging in unreasonably dangerous or harmful activities. Second, victims who have been harmed through no fault of their own can be compensated for their injury. Finally, the tort system encourages innovation. Since the system holds an actor responsible for the harm caused by his or her dangerous activity, there is an incentive to find ways to make it safer, or less harmful.

In the public health realm, civil litigation can redress many kinds of public health problems. Companies that pollute, or use toxic substances, can be held liable for the environmental damage and adverse health effects that they have caused. Similarly, companies that produce inherently dangerous products (e.g., firearms, tobacco) or defectively produced goods can be forced to compensate victims injured by their merchandise. For example, in 1998, tobacco companies reached a settlement with American States totaling $206 billion over the next 27 years. Similarly, there has been a recent series of cases against firearms producers, with plaintiffs arguing that the companies should be held liable for producing an inherently dangerous product (Lytton, 2005).

Deregulation: Removing Laws that Negatively Affect the Public’s Health

Although law gives government the power to protect the public’s health, law can also serve as an impediment to this goal. In such cases, deregulation can be a useful tool. Politically popular policies, such as banning needle exchange, can actually increase the spread of HIV infections. Similarly, the criminalization of sexual acts performed by HIV-positive individuals (without disclosure) can serve as a disincentive to get tested or seek medical treatment.

Deregulation can be controversial because it often requires the removal of superficially popular laws that get their support from moral or ethical arguments. Needle exchange bans and HIV-specific criminal penalties represent society’s moral condemnation of disapproved behaviors (Gostin, 2004). Since public health is concerned with reducing morbidity and mortality by using scientifically based techniques, interventions can often appear to conflict with a society’s set of morals. However, it is important for public health officials to examine the real health effects of public policies and to push for their deregulation when evidence demonstrates an unintended consequence.

Law as a Limit on Government Power

Protecting the public’s health is not possible without constraining a wide range of private activities that pose unacceptable risks. The legal tools discussed above infringe on a number of values that occupy a core place in many societies. Public health can require the government to infringe on privacy, restrict speech, and limit movement and autonomy (e.g., quarantine, isolation, vaccination). Given the importance of the public’s health, government must have the power to restrict individual rights and freedoms in the interest of the collective good. However, government must do so consistently with constitutional and statutory constraints on state action. This section discusses how legal frameworks can ensure that government does not abuse its power; law can make sure that government uses its coercive powers only when necessary and appropriate.

Any theory of public health law presents a paradox. Government, on the one hand, is compelled by its role as the elected representative of the community to act affirmatively to promote the health of the people. To many, this role requires vigorous measures to control obvious health risks. On the other hand, government cannot unduly assault individuals’ rights in the name of communal goods. Health regulation that overreaches, in that it achieves a minimal health benefit with disproportionate human burdens, is not tolerated in a society based on the rule of law and is antithetical to ethical considerations. Consequently, scholars and practitioners often perceive a tension between the claim of the community to reduce obvious health risks and the claim of individuals to be free from government interference. This perceived conflict might be agonizing in some cases and absent in others. Thus, public health law must always pose the questions: does a coercive intervention truly reduce aggregate health risks, and what, if any, less intrusive interventions might reduce those risks as well or better? Respect for the rights of individuals and fairness toward groups of all races, religions, and cultures remains at the heart of public health law.

Substantive Restrictions

Public health powers are permissible only if they are exercised in conformity with five standards: public health necessity, reasonable means, proportionality, harm avoidance, and fairness (Childress et al., 2002). These standards, while permissive of public health intervention, nevertheless require a deliberative governmental process to safeguard liberty. If these standards are followed, they often result in a requirement that public health authorities use the least restrictive effective means necessary to protect the public from legitimate dangers.

Public health necessity

Public health powers are exercised under the theory that they are necessary to prevent an avoidable harm. Some courts have required that police powers go no farther than that which is reasonably necessary to protect the public. Early meanings of the term ‘necessity’ are consistent with the exercise of police powers: to ‘necessitate’ was to force or compel a person to do that which he would prefer not to do, and the ‘necessaries’ were those things without which life could not be maintained. Government, in order to justify the use of compulsion, therefore, must act only in the face of a demonstrable health threat. The standard of public health necessity requires, at a minimum, that the subject of the compulsory intervention must actually pose a threat to the community.

