C. Everett Koop: Paragon of Public-Health Paternalism


National Library of Medicine

C. Everett Koop, who died yesterday at the age of 96, embodied a vision of the U.S. surgeon general as "America's family doctor." That is what Koop, who served throughout the Reagan administration, called himself in the title of his memoirs, where he explained why he decided to wear the gold-braided, dark blue uniform of a vice admiral, corresponding to his honorary military rank as head of the U.S. Public Health Service:

I put it on immediately, because I felt it would help reestablish the languishing authority of the Surgeon General and revive the morale of the Commissioned Corps of the United States Public Health Service. There is something about a uniform.

Indeed there is, but whether you view that something as inspiring or ridiculous in this context probably depends on whether you think the country needs a paramilitary nag in chief to tell us how we should behave so as to minimize morbidity and mortality. From the perspective of New York Times columnist Mark Bittman, for example, Koop is the very model of the modern surgeon general, who he says should be "the nation's doctor," taking on Big Food in the same way that Koop took on Big Tobacco. Bittman, who welcomes the "fun" opportunity to meddle in other people's diets and thinks the government is "on our side" when it stops us from eating what we want to eat, complains that the current surgeon general, Regina Benjamin, is so retiring that people don't even know her name. To me, that counts in Benjamin's favor, although she has been known to pose in that absurdly self-aggrandizing uniform. 

In a glowing 1986 profile, People noted that "Koop has always lived as if he were on a mission from God." A pioneer in pediatric surgery, he combined a surgeon's arrogance with a preacher's moral certitude as he launched his crusade for "a smoke-free society by the year 2000," which consisted largely of scolding but also employed coercive policies such as smoking bans and cigarette taxes. It is a good thing Koop did not have much in the way of real political power, given the views he expressed about the government's role in making us all as healthy as we can be, without regard to our personal preferences. "From my point of view," Koop told the Philadelphia Inquirer in 1996, "anything that stops smoking is good." And not just smoking. "I think that the government has a perfect right to infuence personal behavior  to the best of its ability," he wrote  that same year in Priorities, a publication of the American Council on Science and Health, "if it is for the welfare of the individual and the community as a whole."

Although the scary implications of that premise are not hard for a libertarian to see, Koop did not simply disagree; he seemed genuinely puzzled by the distinction between risks that are imposed by others and risks that are voluntarily assumed, likening government policies aimed at discouraging unhealthy habits to laws against assault. The failure to understand principled objections to paternalism is an occupational hazard for public health specialists, who routinely jump from is to ought, conflating medical and moral judgments. "Smoking raises the risk of lung cancer" is a medical judment; "therefore you should not smoke" is a moral judgment.

A 1989 New York Times editorial illustrated the tendency to confuse the two, praising Koop for "put[ting] medical integrity above personal value judgments." Similarly, the Times reports that Koop "said he had declined to speak out on abortion because he thought his job was to deal with factual health issues like the hazards of smoking, not to express opinions on moral issues." Yet the question of whether people should trade health or longevity for other things they value, such as pleasure or convenience, is a moral issue. Koop believed they should not, and he was, like Mark Bittman, eager to impose that judgment on other people by force.

Video bonus: Koop thinks Ali G is stupid.

Koop plays a prominent role in For Your Own Good, my book about the anti-smoking movement.

Addendum: Gilbert Ross of the American Council on Science Health praises Koop for "transmitting science-based information about AIDS" when doing so was politically risky, while Americans United for Life remembers him as "a pro-life giant and pioneer."