From ‘nanny state’ to ‘therapeutic state’

The bogey of the ‘nanny state’ hovers over every discussion of public health policy. Faced with demands for measures to curtail smoking in public, obesity, binge-drinking or gambling, ministers declare that ‘we must guard against charges of nanny statism’. In response, health promotion enthusiasts — like Anna Coote of the King's Fund — ask ‘what's so terrible about the nanny state anyway?’.1 Coote cites a list of legislative restrictions introduced to reduce road traffic accidents — speed limits, safety belts, motorcycle helmets, breathalyser tests — that were once fiercely resisted as ‘nanny statism’, but are now generally accepted. She believes that policies now under discussion will soon be similarly regarded as part of the long march of progress towards a more enlightened and healthier society.

But a comparison of current debates over state interference in individual behaviour in the cause of improving health with those of the recent past reveals some striking contrasts. One is that, whereas the health benefits of the regulations affecting driving were immediately apparent — and rapidly realised — those resulting from, say, banning smoking in public places, are dubious and contentious. They are likely to be so small that they will be (like the dangers of passive smoking) the focus of disputes among statisticians for decades to come. The link between the advertising of so-called junk food and childhood obesity is so tenuous that restrictions are highly unlikely to reduce the problem (and any associated health benefits are, anyway, impossible to measure).

Another contrast is in public attitudes; in the past, intrusive public health measures were — in common with attempts to extend medical influence over wider areas of the life of individuals and society — fiercely resisted. Politicians and leading medical authorities promoted interventionist health policies in the face of public opposition. Today, ministers indulge in postures of reticence and express concerns about ‘nannyism’ in response to popular demands for further regulations covering smoking, drinking and eating. But ministerial postures are disingenuous; in reality, complaints about ‘nannyism’ have negligible influence. There is virtually no resistance to the advance of government intrusion in lifestyle if it is deemed to be justified in terms of public health.

Whereas popular campaigns once opposed driving regulations, who now opposes bans on public smoking or measures to curtail obesity? The tobacco and fast food industries have been so demonised that even they can scarcely raise a protest. Recent surveys reveal high levels of public support for government restrictions on smoking and unhealthy lifestyles — even among those who pursue such unhealthy lifestyles.2 Resistance to medicalisation was a common theme of the anti-psychiatry, gay liberation and feminist movements of the 1970s. But feminists who once opposed state intervention as patriarchal and oppressive, now demand more intrusive and coercive measures to deal with domestic violence and child abuse. Radical campaigners are more likely to demand medical recognition of conditions such as ME or Gulf War Syndrome than oppose it as pathologising and stigmatising. Whereas, in the past, the pressure for medicalisation came from the medical profession or the government, now it also comes from below, from society itself.

In fact, the ‘nanny state’ of the past no longer exists; it has metamorphosed into the ‘therapeutic state’; nanny has given way to counsellor.3 If the ‘nanny state’ was austere, punitive and authoritarian, the therapeutic state is touchy-feely, supportive — and even more authoritarian. Nanny merely told people what to do; counsellors also tell them what to feel and what to think.

According to sociologist Frank Furedi, the current demand for medicalisation ‘is generated by cultural changes that inflate the sense of individuation and powerlessness’.3 The demise of politics and the decline in social solidarity have produced an enhanced sense of individual frailty and vulnerability. The redefinition of personal difficulty as a form of pathology requiring professional management has driven the explosion in counselling services that now offer support in relation to every vicissitude of modern life, and particularly in relation to behaviours deemed unhealthy. But further professional intervention in the intimate life and behaviour of the individual is destined to intensify the subjective experience of incapacity, which is unlikely to be beneficial to wellbeing — or to health.

• © British Journal of General Practice, 2004.