"I want to consume this product, should public health experts stop me?” — No

Public health traditionally focused on the health consequences of unwanted phenomena. Nobody wanted to drink faeces-flavoured water, but they did want convenient disposal of sewage.1 In contrast, today’s public health focuses increasingly on restricting the active and deliberate consumption of desired products and services, thus imposing government lifestyle mandates (GLMs) on the population.

Alcohol, fast food, cigarettes, shopping, soft drinks, gambling and other “vices” unquestionably bring utility as well as harm. What price for the enjoyment of, say, a night of alcohol intoxication? Only the individual knows the answer. The long-established principle of autonomy acknowledges that only the individual can apportion the appropriate weighting to each of the myriad factors in any harm–benefit calculation.

GLMs are health interventions, and, like any intervention, need to be consistent with contemporary medical ethics. Sensationalist studies of harm are inadequate to justify enforcing health interventions against peoples’ will. Political scientist Eli Feiring summarises: “Given that respect for the autonomous choices of patients runs deep in modern healthcare, there are strong reasons to value the claim that competent and well-informed individuals are the best interpreters of their own interest and that they should be free to make choices others would regard as non-beneficial to them”.2

Furthermore, it is meaningless to present the sum of harm resulting from a product without reference to fault. A fully established societal and legal principle is that harm caused to oneself is treated differently from harm caused to others. There is certainly no academic basis to nihilistically accept that people who are “glassed” in the face or killed by drunk drivers are merely victims of alcohol-related harm. The solution is not to apply prohibitionist measures to collectively punish everyone. Unfortunately, it is this same failure to rationally distinguish between responsible and reckless use that frustratingly perpetuates the stalemate in the war on illegal drugs. Internationally, challenges to the limits of restrictions (of even smoking) are being countenanced, when the harm is only to the user.3 Similarly, the “freedom to endanger others behind a car wheel with a lead foot or a skinful”4 cannot be equated with the volitional use of products that harm only the user.

A common straw-man argument implies that antipathy towards GLMs is a concern only about the overreach of government to run our lives. Admittedly, many public-health-inspired intrusions are minimal, such as the perennial example of seatbelts. But this example is then misused to justify extreme mission creep, up to and including prohibition-like measures. All behaviour can ultimately be coded as health-related in our system and, by reductio ad absurdum, a truly Orwellian state can be justified. Where does it end? Who decides? Yes, Prime Minister’s Sir Humphrey Appleby, or some other fictitious public servant?

A more potent concern with the nanny state is the propagation of the “disease” model, which promotes society-damaging, malignant lack of personal responsibility — “it’s not my fault, it’s my disease”. Conceptualising the degree of responsibility for one’s behaviour is at the intersection of neuroscience, ethics and, ultimately, philosophy within the burgeoning field of neuroethics.5 If decision making is a function of the brain, should individuals really be held responsible for their decisions? With this neuroscientific and philosophical uncertainty, “addictions” should not be equated with other diseases in medicine. While the concept of addiction is complex and evolving,6 the current tendency to regard even the most reckless, selfish and antisocial behaviour as the biologically bound phenomena of a particular product is essentially just an expression of opinion and ideology. Regarding autonomy, does an individual who is smoking, drinking, gambling, eating junk food and being indiscriminate about sexual partners (“sex addiction”) really employ a sophisticated risk management equation and decide that the benefits outweigh the costs? Ultimately, public health advocates believe that such people are incapable of making the right decisions; we, the “elite” who know best, therefore have the right to decide what’s good for them.

A further justification to usurp established ethical principles is based on the divisive and emotive argument that we have the right to control people because they cost us money in the form of health care expenditure. However, contradictory economic analyses on the real costs of alcohol, cigarettes and fatty foods abound. History and the human condition teach us that it would be dangerously naive to enforce interventions against peoples’ will on the basis of conflicting, often ideologically inspired economic analyses. Crucially, again, government overreach would then make it legitimate to forcibly treat individuals against their will, if it meant a reduction in government expenditure.

Let me opt out.