Thinky: On the Ethics of a “Nanny State”
It’s fair to say that my politics are not those of The IPA, but I do quite enjoy reading Chris Berg – he’s rather amusing on twitter and he’s written some cracking articles on videogame violence, the expansion of national security because terrrorism and internet censorship. As you might expect from a left-of-centre geek, I get my news from ABC Online and Crikey – I used to live in Brisbane and since nobody actually thinks the Courier-Mail is a real newspaper, I tried to read the Australian – although I gave up in disgust at their partisanship when they launched their pogrom on the Greens. I generally find the political analysis of Bernard Keane (twitter) to be on the money. If you’re interested in Internet freedom, I strongly suggest grabbing a copy of his book War on the Internet. Apart from internet censorship, one thing Chris Berg and Bernard Keane agree on is their deep disdain (to put it mildly) for the public health “nanny state”. See articles by Chris here, here, here and here and by Bernard here, here and here. See here for a wrap-up of rebuttals to Bernard’s posts (the articles from Richard Di Natale and Simon Chapman are particularly worth a read.
I’d encourage you to read the articles I’ve just linked to; I’m going to try and pose the case for the other side. I don’t expect to move the positions of Berg or Keane, but it’s more for the people who read their articles and say “yes, that makes sense” – I’ve had some discussion on Twitter with some people from the Pirate Party which – although it doesn’t have a preventive health policy is generally libertarian in its ideals.
Medical Ethics 101
Doctor-friends and medical readers can skip to the next subheading, unless you enjoyed ethics at med school or need some revision.
Beneficence: The things we do for patients should serve the best interests of patients. This is pretty straight forward.
Non-maleficence: This is the principle of “primum, non nocere” – first, no harm. This is a little bit more nuanced than just not doing things that cause harm to patients. The implication is that it may be better to do nothing than to do something that poses a risk of net harm to a patient. It involves considering the risk/benefit of medical interventions and the less obvious side-effects of our medical interventions.
Autonomy: In the past, medicine operated in a more paternalistic manner – “doctor knows best”. Medical advice was given by the doctors to the patient, with an expectation it be followed. Modern healthcare stresses the “therapeutic partnership” much more – where doctors and patients work together to achieve good outcomes for the patient. I’ll come back to this shortly.
Distributive Justice: Isn’t very well covered in the Wikipedia article, but it relates to ensuring needs-based access to health care. This too, is much more complex than just having a public health system as I’ll discuss further below.
Applied Ethics in the Real World
You can find your own definition of ethics, but I like the one that involves it being the study of the interaction between the rights of the individual and the rights of society. In medical ethics, there is going to be a necessary compromise between some of the principles. An easy example is informed consent for an elective surgical procedure in the public healthcare system. The procedure is recommended by the doctor because he thinks the procedure is indicated (beneficence) and that the benefits outweigh the risks (non-maleficence). The patient is given an informed discussion on the risks of the procedure, and allowed to decide whether they want to go ahead or not, and what the alternatives would be (autonomy). The patient goes ahead and is placed on a waiting list (justice) such that more urgent cases, or those which have been waiting longer are done first.
It’s worth considering that you can’t give absolute priority to one principle over another. If you literally interpreted “no harm” you’d never perform any surgery or prescribe any medication because they all have risks of side-effects attached. Complete patient autonomy would create a situation where patients’ wishes about their management would override the doctor’s assessment (it’s worth noting that a patient can’t force a doctor to provide a treatment they feel is inappropriate or unethical; but the doctor provide a referral to someone else for a second opinion).
In the non-medical sphere, there is also a balance between ethical principles; we accept some limits on our autonomy (laws) in exchange for living in a safe(r) society.
The Berg / Keane argument is that individual autonomy should not be infringed by public health programs seeking to improve the health of the population at large, along with a good dose of downplaying the health benefits of public health.
Tim Wilson from the IPA writes “Nanny state advocates argue the job of government is to coddle us from the world’s evils, avoid risk and use taxes, laws and regulations to either steer or direct our behaviour.” Obviously there is some rhetorical flourish in there – or at least I certainly hope there is.
As Richard di Natale points out, our work plan in public health meetings don’t generally proceed along the lines of “how can we infringe on people’s liberty today”, rather along the lines of “what can we do to improve health” – a novel concept, to be sure.
Looking at Public Health Ethics Another Way
1. Public Health as Beneficence
This is hopefully pretty obvious. Stopping people from getting sick in the first place is a good thing to do – in the ethical sense, as it reduces disease and human suffering. If you haven’t already read it, see the final paragraph of Simon Chapman’s rebuttal to Bernard Keane. It also makes financial sense – healthy people don’t cost the health system money. (Although obviously you can debate the cost-effectiveness of public health campaigns – see here for a list)
2. Public Health doesn’t actually care about how much you <risk>
Clinical medicine is focused on the care of the individual patient. It’s often said that the unit of care of paediatrics (and palliative care) is the patient and their family. But public health is focused on the health of the population.
As an individual, you make up part of the bell curve. Your position on the bell curve isn’t particularly important to public health authorities, but what does matter is reducing the area under the curve. This can be done by “shifting the curve to the left” (see here for an example (the graph) and a discussion of the principle). If everyone drinks a bit less, then the “extreme drinkers” will be less numerous and/or drink a bit less and therefore alcohol-related harm will be reduced.
3. Public Health as pro-autonomy
The principle of autonomy relies on people making an informed decision about what to do. This is the argument for (for example) calorie displays on fast-food menus and traffic-light labeling of foods. There is compelling evidence that people with poor health literacy have worse health outcomes. Public health education campaigns – and indeed the whole discipline of health promotion – aim to allow people to make better informed decisions about what they do. Nobody can really complain if people make an autonomous informed decision to do something, a decision without all the available information cannot truly be said to be autonomous.
4. Public Health as Distributive Justice
There’s a couple of aspects to this, so I’ll tackle them one at a time.
a) “Regressive Taxation”
People from lower socioeconomic backgrounds have worse health literacy and also higher rates of use of tobacco and alcohol and lower rates of exercise. Tax-based disincentives (like cigarette excise and alcohol taxes) target people of lower incomes more than they do people of higher incomes, as the taxes make up a greater proportion of their disposable incomes.
Stop and think about that for a second – people with higher rates of and worse health outcomes associated with (and everything else) are disproportionately targeted by measures which aim to reduce . Also, for some values of (cigarette smoking; the recent “alcopops tax” not so much) we know that these measures are effective.
The flip-side of that is if you are well-off (and therefore more likely to have good health literacy), the tax will be a smaller proportion of your disposable income and less likely to influence your behaviour.
b) Health Access
In Australia, we have a public healthcare system. Of course, there is also a private system, but the realities of how this works is that people with acute care needs will go to the public system and some of them will then be decanted off to the private system, which generally deals with less urgent or elective cases.
Health is a major government expenditure and continues to grow. Public health services are a finite pie, not a magic pudding. If you want to make an informed decision to drink yourself until you look like this or this and your liver looks like this then you will be spending tax dollars on yourself that might otherwise be directed elsewhere (take your pick of other patients or lower taxes, depending on your politics).
I could go on at greater length, but it’s taken me a month to get this far (new baby). The short version of the message is that those of us that work in public health aren’t stopping you from having fun. We’re about improving health, not infringing liberty. My argument is very much that rather than primarily an issue of autonomy, public health is an issue of justice.
Finally, since ethics has a large chunk of relativism, when the liberty brigade tell you that the public health industry are anti-autonomy wowsers, maybe take a second to consider the fact that I think they’re a bunch of selfish, heartless individualists. Understanding is a three-edged sword, after all.