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Reducing the Burden of Injury: Advancing Prevention and Treatment
injured as a result of his or her own risk taking rarely "internalizes" the cost of the injury and that everyone therefore has a stake in reducing the social costs of injury. Finally, some might argue that even if the intervention is paternalistic, it still may be justified as long as some other criterion is met (e.g., that the aggregate social benefits of the intervention outweigh its costs). Recent studies have shown, for example, that mandatory helmet laws and mandatory safety-belt use laws substantially reduce injury costs (Graham et al., 1997; Max et al., 1998). In the final analysis, opposition to mandatory safety-belt laws virtually evaporated in the face of unequivocal evidence that the safety gains (lives saved and disability avoided) far outweigh the costs of enforcement and the slight reduction in freedom.
Regardless of one's views on the issue of paternalism, injury prevention interventions always require attention to costs and benefits, and a restriction of individual freedom must sometimes be "weighed" as one of the "costs" of the intervention. One example is the argument that reducing the blood alcohol level (BAL) that constitutes conclusive evidence of drunk driving (from 0.10 g/dL to 0.08 g/dL) will curtail the opportunity for social drinking in bars and restaurants by many people who would not have posed a higher crash risk. How does one quantify the "costs" of this reduced freedom to drink and weigh them against the safety gains effected by the 0.08 BAL laws? Another contentious example is the argument that reducing access to handguns in the home poses a trade-off between the value of the lives that would be saved by reduced access and the value of a reduced sense of security for homeowners. One of the important challenges facing the field is to promote rational discourse about the empirical issues and value judgments raised by these recurrent conflicts between safety regulation and personal freedom (see Chapter 5).
Federalism and Priority Setting
As in many areas of public health, an ongoing dispute concerns the role of the federal government in priority setting. Some argue that the most useful role of the federal government in the sphere of injury prevention is to support states and communities in their efforts to set and implement local priorities. The counterargument is that limited federal dollars should be used to generate new knowledge and to spur states and communities to implement policies and programs that have been identified as federal priorities. This dispute is evident in debates between those who want federal money to be used for capacity building in state health departments and those who prefer that the money be used to support the implementation and evaluation of programs identified as federal priorities.
Another dimension of this controversy is the degree of pressure that should be brought to bear on states to implement federal priorities. Sometimes Congress uses the "carrot," making grants available for the specific purpose of implement-