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Healthy People noted that “formidable obstacles” stand in the way of improved public health. “Prominent among them are individual attitudes toward the changes necessary for better health,” it said. “Though opinion polls note greater interest in healthier lifestyles, many people remain apathetic and unmotivated.…Some consider activities to promote health moralistic rather than scientific; still others are wary of measures which they feel may infringe on personal liberties. However, the scientific basis for suggested measures has grown so compelling, it is likely that such biases will begin to shift.” In other words, people engage in risky behavior because they don’t know any better. Once they realize the risks they are taking, they will change their ways.
Surely there is a measure of truth to this. The publicity surrounding the first surgeon general’s report on the health hazards of smoking, published in 1964, was followed by a more or less steady decline in the prevalence of smoking among Americans, from 42 percent of adults in 1965 to about half that today. Some of that decline, especially in recent years, probably has been due to coercive measures such as smoking bans and cigarette tax hikes, but most of it was seen in the first couple of decades, when the main tactics of the anti-smoking movement were education and persuasion. Likewise, the dramatic increase in seat belt use by Americans, from 15 percent of drivers and front-seat passengers in 1984 to 80 percent two decades later, may have been partly due to the threat of fines, but greater awareness of the safety benefits also has played an important role.
Still, some people, even after they understand the risks they’re taking, obstinately continue to take them. To Richard Carmona, it may be obvious that “every American needs to eat healthy food in healthy portions and be physically active every day.” But what if some Americans, or many, or most, refuse to get with the program?
An Unspoken Moral Premise
As early as June 1975, in its Forward Plan for Health, the U.S. Public Health Service was suggesting “strong regulations to control the advertisement of food products, especially those of high sugar content or little nutritional value.” Since then, as Americans have gotten fatter, calls for restrictions on ads, especially those aimed at children, have intensified. Anti-fat crusaders such as the Yale obesity expert Kelly Brownell are pushing “junk food” taxes to discourage consumption of cheeseburgers and potato chips, along with subsidies to encourage consumption of fruits and vegetables. You could extend that idea to the energy expenditure side of the equation, taxing products associated with sloth, such as books and TV sets, and subsidizing products associated with exercise, such as bicycles and treadmills. Other proposals include lawsuits to compel restaurant menu changes, bans on fast food near schools, and an “equal time” rule requiring stations that air ads for fast food and sugary breakfast cereals to carry propaganda urging people to eat better and exercise more.
None of this is likely to work. There is little evidence that kids like candy and ice cream, or eat more of it, because of advertising; that they see more food advertising now than they did when they were thinner; or that bans on ads aimed at children, which have been imposed in Sweden and Quebec, make kids slimmer. The price control system envisioned by Kelly Brownell and like-minded activists raises insoluble calculation problems, and since tax rates would be the same for every buyer, it would either overdeter moderate eaters or underdeter gluttons—probably both. Restaurants can sell only what people are willing to eat, and litigation will not change that. Establishing fast-food-free zones near schools would not prevent students from bringing their own fattening food to school, and it would not affect most of their meals in any case. And even if a policy of forcing stations to carry anti-obesity messages survived a First Amendment challenge (which it wouldn’t), it is doubtful that telling people what they already know—that exercise and a balanced diet are important to good health—would have much of an impact.
But I can think of a couple of policies that would make a difference. Instead of a “junk food” tax, which is inefficient and unfair because it is paid by the thin as well as the fat, why not tax people for every pound over their ideal weight? People would be required to get weighed once a year at an approved station, which would send its report to the Internal Revenue Service. If the tax were set high enough, I’m sure many people would lose weight. If that seems too complicated, how about mandatory calisthenics in the town square every morning? Assuming these policies are feasible and cost-effective, is there any basis for objecting to them “from a public health perspective”?
If not, I’d suggest that the public health perspective leaves out some important considerations. Maximizing health is not the same as maximizing happiness. The public health mission to minimize morbidity and mortality leaves no room for the possibility that someone might accept a shorter life span, or an increased risk of disease or injury, in exchange for more pleasure or less discomfort. Motorcyclists, rock climbers, and sky divers make that sort of decision all the time, and not all of them are ignorant of the relevant injury and fatality statistics. With lifestyle choices that pose longer-term risks, such as smoking and overeating, the dangers may be easier to ignore, but it is still possible for someone with a certain set of tastes and preferences to say, “Let me enjoy myself now; I’ll take my chances.” The assumption that such tradeoffs are unacceptable is the unspoken moral premise of public health. When the surgeon general declares that “every American needs to eat healthy food in healthy portions and be physically active every day,” where does that leave a guy who prefers to be fat if it means he can eat what he likes and relax in his spare time instead of looking for ways to burn calories?
