Paternalism, Public Health Ethics, and Equality

Abstract

Abstract People’s lifestyles or their health choices importantly affect their general health. Furthermore, there is a social gradient in these choices such that people in relatively disadvantaged social positions tend to make worse choices with regard to their health than people in more advantaged positions. The consequence is deep inequalities in health. The state, to the extent it is part of its role to prevent harm and to reduce inequality, appears obliged to try to influence people’s health choices in the interest of their own health and general well-being. However, the state acting to prevent people from harming themselves is notoriously controversial, at least to liberals. It amounts to paternalism – something liberals have traditionally been loath to accept. Furthermore, the equality-generating credential of the available policy measures is in some cases doubtful. To assess the problem of paternalism in relation to government efforts to change lifestyles, partly with the aim of reducing inequalities in health, we need a clear notion of paternalism. The latter may, roughly, be seen as follows: A acts paternalistically in relation to B, if, and only if, (a) A restricts B’s liberty; (b) A does so against B’s will; (c) A does so in B’s interest; (d) A’s behavior cannot be justified without counting its beneficial effects to B in its favor. According to this conception, when the government informs citizens of the danger involved in certain types of health-related conduct, it is not acting paternalistically. However, campaigns may in fact increase rather than decrease inequality of health (because the worse off are less responsive to such measures than the better off). Nudging, on the other hand, stands a better chance of reducing inequality in health. However, nudging policies are less uncontroversial in terms of the problem of paternalism than their proponents are inclined to think. More familiar measures aiming to make the health-endangering behavior more expensive and/or difficult or outright prohibiting it stand a good chance of reducing inequalities, whilst not being more controversial than nudging policies (perhaps less) in terms of the paternalism they involve.