The Tyranny of Public Health

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, and report 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 (also known as tobacco taxes), tax-supported nagging, and bans on smoking outside the home.

New York City lung surgeon William Cahan, a prominent critic of the tobacco industry, has explained the rationale for such policies. "People who are making decisions for themselves," he said, "don’t always come up with the right answer."

The dangers of basing government policy on this attitude are clear, especially given the broad concerns of the public health movement. According to the 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, then, 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 Healthy People, the 1979 surgeon general’s report. "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 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."

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." But former Surgeon General C. Everett Koop–who became famous as a foe of tobacco and now is campaigning against obesity–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.