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- Anthony N. DeMaria, MD, MACC, Editor-in-Chief, Journal of the American College of Cardiology⁎ ()
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Dr. Anthony N. DeMaria, Editor-in-Chief, Journal of the American College of Cardiology, 3655 Nobel Drive, Suite 630, San Diego, California 92112
“The free man owns himself. He can damage himself with either eating or drinking; he can ruin himself with gambling. If he does he is certainly a damn fool, and he might possibly be a damned soul; but if he may not, he is not a free man any more than a dog.”
G. K. Chesterton (1)While researching a recent Editor's Page on obesity I came across the concept of the “nanny state,” and was surprised that many of my friends were unfamiliar with the term. The Free Dictionary defines the nanny state variously as: 1) a government that makes decisions for people that they might otherwise make for themselves, especially those relating to private and personal behavior; and 2) a government perceived as having excessive interest in or control over the welfare of its citizens, especially in the enforcement of extensive public health and safety regulations. Obviously, the term has pejorative connotations in and of itself. However, the more I read and thought about it, the more I agonized as to how I felt about a role for government in what are considered private and personal decisions. Since many of the articles we publish have implications regarding health care policy, I thought I would elaborate on the issue in an Editor's Page.
The most prominent example of the nanny state, and one that brought enormous attention to the issue, was the legislation proposed by Mayor Bloomberg that 32-ounce servings of soft drinks be prohibited in New York City. The legislation was ultimately struck down in court, but not before it provoked a brisk public reaction. Many individuals applauded the attempt to restrict access to high-calorie beverages as an important public health response to the increasing prevalence of obesity. However, the more voluminous response decried the encroachment upon personal freedom, especially for a behavior that, ostensibly, affected only the individual making the choice. The debate between the benefit of preventing someone from taking an action that might be harmful to their health, versus the detrimental effect of infringing upon an individual's freedom, continues to be fairly heated.
While prohibiting large soft drinks may be the nanny state action that attracted the most attention, it was far from the only such initiative. In his book The Nanny State (1), David Harsanyi details numerous other examples. He indicates that at one time the New York City Council agenda included consideration of bans on trans fats, aluminum bats, tobacco purchases by adults age 18 to 20 years, candy-flavored cigarettes, and others. Here in California a law has been passed banning the sale of foie gras at restaurants. As a former motorcycle rider, I always wore a helmet, but I know many of my colleagues bristled at the fact that they were mandated to do so by law. One only has to google the words nanny state to learn of the many actions dealing with even minor elements of personal behavior that elected and appointed officials have considered or proposed in an effort to do good.
There is, of course, one overriding situation in which government intervention is appropriate and important. Specifically, individual behavior can and absolutely should be regulated if it has the ability to negatively impact other individuals. Everyone would agree that driving under the influence of alcohol should be against the law. Similarly, it is clear that secondhand smoke can produce adverse effects on health, and so it is appropriate to restrict smoking in public places. I believe it is also reasonable to place some regulation on the ownership of guns, since they can clearly have devastating consequences in the hands of the mentally ill and criminals. An extension of this principle exists in terms of the monetary cost of harmful self conduct to society. Disease that is self-induced by the abuse of drugs, alcohol, tobacco, or obesity can result in health care expenses that must be borne by everyone, and not just the individual choosing such behavior. We in medicine are only too familiar with such circumstances. So in the face of escalating health care costs and the need to contain spending, it is not surprising that measures will be advocated to prevent conduct that can increase health care expenditures. However, there are gradations of detrimental actions. While obesity is harmful, a high-calorie meal or ice cream sundae with whipped cream is something virtually all of us enjoy from time to time. Therefore, there is a bit of a slippery slope here; if we start with some measure to prevent obesity, such as banning 32-ounce soda, where do we stop? An example of this potential dilemma is the story of an attempt to prevent girl scouts from selling their traditional cookies because they could contribute to a weight increase.
Inherent to the debate regarding the role of the government in legislating a hygienic behavior is the issue of personal responsibility. According to Harsanyi (2), surveys have shown that the vast majority of the public hold individuals responsible for their harmful behavior. It just seems logical that, if a person has full freedom of choice, he/she must be prepared to accept the consequences of their decisions. My sense is that most people who lead unhealthy lives accept, at least tacitly, the consequences of their lifestyle. Those who choose to smoke or eat and drink to excess do so with the recognition that they may pay the price for such actions by incurring illness. Therefore, one would think that if they did so in a way that did not endanger any others, there would be little justification other than financial for the government to intervene.
Despite the above, in a New York Times article defending Mayor Bloomberg's proposed ban on soda (3), Sarah Conley, a professor of philosophy and author of the book “Against Autonomy: Justifying Coercive Paternalism” opines that humans are often just incapable of making the right decision. She describes several types of “cognitive bias” that “make it difficult for us to take in the relevant information and choose accordingly”. This absolution of personal responsibility takes different forms by others. They argue that the information may be hidden from the public by the vendors, or that we may be systematically subconsciously habituated to certain behaviors, or even that some are biologically programmed to be incapable of overcoming the urge for injurious conduct. Having diminished or eliminated the role of personal responsibility, proponents then propose an important function for government in protecting the public from themselves or vendors. In this scheme personal freedom must give way to regulation, and a beneficent government is justified and even lauded for coercive paternalism. Of the several rationales for an active role of government in influencing decisions that individuals should normally make on their own, I find this to have the least merit.
As I said in the beginning, I find the role of government regulation of personal behavior to be a complex issue, and filled with “double-edged swords.” There is no question that self-induced disease is common, largely preventable, and at the very least an economic burden to society. There is absolutely no doubt that government should prohibit any individual behavior that potentially endangers others. I have even been comfortable, at least to this point, with restrictions on some individual activities that typically do not endanger others, such as prostitution and pornography. Whether the economic burden of harmful behavior justifies the encroachment upon individual rights is a tough call. My view is that, to be warranted, it would have to be for issues involving major financial costs. I have problems with the concept of the nanny state, at least as defined as government making decisions for people that they might otherwise make for themselves, especially those relating to private and personal behavior. It seems to me that government should stay out of our private affairs. I believe that the best answer here is education, although I recognize that changing human conduct through education is extremely difficult and not frequently successful. Nevertheless, it would seem imperative to establish that individuals had a clear understanding of the risks that they were taking with unhealthy lifestyles before imposing external controls over their lives. We have a long tradition of cherishing personal freedom, and have been willing to pay a large price to preserve it. I cannot see giving this up for coercive paternalism. I guess I agree with Chesterton. People may do a lot of dumb things that injure themselves and impose a cost on society, but this is the price of personal freedom.
- American College of Cardiology Foundation