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If the cost of taxpayer-funded health care were counted as the sort of harm that justifies government intervention under Mill’s principle, the exception would swallow the rule. The same goes for harms to other people that do not constitute crimes or torts, such as the emotional pain of losing a friend to smoking-related lung cancer or the burden of assisting a relative who is so fat he has trouble getting around. If costs like these were grounds for government intervention, no one anyone cared about would ever be free to run his own life. Likewise, the fact that some people who engage in a particular activity commit crimes or torts, such as gamblers who steal or drinkers who drive while intoxicated and get into crashes, is not sufficient grounds for prohibiting the activity. Such a position would, like the determination to avoid any possible impact on the public treasury, obliterate the distinction between self-harm and harm to others.
The Corruption of Medicine by
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 enlisting the state in their cause. Writing in 1879, John Shaw Billings put it this way: “All 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 measures aimed at traditional public health targets, such as infectious diseases and toxic pollution. It’s reasonable to expect that such efforts 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, many people will continue to 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 do indeed treat adults like children.
One such expert, Boston public health official Leon S. White, reflected on the recalcitrance of risktakers in 1975, the year the federal government published its Forward Plan for Health, which set forth a “prevention strategy” that included various laws aimed at stopping people from harming themselves. “The real malpractice problem in this country today,” White wrote in The New England Journal of Medicine, “is not the one described on the front pages of daily newspapers but rather the malpractice that people are performing on themselves and each other.…It is a crime to commit suicide quickly. However, to kill oneself slowly by means of an unhealthy life style is readily condoned and even encouraged.” White’s article prompted a response from Robert Meenan, a professor at the University of California School of Medicine in San Francisco, who observed: “Health professionals…have no personal attributes, knowledge, or training that qualifies 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 priorities.”
This is what H.L. Mencken had in mind when he remarked that “hygiene is the corruption of medicine by morality. It is impossible to find a hygienist who does not debase his theory of the healthful with a theory of the virtuous. The whole hygienic art, indeed, resolves itself into an ethical exhortation. This brings it, at the end, into diametrical conflict with medicine proper. The true aim of medicine is not to make men virtuous; it is to safeguard and rescue them from the consequences of their vices. The physician does not preach repentance; he offers absolution.” Whether or not you agree with Mencken’s view of the physician’s proper role, the danger of transforming a doctor’s orders into the government’s orders should be clear.
But not to everyone. Some public health theorists explicitly recognize that their aims are fundamentally collectivist and cannot be reconciled with the American tradition of limited government.In 1975 Dan 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.”
Not only are all persons entitled to health protection, but they’re going to get it, whether they want it or not. Beauchamp 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.” 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.” So the right to be left alone—the right Supreme Court Justice Louis Brandeis considered “the most comprehensive of rights and the right most valued by civilized men”—turns out to be the leading risk factor for disease and injury.
Beauchamp may be unusually candid, but his vision is implicit in
the way public health is currently understood. According to John
Hanlon’s 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
place.” The textbook 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.’ ” Especially in light of this definition, the WHO’s goal of “Health for All,” if it is meant to be a prescription for state action, has a chilling sound to it.
“Over himself, over his own body and mind, the individual is sovereign,” Mill insisted. The mandate “Health for All” replaces that principle with a legally enforceable duty to be well, a demand by the collective to keep one’s body and mind in optimal condition. A government empowered to maximize health is a not a government under which anyone who values liberty would want to live.
Senior Editor Jacob Sullum is the author of For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health (Free Press). This article is adapted from a talk he gave at a conference on “Public Health and the Legacy of John Stuart Mill” at Columbia University’s Mailman School of Public Health in December.
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