Volume 195 - Issue 7
“I want to consume this product; should public health experts stop me?” — Yes
Author: Ken J Harvey
Med J Aust 2011; 195 (7): 378. || doi: 10.5694/mja11.11074
Published online: 3 October 2011
Published online: 3 October 2011
Public health expert Ken Harvey believes that they should
In theory, allowing people to make their own choices about purchasing products, unfettered by a “nanny state”, sounds fine. However, this assumes that consumers can make informed, rational choices about the cost, risks and benefits of a given product, and that their decisions have no impact on others.
In practice, humans are far from rational. We have problems controlling consumption and behaviour, such as how much we eat, drink, or smoke, and how much we spend on poker machines. Advertisers aim to maximise the apparent benefits of products and minimise their risks, and to convince us that expensive, branded products are worth more than no-frills ones. They argue, with the powerful voice of large corporations, that interventions to reduce our consumption of harmful products are an affront to our autonomy.
Furthermore, many of our individual decisions do affect others: smoking in enclosed shared spaces and drink-driving cause harm, injury and death to others; and gambling addiction destroys families. Such individual actions have societal costs — premature death, hospitalisation and the need for remedial services — problems often most prevalent in poorer, more disadvantaged populations; some industries specifically target these groups.1 Clearly, the problem of unhealthy consumption and the associated health consequences are societal problems that require a societal approach.
Public health policy, appropriately based on relevant evidence and research, is key to a societal approach. Public health is defined as “what we, as a society, do collectively to assure the conditions in which people can be healthy”.2 To know if governments need to restrict people’s choices for the sake of public health, we need evidence about the causes of ill-health, and the effectiveness of proposed interventions. For example, the link between smoking, lung cancer and other diseases is well established, but establishing how much obesity is “caused by” advertising of junk food is harder to quantify. We also need to know if interventions work, and their potential for both benefit and harm in different segments of the population. However, where evidence supports it, policy should be formulated to appropriately limit choices that impact on health.
The range of options available to government and policymakers can be thought of as a ladder of interventions, with the rungs representing the degree of freedom individuals should have to make individual choices about their health.3 In considering which “rung” is appropriate for a particular public health goal, the benefits to individuals and to society must be weighed against the erosion of individual freedom. Economic costs and benefits need to be considered alongside health and societal benefits.
At the top (most restrictive end) of the intervention ladder, legislation eliminates choice (eg, compulsory seatbelt legislation, banning smoking in public places and random breath testing). One rung down from this, the range of options available are restricted (eg, removing unhealthy ingredients from foods, or unhealthy foods from shops or restaurants).
On the next two rungs down, a full range of choices may remain available, but (i) fiscal or other disincentives can be used to influence behaviour (eg, taxes on cigarettes, alcohol and junk food; precommitment limits on gaming machines), and (ii) people can be encouraged to make beneficial choices (eg, by subsidising the cost of nicotine patches through the Pharmaceutical Benefits Scheme). A variant of this is leaving a full range of options available, but changing a default policy so that people need to actively “opt out” (eg, changing from chips to salad as a standard side dish on a restaurant menu, with chips only available as an option).
Near the bottom of the intervention ladder, a full range of choices is available, but people are empowered to make beneficial choices. Choice can be enabled (eg, offering participation in “stop-smoking” programs, providing free fruit in schools and building cycle lanes) or the public can simply be provided with information (eg, good food labelling, campaigns to encourage adequate daily fruit and vegetable intake, and encouraging people to walk more). At the bottom of the ladder, the approach is to simply monitor the situation, but this may have its own adverse outcomes.
The above policy options are not mutually exclusive. Implementing less restrictive policy options (such as information provision) can increase public acceptance of more restrictive (and often more effective) interventions. Australians have accepted compulsory seatbelts, random breath testing, increasingly tighter regulation of the advertising and sale of alcohol, and smoking bans in enclosed spaces. The Productivity Commission’s proposal for a comprehensive, coordinated and carefully sequenced package of reforms to gambling regulation is a recent example of the public health approach.4 The public has a right to better health. Evidence-based public health strategies, appropriately implemented, are vital to this effort. This may entail impinging on individual freedoms. However, when informed of the benefits, people are prepared to accept sensible curtailment of choice for a better life for themselves and the community as a whole.
Competing interests
No relevant disclosures.
References
- Doughney J. Socioeconomic banditry: poker machines and income redistribution in Victoria. In: Eardley T, Bradbury B, eds. Competing visions: refereed proceedings of the National Social Policy Conference 2001. SPRC Report 1/02. Sydney: Social Policy Research Centre, University of New South Wales, 2002: 136-154. http://www.sprc.unsw.edu.au/media/File/NSPC01_Doughney.pdf (accessed Aug 2011).
- Committee for the Study of the Future of Public Health, Institute of Medicine (USA). The future of public health. Washington: National Academy Press, 1998. 0_i1115277
- Nuffield Council on Bioethics. Public health. Chapter 3. Policy process and practice. London: Nuffield Council, 2007. http://www.nuffieldbioethics.org/sites/default/files/files/Public%20health%20Chapter%203%20-%20Policy%20process%20and%20practice.pdf (accessed Aug 2011).
- Australian Government Productivity Commission. Gambling. Inquiry report. Canberra: Productivity Commission, 2010. http://www.pc.gov.au/projects/inquiry/gambling-2009/report (accessed Aug 2011).