Reasonable means

Under the public health necessity standard, government may act only in response to a demonstrable threat to the community. The methods used, moreover, must be designed to prevent or ameliorate that threat. Courts have adopted a means/ends test that required a reasonable relationship between the public health intervention and the achievement of a legitimate public health objective. Even though the objective of the legislature may be valid and beneficent, the methods adopted must have a real relationship to protection of the public’s health.

Proportionality

The public health objective may be valid in the sense that a risk to the public exists, and the means may be reasonably likely to achieve that goal. Still, a public health regulation is legally troublesome if the human burden imposed is wholly disproportionate to the expected benefit. ‘‘[T]he police power of a State,’’ said Justice Harlan in the foundational American case of Jacobson v. Massachusetts, ‘‘may be exerted in such circumstances or by regulations so arbitrary and oppressive in particular cases as to justify the interference of the courts to prevent wrong … and oppression.’’ Public health authorities have a responsibility not to overreach in ways that unnecessarily invade personal spheres of autonomy. This suggests a requirement for a reasonable balance between the public good to be achieved and the degree of personal invasion. If the intervention is gratuitously onerous or unfair it may overstep constitutional boundaries.

Harm avoidance

Those who pose a risk to the community can be required to submit to compulsory measures for the common good. The control measure itself, however, should not pose a health risk to its subject. The legality of vaccinating a fit person against a contagious disease is very different than that of vaccinating someone who is medically contraindicated. Likewise, quarantine is not permissible if it creates conditions likely to spread disease or if it is conducted without regard to the basic needs of people being detained. Courts have required safe and habitable environments for persons subject to detention to protect the public’s health on the theory that public health powers are designed to promote well-being, not to punish the individual.

Fairness

The courts require that public health measures be implemented in a fair way. Interventions cannot target particular classes of people – members of a race, religion, ethnicity, for example – without a compelling reason. The law can discriminate among people in two ways. First, the law can expressly make distinctions among persons or groups. This kind of discrimination is called a facial classification because the distinction among people is ‘on the face’ of the statute. For example, a statute that requires searches of persons of Middle-Eastern descent facially discriminates on the basis of national origin. Second, the law can be ‘facially neutral’ in that it applies a general standard to all people. Statutes of general applicability, nonetheless, often disproportionately affect particular persons or groups. For instance, a law that requires prenatal screening in all communities with a specified high prevalence of HIV infection will have a disparate impact on minority and low-income populations. The courts will not necessarily find that a law of general applicability violates equal protection even if a demonstrably inequitable effect on vulnerable groups exists. If a law is facially neutral, the disproportionately burdened class must demonstrate that the government’s actual purpose was to discriminate against that group, which can be exceedingly difficult to prove.

If a law expressly discriminates or if a facially neutral law adversely affects persons or groups and the government intends to discriminate, an equal protection problem exists. Contrary to popular belief, however, government is not obliged to treat all people identically. Instead, government is required to treat like cases alike but is permitted to treat unlike cases dissimilarly. Virtually any public health policy establishes a class of people that receives a benefit or burden and a class that does not. For example, case isolation is only applied to the class of infectious people. The critical inquiry is whether a sufficient justification exists for the distinction among classes. Put another way, do public health authorities have a valid reason for distinguishing among people and, if so, how substantial is that reason? Medicare eligibility, for example, is based on a person’s age, but the government has a plausible reason for offering the benefit to the elderly and excluding others. However, quarantining a particular ethnic group in an area where disease is endemic has no justification.

Procedural Due Process

Fair procedures are required if an individual or business suffers a deprivation of property or liberty. However, this does not decide the question of exactly what kinds of procedures the government must provide. Due process is a flexible concept that varies with the particular situation. In deciding which procedures are required, courts should balance several factors. First, the courts should consider the nature of the private interests affected. The more intrusive or coercive the state intervention, the more rigorous the procedural safeguards. In cases of plenary deprivation of liberty, such as civil commitment of a person with mental illness or tuberculosis, the state must provide the full panoply of procedures – notice, counsel, impartial hearing, cross-examination, written decision, and appeal. The justification for rigorous procedural protections is found in the fundamental invasion of liberty occasioned by long-term detention.

Second, the courts should consider the risk of an erroneous deprivation and the probable value, if any, of additional or substitute procedural safeguards. Here, the courts are concerned with the value of procedures as a method of protecting against erroneous decision making. If the court feels that an informal process is likely to lead to a ‘correct’ result, it will not require procedural formalities that it regards as unnecessary.

