Author's response

The world of general practice looks very different from the perspective of my surgery in Hackney than it does from the lofty heights of Imperial College. As it happens, I do not spend ‘significant portions’ of my day dealing with the consequences of smoking, alcohol, and poor diet. Most of my patients are children, older people, and others for whom these are non-existent or marginal issues. We do face challenging problems in rheumatology, endocrinology, neurology, psychiatry, and cancers (notably of the breast and prostate), and many more that are little influenced by behavioural factors. I am greatly encouraged that over the two decades I have been in practice, thanks in part to better medical diagnosis and treatment, and despite what the fellows and professors of Imperial would regard as disgustingly unhealthy lifestyles, our patients are living longer and healthier lives.

Of course, I have some patients whose health has been adversely affected by smoking and alcohol, and others who suffer from car accidents, violence, and sports injuries. My job as a doctor is to help them with their medical problems, however they have arisen, not to tell them how to live their lives. I am not ‘in the business of influencing behaviour’: that is a legitimate activity for parents and teachers in relation to children, or circus trainers in relation to performing animals, and perhaps for clergyman, and probation officers. In my experience, patients are well aware that smoking and excessive drinking are not good for their health. Taking advantage of a medical consultation in an attempt to change these habits is impertinent, obtrusive, and implicitly authoritarian. (I do not, by the way, consider having a vaccination or a screening test as ‘behaviour’, a concept that implies a customary or habitual activity.)

Doctors' moralistic interventions are also likely to be counterproductive as they are corrosive of moral autonomy.1 They also give the impression that doctors have some expertise in the sphere of righteous living – which they have not – and that novel psychological techniques can enable them to achieve the desired outcomes – that, notwithstanding the extravagant claims of behavioural economics, remains to be seen. It is disturbing that the elitist ideology of nudge, that reflects such a paternalistic and disrespectful approach towards patients, is enjoying a growing influence over health policy.

• © British Journal of General Practice, January 2011