From the Nanny State to the Bully State

Consequently, the case for state interventions to change the health environment and individual behaviour is, it is claimed, an unassailable one. During the past couple of years, therefore, Western nations have been introducing a myriad of case studies representing health stewardship-in-action. These have included regulations, taxes, and program addressing obesity, alcohol, gambling, and smoking.

This is the point in the story line where, one may reasonably assume, one of the characters poses the perfectly reasonable question, what does the evidence say? Sadly and perplexingly, rarely has that happened. But, if it did, what would a balanced reading of the research literature tell us?

It would inform us that:

Providing health information has not failed. What has failed is the state's expensive attempt to instill fear in the minds of its citizens about many of their dietary and recreational choices. Serious health warnings are diluted when consumers are deluged by “warnings” about every imaginable item, ingredient, and eventuality. There is already evidence that consumers are confused by warning labels, for example. Clearly, most of these labels should come with their own warning: “Caution: Bureaucrats at Work”.
Prevention has failed to ward off lifestyle illnesses for the fundamental reason that such illnesses are multifactoral and, therefore, it is clinically impossible to identify the sole cause of a disease. Consider, for instance, the multiplicity of risk factors for both lung cancer and heart disease - 30 for the former and more than 300 for the latter.

Consequently, health promotion has failed as a policy tool. Since Canada's then-Health Minister Marc Lalonde articulated the health promotion philosophy in 1974, the central tenets of health promotion have remained two-fold, namely, that (1) science clearly shows that, if people are to be healthy, they must change their lifestyles, and (2) it is the public health establishment's role to see that this change takes place, either voluntarily, or, if necessary, through various modes of coercion.

There is little compelling evidence, however, that multifactoral diseases can be prevented, particularly through lifestyle interventions. Respective governments' specific policies on obesity, alcohol, gambling, and smoking are unjustified and unsuccessful because they are based upon evidence-free arguments. These policies never stood a chance of success.

The standards of scientific evidence required to justify public health interventions are far, far higher than those employed by policymakers. Evidence-light, photo-op policymaking often makes for good media coverage and, at times, good politicking, but it rarely makes for good public health.

In addition to a dissection of the health paternalism mantra underlying the Bully State, what is needed is a robust articulation of the case for individual autonomy. Such a case would flesh out the following points: individual autonomy is the core value of a democratic society; there is an inherent trade-off between individual autonomy and public health under health paternalism; and the abandonment of individual autonomy in health policy poses a threat to our other freedoms.

One need not be an American libertarian or a European classical liberal to appreciate the stewardship ethic's threat to a democratic society. Rather than the product of an ideological agenda, a plea for personal choice as the foundational value of public health is, in stark contrast, a plea for both common sense and morality in policymaking.

As Bully Staters do not want us to smoke cigarettes, gamble, drink alcohol, or gain weight, they will ratchet up their campaign to shame and coerce those who rejoice in the individual's right to pursue pleasure. Under the Bully State, the real bully is Nanny the Policy Nurse, who dispenses regulatory “cures” for all manner of alleged social ills, from smoking to simply having fun.

Thankfully, there will be dramatic growth in people's unwillingness to be bullied out of, and into, particular habits. This will create an opportunity for the first politician who stands in front of the Bully State's regulatory march yelling, “Stop!” By the end of the decade, it is entirely possible that most Westerners will be actively rebelling against their respective Department of the Domestic Bully.

Appropriately harnessed, such a popular groundswell may demand a scaled-down state in the public health arena. This would ensure a focus on the legitimate role of government in health- care policy: providing credible information, refraining from propaganda and persuasion, and funding evidence-based care.