Third, the courts should consider the fiscal and administrative burdens in providing additional procedures and the extent to which the government’s interests would be undermined. Most mental health or public health statutes permit an expedited form of due process in cases of emergency. Reduced due process is justified by the fact that the state’s interests in rapid confinement of immediately dangerous persons would be undermined by elaborate, time-consuming procedures.

In sum, in ascertaining the procedures that are constitutionally required, the courts should weigh three factors: the extent of the deprivation of liberty or property, the risk of an erroneous decision, and the burdens that additional procedures will entail. Thus, the procedures in any given circumstance depend on the public health context and vary from case to case. The process required can range from a full-blown hearing to an informal, nonadversarial review.

Accountability and Transparency

In a republic, public health measures are legitimate only when they reflect transparent legislative decisions. Public health activities in a democracy cannot be organized, funded, or implemented without the assent of the people. It is government that possesses the sole authority to empower, regulate, or carry out activities designed to protect or promote the general health, safety, or welfare of the population. It is the public that bands together to achieve social goods that could not be secured without collective action. And it is the public, or electorate, that legitimizes or authorizes government to act for the common welfare. However, the political commitment to public health is not absolute. What constitutes ‘enough’ public health? How much? What kinds of services? How will they be paid for and distributed? These remain political questions. Democratic governments will never devote unlimited resources to public health; core public health functions compete for scarce resources with other demands for services, and resources are allocated through a prescribed political process. There must be a vigorous and expanded democratic discussion about the population’s health.

Public health measures must be based on clearly defined criteria. When policies are enacted, it must be clear what harms they are intended to ameliorate or prevent, what means will be employed to do so, and what circumstances will trigger implementation (Daniels, 2000). The first requirement facilitates democratic prioritization of issues. Governments should be responsive to the concerns of the public and address those issues that most affect it. The second requirement allows the populace to weigh public health ends against means and ensure that restrictions are not pyrrhic in the eye of those whom the government is to serve. The third requirement helps protect proportionality. Even when there is broad agreement that particular harms, if present, justify restrictive interventions, disagreement about when those harms actually exist in sufficient magnitude to trigger a response will exist. These requirements for accountability are particularly important when public health policies are adopted to address future or extraordinary concerns. When policy is made to address risks that have not yet come into fruition, it is important that the goals and methods of intervention be set out clearly in advance so that the public can state a preference for how government should behave during the exercise of emergency powers. Consider the risk of pandemic influenza. Policy created during the stress of such an emergency would have little accountability. Thus, determinations should be made beforehand about what level of priority disease prevention should be given when it is in tension with economic stability or other important public goods. The extent to which coercive measures will be exercised should be debated at the national, state, and local levels, and government should make clear at what point it will implement various interventions and when they will be lifted.

Transparency is essential to create and maintain public trust and accountability. Openness and accountability are important to public health governance because of their intrinsic value and capacity to improve decision making. Citizens gain a sense of satisfaction by participating in policymaking and having their voices heard. Even if government decides that personal interests must yield to common needs, the individual feels acknowledged if he or she is listened to and his or her values are taken into account. Transparency also has instrumental value because it provides a feedback mechanism – a way of informing public policy and arriving at more considered judgments. Open forms of governance engender and sustain public trust, which benefits the public health enterprise more generally. Without public support, and the voluntary cooperation of those at risk, coercive public health interventions would be difficult to achieve. The populace must be able to trust that its government is acting in its best interests.

Public Health Law Reform

The laws relating to public health are scattered across countless statutes and regulations at multiple levels of government. Problems of antiquity, inconsistency, redundancy, and ambiguity often render these laws ineffective, or even counterproductive, in advancing the population’s health (Gostin, 2001). In particular, health codes frequently are outdated, built up in layers over different periods of time, and highly fragmented among subnational political units. Some regions have made efforts to modernize their public health laws, but many are still plagued by these problems.

Public health law reform will present unique difficulties to individual nations. In order for public health laws to be effective, they need to be tailored to a country’s capacities and needs. Each country must consider state-specific factors such as national political structures and principles, educational and cultural environment, prevalence patterns of disease, available resources, and the strengths and weaknesses of the health-care system. However, improving global public health should not be seen as a purely intranational endeavor. Internationally, developed countries are increasingly concerning themselves with global health issues and have an emerging responsibility to assist developing countries in improving the health of their populations (Gostin, 2007).

Problem of Antiquity

The most striking characteristic of state public health law, and the one that underlies many of its defects, is its overall antiquity. Certainly, some statutes are relatively recent in origin, such as those relating to health threats that became salient in the latter part of the twentieth century (e.g., environmental law). However, a great deal of public health law was framed in the late nineteenth and early to mid-twentieth century and contains elements that are 40 to 100 years old, such as infectious disease law. Old laws are not necessarily bad laws. A well-written statute may remain useful, effective, and constitutional for many decades.

