Damned Tobacco

What was once a joke is now a serious policy proposal. Kelly Brownell, a professor of psychology at Yale University who directs the school’s Center for Eating and Weight Disorders, has suggested taxing foods based on their nutritional content. "A militant attitude is warranted here," he told the New Haven Register. "We’re infuriated at tobacco companies for enticing kids to smoke, so we don’t want Joe Camel on billboards. Is it any different to have Ronald McDonald asking kids to eat foods that are bad for them?" In its first issue of the year, U.S. News & World Report included the idea of a junk food tax on its list of "16 Silver Bullets: Smart Ideas to Fix the World."

Of course, a tax on junk food would be paid by the lean as well as the plump. It might be more fair and efficient to tax people for every pound over their ideal weight. Such a market-based system would make the obese realize the costs they impose on society and give them an incentive to slim down.

If this idea strikes most people as ridiculous, it’s not because the plan is impractical. In several states, people have to bring their cars to an approved garage for periodic emissions testing; there’s no logistical reason why they could not also be required to weigh in at an approved doctor’s office, say, once a year, reporting the results to the Internal Revenue Service for tax assessment.

Though feasible, the fat tax is ridiculous because it’s an odious intrusion by the state into matters that should remain private. Even if obesity is apt to shorten a person’s life, most Americans would (I hope) agree, that’s his business, not the government’s. Yet many of the same people believe not only that the government should take an interest in whether a person smokes but that it should apply pressure to make him stop, including fines (a.k.a. tobacco taxes), tax-supported nagging, and bans on smoking outside the home.

Accustomed to Power

Because the public health field developed in response to deadly threats that spread from person to person and place to place, its practitioners are used to dictating from on high. Writing in 1879, John Billings put it this way: "[A]ll admit that the State should extend special protection to those who are incapable of judging of their own best interests, or of taking care of themselves, such as the insane, persons of feeble intellect, or children; and we have seen that in sanitary matters the public at large are thus incompetent."

Billings was defending traditional public health measures aimed at preventing the spread of infectious diseases and controlling hazards such as toxic fumes. It’s reasonable 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 after the public is informed 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, eschew seat belts and motorcycle helmets, and otherwise behave in ways frowned upon by the public health establishment. This is not because they misunderstood; it’s because, for the sake of pleasure, utility, or convenience, they are prepared to accept the risks. When public health experts assume these decisions are wrong, they are indeed treating adults like incompetent children.

The dangers of basing government policy on this attitude are clear, especially given the broad concerns of the public health movement. According to textbook Public Health Administration and Practice, "public health is dedicated to the common attainment of the highest levels of physical, mental, and social well-being and longevity consistent with available knowledge and resources at a given time and place." Principles of Community Health tells us that "the most widely accepted definition of individual health is that of the World Health Organization: ‘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 totalitarian government.

In response to such fears, 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," noted Surgeon General Julius Richmond’s 1979 report Healthy People, "and opponents of mandatory [helmet] laws argue that since other people usually are not endangered, the individual 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 line of reasoning, which is also used to justify taxes on tobacco and alcohol, implies that all resources–including not just taxpayer-funded welfare and health care but private savings, insurance coverage, and charity–are part of a common pool owned by "society as a whole" and guarded by the government.

As Robert F. Meenan, a professor at the University of California School of Medicine in San Francisco, noted in The New England Journal of Medicine two decades ago, "virtually all aspects of life style could be said to have an effect on the health or well-being of society, and the decision reached that personal health choices should be closely regulated." Writing 18 years later in the same journal, Faith Fitzgerald, a professor at the University of California at Davis Medical Center, observed: "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 consequences."

Public Health vs. Freedom

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." C. Everett Koop, for his part, seems untroubled. "I think that the government has a perfect right to influence personal behavior to the best of its ability if it is for the welfare of the individual and the community as a whole," he writes. Koop thus implies that the government is authorized to judge "the welfare of the individual," and he elevates "the community as a whole" above mere people.

Some defenders of the public health movement have explicitly recognized 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, 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 primary duty to avert disease and injury still rests with the individual." Beauchamp 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."

Public health, in other words, is inconsistent with the right to be left alone. Of all the risk factors for disease or injury, it seems, freedom is the most pernicious.