Fact‐value framework for adjudicating public health policy debates

Abstract

AbstractThat policy should be evidence‐based has become a widely accepted dictum, especially in public health, where evidence‐based policy is strongly emphasized. Yet, most public health controversies arise because there is a conflict over values, which facts alone cannot resolve. Moreover, promoting population‐based health interventions requires the art of political actors to arouse public support. In discussing this tension in public health, studies often frame value conflicts as a barrier to rational decision‐making rather than viewing value considerations as an inherent part of democratic policymaking. We argue that by failing to engage value‐conflicts directly, public health professionals actually stymie evidence translation, which requires public and political buy‐in. We suggest a two‐by‐two framework that seeks to make value concerns more explicit in public health policymaking by breaking out policy controversies and alternatives along two dimensions—factual debates and value debates, creating four categories: uncontested alternatives, value debates, fact debates, and contested alternatives. We demonstrate that the policies that are most likely to be contested are those with a strong value conflict and where the evidence‐base is less solid. We also show that the framework is dynamic: fact and value conflicts are neither static nor inevitable. Rather, interested actors use both fact and value to try to push issues from contested to uncontested and vice‐versa. We conclude by demonstrating how the framework can help specify the role of both value and fact debates in public health policymaking through examples from U.S. public health policy controversies, including during the present COVID‐19 crisis.