Nevertheless, old public health statutes that have not been substantially altered since their enactment are often outmoded in ways that directly reduce both their effectiveness and their conformity with modern standards. These laws often do not reflect contemporary scientific understandings of injury and disease (e.g., surveillance, prevention, and response) or legal norms for protection of individual rights. Rather, public health laws utilize scientific and legal standards that prevailed at the time they were enacted. Society faces different sorts of risks today and deploys different methods of assessment and intervention. When many of these statutes were written, public health (e.g., epidemiology and biostatistics) and behavioral (e.g., client-centered counseling) sciences were in their infancy. Modern prevention and treatment methods did not exist.

At the same time, many public health laws predate the vast changes in constitutional (e.g., tighter scrutiny and procedural safeguards) and statutory (e.g., disability discrimination) law that have transformed social and legal conceptions of individual rights. Failure to reform these laws may leave public health authorities vulnerable to legal challenge on grounds that they are unconstitutional or that they are preempted by modern statutes. Even if state public health law is not challenged in court, public health authorities may feel unsure about applying old legal remedies to new health problems within a very different social milieu.

Problem of Multiple Layers of Law

Related to the problem of antiquity is the problem of multiple layers of law. The law usually consists of successive layers of statutes and amendments, built up in some cases over 100 years or more in response to existing or perceived health threats. This is particularly troublesome in the area of infectious diseases, which forms a substantial part of state health codes. Because communicable disease laws have been passed piecemeal in response to specific epidemics, they tell the story of the history of disease control (e.g., smallpox, yellow fever, cholera, tuberculosis, venereal diseases, polio, and AIDS).

Through a process of accretion, some governments have come to have several classes of communicable disease law, each with different powers and protections of individual rights: those aimed at traditional STDs (or venereal diseases), including gonorrhea, syphilis, chlamydia, and herpes; those targeted at specific currently or historically pressing diseases, such as tuberculosis and HIV; and those applicable to ‘communicable’ or ‘contagious’ diseases, a residual class of conditions ranging from measles to malaria whose control does not usually seem to raise problematic political or social issues. There are, of course, legitimate reasons to treat some diseases separately. Nevertheless, affording health officials substantially different powers, under different criteria and procedures for different diseases, is more an accident of history than a rational approach to prevention and control.

The disparate legal structure of public health laws can significantly undermine their effectiveness. Laws enacted piecemeal over time are inconsistent, redundant, and ambiguous. Even the most astute lawyers in public health agencies or offices of the attorney general have difficulty understanding these arcane laws and applying them to contemporary health threats.

Problem of Inconsistency among Political Subunits

Public health laws remain fragmented not only within specific jurisdictions, but among them as well. Health codes in various regions have evolved independently, leading to profound variation in the structure, substance, and procedures for detecting, controlling, and preventing injury and disease. In fact, statutes and regulations can vary so significantly in definition, method, age, and scope that they defy orderly categorization. Ordinarily a different approach is not a problem and is often perceived as a virtue; independent areas can become laboratories for innovative solutions to challenging health problems. Nevertheless, there may be good reason for greater uniformity in matters of public health. Health threats are rarely confined to single jurisdictions but pose risks within whole regions or the nation itself. For example, geographic boundaries are largely irrelevant to issues of air or water pollution, disposal of toxic waste, or the spread of infectious diseases. Similarly, a bioterrorism event threatens the nation and is not confined to a single location.

Public health law, therefore, should be reformed so that it conforms with modern scientific and legal standards, is more consistent within and among states, and is more uniform in its approach to different health threats. Rather than making artificial distinctions among diseases, public health interventions should be based primarily on the degree of risk, the cost and efficacy of the response, and the burdens on human rights. A single set of standards and procedures would add needed clarity and coherence to legal regulation, and would reduce the opportunity for politically motivated disputes about how to classify newly emergent health threats.

Conclusion

These are the challenges of public health law: Does it act modestly or boldly? Does it choose scientific neutrality or political engagement? Does it leave people alone or change them for their own good? Does it intervene for the common welfare or respect civil liberties? Does it aggressively tax and regulate or nurture free enterprise? The field of public health law presents complex tradeoffs and poses enticing intellectual challenges, both theoretical and essential, to the body politic.

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