LIBERTY
Witnessing the misery wrought by obesity, smoking, and alcohol, I suspect most GPs dismiss talk of a ‘nanny state’ as tabloid codswallop. But, in his excellent little polemic Killjoys: A Critique Of Paternalism,1 Christopher Snowdon has set out a surprisingly persuasive case that ought to be at least understood. Snowdon invokes John Stuart Mill’s injunction that liberty must only be curtailed when it threatens the wellbeing of others. In order to uphold liberty, Snowdon argues, government policy should not be directed to satisfy seemingly worthy aspirations like prolonging lifespan, since no government can ever understand the goals and values of individuals. The assumption that government knows best undermines freedom and risks all manner of other interventions and restrictions. A free-market economy is the best mechanism to allow individuals to decide how to live their lives, while any attempts to discourage certain behaviours or choices, for example, through taxation, are coercive and unfair. The freedom to smoke and drink unhindered, or live in ways others might consider unwise, is no trivial matter; Snowdon considers such freedoms to underwrite tolerance for diversity of thought.
YOU HAVE TO DIE OF SOMETHING
Some of Snowdon’s critique is uncomfortably valid. It’s hard to deny that restricting harmful behaviour amounts to imposing value judgements on others ‘for their own good’. Snowdon has a good ear for shoddy arguments, skewering, justifiably I think, those who cannot bring themselves to embrace the harm reduction role for electronic cigarettes because of their distaste for the tobacco industry. Doctors who have called out bunkum about missed appointments2 and the weekend effect3 may well share Snowdon’s disdain for the ropey statistics used to hector the public.4
Some of his arguments are less persuasive. He agrees with Kingsley Amis that ‘no pleasure is worth giving up for the sake of two more years in a geriatric home’. Although this sounds reasonable, unfortunately hastened death usually comes bundled with many years of misery, pain, and declining independence beforehand. In my experience smokers fear lung cancer, but arguably they ought to be more scared of COPD, angina, and limb ischaemia.
Snowdon is surely right to insist that it is disingenuous to pretend that smoking and drugs do not bring pleasure, yet his endorsement of the view that unhappy people who develop addictions ‘would be even more unhappy if they were prevented from consuming the addictive goods’5 is difficult to accept.
Nowhere in Killjoys does Snowdon concede that many in public health and medicine favour drug decriminalisation to achieve overall harm reduction.6 On so-called ‘sin taxes’, Snowdon agrees there is an economic case for taxation to cover the shared treatment costs of tobacco and alcohol. However, such taxes, according to Snowdon, should be greatly lowered to cover only the direct treatment costs incurred. I’m no economist, but Snowdon’s insistence that it is illegitimate to consider wider costs, such as lost productivity, seems to stand merely as an article of faith, without any clear justification.
Snowdon insinuates, perhaps justifiably, that snobbery inspires middle-class do-gooders to regulate the lives of others. Yet the corollary of his logic seems to be that the poor die younger because either they are fun-loving free spirits or that an unhealthy ‘lifestyle’ is the inevitable consolation for those facing adversity.
SCOLDING AS PUBLIC HEALTH POLICY
Of course, Snowdon is right to suggest that this all comes down to values. But placing individual freedoms beyond the reach of measures to reduce harm and promote health also seems, to me, rather eccentric and akin to an overvalued idea. Restricting access to harmful products is a reduction of absolute freedom, but I cannot really believe making smoking or drinking more expensive amounts to coercion that undermines the richness of everyday life. As long as scolding about ‘personal responsibility’ substitutes for public health policy, doctors need to master the debate and speak up for the proportionate, effective, and evidence-based measures we need to curb preventable disease and improve lives.
- © British Journal of General Practice 2019
REFERENCES
- 1.↵
- 2.↵
- 3.↵
- 4.↵
- 5.↵
- 6.↵
(2018) RCP supports Royal Society for Public Health report on drug policy (Royal College of Physicians), .
