What the Doctor Orders

By treating risky behavior like a communicable disease, the public health establishment invites government to meddle in our private lives.

Jacob Sullum from the January 1996 issue

(Page 4 of 4)

Billings was defending traditional public health measures aimed at preventing the spread of infectious diseases and controlling health hazards such as rotting animal carcasses. It is reason able to expect that such measures will be welcomed by the intended beneficiaries, once they understand the aim. The same cannot be said of public health's new targets. Even when they know about the relevant hazards (and assuming the information is accurate), many people will continue to smoke, drink, take illegal drugs, eat fatty foods, buy guns, speed, eschew seat belts and motorcycle helmets, and otherwise behave in ways frowned upon by the public health establishment. This is not because they misunderstand; it's because, for the sake of pleasure, utility, or convenience, they are prepared to accept the risks. When public health experts assume that these decisions are wrong, they do indeed treat adults like incompetent children.

One such expert, writing in the New England Journal of Medicine 20 years ago, declared, "It is a crime to commit suicide quickly. However, to kill oneself slowly by means of an un healthy life style is readily condoned and even encouraged." The article prompted a response from Robert F. Meenan, a professor at the University of California School of Medicine in San Francisco, who observed: "Health professionals are trained to supply the individual with medical facts and opinions. However, they have no personal attributes, knowledge, or training that quali fies them to dictate the preferences of others. Nevertheless, doctors generally assume that the high priority that they place on health should be shared by others. They find it hard to accept that some people may opt for a brief, intense existence full of unhealthy practices. Such individuals are pejoratively labeled 'noncompliant' and pressures are applied on them to reorder their priori ties."

More than 75 years ago, H.L. Mencken complained about this tendency to impose a moral valuethe par-amount importance of healthin the guise of medical science. "Hygiene is the corruption of medicine by morality," he wrote in 1919. "It is impossible to find a hygienist who does not debase his theory of the healthful with a theory of the virtuous." The public health establishment seeks government power to impose its vision of virtue on the rest of America.

And public health doctrine admits no limits. Principles of Community Health tells us that "the most widely accepted definition of individual health is that of the World Health Organiza tion: 'Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.'" A government empowered to maximize "health" is a totalitar ian government.

In response to such concerns, the public health establishment argues that government intervention is justified because individual decisions about risk affect other people."Motorcyclists often contend that helmet laws infringe on personal liberties," notes Healthy People, "and opponents of mandatory laws argue that since other people usually are not endangered, the individ-ual motorcyclist should be allowed personal responsibility for risk. But the high cost of disabling and fatal injuries, the burden on families, and the demands on medical care resources are borne by society as a whole." This familiar line of reasoning implies that all resourcesincluding not just taxpayer-funded welfare and health care but private savings, insurance coverage, and charityare part of a common pool owned by "society as a whole" and guarded by the government. Similarly, "social cost" calculations for tobacco and alcohol count medical expenses, regardless of who pays them or under what circumstances, and "lost produc tivity," as if every individual owes a full lifetime of income (at the highest possible wage?) to "society as a whole."

As Faith T. Fitzgerald, a professor at the University of California, Davis, Medical Center, writes in the New England Journal of Medicine : "Both health care providers and the commonweal now have a vested interest in certain forms of behavior, previously considered a person's private business, if the behavior impairs a person's 'health.' Certain failures of self-care have become, in a sense, crimes against society, because society has to pay for their con -sequences....In effect, we have said that people owe it to society to stop misbehaving, and we use illness as evidence of misbehavior."

Most public health practitioners would presumably recoil at the full implications of the argument that government should override individual decisions affecting health because such decisions have an impact on "society as a whole." They are no doubt surprised and offended to be called "health fascists," when their goal is to extend and improve people's lives. But some defenders of the public health movement recognize that its aims are fundamentally collectivist and cannot be reconciled with the American tradition of limited government. In 1975 Dan E. Beauchamp, then an assistant professor of public health at the University of North Carolina and currently a professor in the School of Public Health at the State University of New York at Albany, presented a paper at the annual meeting of the American Public Health Association in which he argued that "the radical individualism inherent in the market model" is the biggest obstacle to improving public health.

"The historic dream of public health that preventable death and disability ought to be minimized is a dream of social justice," Beauchamp said. "We are far from recognizing the principle that death and disability are collective problems and that all persons are entitled to health protection." He rejected "the ultimately arbitrary distinction between voluntary and involuntary hazards" and complained that "the the primary duty to avert disease and injury still rests with the individual.' He called upon public health practitioners to challenge 'the powerful sway market-justice holds over our imagination, granting fundamental freedom to all individuals to be left alone.' Of all the risk factors for disease and injury, freedom may be the most important."