It’s true that, as the anti-smoking activist William Cahan pointed out on a CNN talk show several years ago, “People who are making decisions for themselves don’t always come up with the right answer.” They don’t necessarily make tradeoffs between health and other values in an informed or carefully considered manner. Sometimes they regret their decisions. But they know their own tastes and preferences, and they have access to myriad pieces of local information about the relevant costs and benefits that no government regulator can possibly know. They will not always make good decisions, but on balance they will make better decisions, as measured by their own subsequent evaluations, than any third party deciding for them. Leaving aside the question of who is better positioned to decide whether a given pleasure is worth the risk associated with it, there is an inherent value to freedom: When it comes to how people feel about their lives, they may well prefer to make their own bad choices rather than have better ones imposed on them.
Needless to say, people make mistakes—sometimes expensive, hard-to-correct mistakes—in many areas of life. If that fact is reason enough for the government to second-guess their decisions about dangerous activities such as smoking cigarettes and riding motorcycles, why on earth should the government let people make their own choices when it comes to such consequential matters as where to live, how much education to get, whom to marry, whether to have children, which job to take, or what religion to practice? These decisions are at least as important, and the government is at least as well equipped to make them as it is to decide which health risks are acceptable.
While people are not perfect judges of their own interests, they are better judges, by and large, than government officials are apt to be. That is the utilitarian case against paternalism and in favor of individual freedom. But what if people making health-related decisions are not truly free? Some paternalists claim that surrendering to certain habits, such as drug use or gambling, is akin to selling yourself into slavery, which Mill himself said was not an acceptable use of freedom.
It’s pretty clear from Mill’s condemnation of alcohol prohibition that he did not share this view of addiction. In any case, there is abundant evidence that addiction is a pattern of behavior shaped by a complex interaction of personal and situational variables, not an automatic process in which people become “hooked” without regard to their own choices or desires. In that sense it is quite different from being clapped in chains and forced to follow another person’s commands.
Mill also made an exception for minors, of course; and so-called public health threats, such as the violent entertainment that vexes Hillary Clinton, are often described as menaces to children. People who oppose paternalism vis-à-vis adults can nevertheless support measures, such as a legally enforced cigarette purchase age, that are narrowly targeted at preventing minors from making risky decisions that are properly reserved for grownups. But child protection often becomes an excuse for restricting the freedom of adults. The aforementioned fast-food-free zones, for example, probably would not make kids noticeably thinner but certainly would make life harder for adults looking for a quick and convenient lunch while working or running errands near schools.
Sometimes politicians and activists who claim to be fighting for parents are actually complaining about the appalling stuff that parents let their kids see, do, or eat. They want to override parental prerogatives instead of reinforcing them. Sen. Clinton, for example, worries that parents do not make enough use of the “V chip” her husband championed as a way to prevent children from seeing inappropriate TV shows. But perhaps they simply are not as alarmed as she is about the state of popular culture. Likewise, activists who want to ban food marketing aimed at children do not seem to trust parents to say no when their kids demand SpongeBob SquarePants Pop-Tarts or Dora the Explorer cookies.
The Dictatorship of Health Care
Since naked appeals to paternalism do not go over very well in the U.S., and since the child protection argument is not always plausible, advocates of enlisting the government to discourage unhealthy behavior often argue that risky habits are a legitimate matter of public concern because they cost taxpayers money. This is not necessarily true. Smoking, for example, raises the cost of treating certain illnesses, but it reduces other costs, since smokers tend to die sooner than nonsmokers and therefore do not use as much health care in old age, do not spend as much time in nursing homes, and do not draw as much on Social Security. A 1997 analysis in The New England Journal of Medicine concluded that total medical spending would go up, not down, if everyone stopped smoking. And that does not even consider the increase in Social Security outlays when smoking becomes less common. The Harvard economist Kip Viscusi, among others, concludes that the long-term taxpayer savings from smoking outweigh the short-term costs. If so, the public health community’s fiscal argument suggests that the government should be encouraging smoking. Something similar might be true of obesity.
But even if certain habits do, on balance, increase taxpayer costs, the problem is not that some people do risky things; it’s that the government forces other people to pay their medical bills. Mill’s harming principle certainly would allow the government to prevent someone from picking your pocket. But in this case, it’s the government that is picking your pocket by requiring you to subsidize the health care of the poor and the elderly. It’s inevitable that some of those patients will have risky habits that contribute to the cost of providing health care for them—habits such as overeating, underexercising, smoking, drinking too much, eating soft-cooked eggs or rare hamburgers, working too hard, sleeping too little, skiing, sunbathing, riding motorcycles, and neglecting to brush and floss, to name just a few. People who don’t want to pay for the consequences of such dangerous behavior shouldn’t support taxpayer-funded health care. If we were to keep these programs but try somehow to prevent people from doing anything that would make them more likely to need medical care, we would once again be facing the prospect of a government with an open-ended license to meddle in what used to be considered private decisions. We would be creating a society of resentful busybodies, where everyone’s personal habits are everyone else’s business.