During the course of this decade we will witness a global battle over the fate of the nascent Bully State. The Bully State will be this decade’s ‘bad cop’ to the Nanny State’s ‘good cop’ of past decades.
The past generation of welfare statism saw the unduly protective Nanny State bleed into every sinew of our daily lives. Sociologist David Marsland explains that, ‘Once you have a big welfare state in place, the excuse for state nannying is infinite in scale’, he says. ‘This … continues the process of reducing self‐reliance and handing responsibility for ourselves to external bodies.’
Yet, just when you thought things could not get worse, they did. Two years ago, Oxford University’s Nuffield Council of Bioethics published a seminal report that provided the international public health establishment with the explicit rationale for a dramatic change in the relationship between the citizen and the State.
Of course, the implications of the Nuffield Report extend far beyond health. Given the expansive way in which health is now defined, the state’s power to enforce behavioural change on individuals reaches considerably beyond the current notion of what falls within health care.
The key assumption of the Nuffield Report‐and of the respective Australian, British, Canadian, and American public health establishments that have begun to implement, at different speeds and with differing emphases, its policy prescriptions‐is that the provision of health information, whereby the state provides citizens with information useful for making informed personal decisions, is a failure.
According to the Nuffield Report, public information often fails to persuade individuals to take the appropriate actions to keep themselves healthy. Primary examples of this failure include alcohol use, poor diet, lack of exercise, and smoking. This means that, as the Nuffield Report put it, ‘more invasive public policy may be needed’.
Several additional assumptions drive both the Nuffield report’s recommendations and, subsequently, Western governments’ public health thinking. These assumptions are:
- Most of the health care burden is driven by disease that results from lifestyle decisions.
- Most of the health care burden is therefore, in theory, preventable.
- The cost of most lifestyle‐related disease is not recovered from the individuals with such diseases or from the industries whose products contribute to these diseases.
- Individual autonomy cannot be the paramount value in health care.
- Individual choice as a basis for health is ‘too simplistic’.
- Individual freedoms may have to give way to the coercive power of the State.
- Interventions, including coercive actions, to change behaviour may proceed in the absence of evidence of their effectiveness.
- Individuals have a clear responsibility to refrain from lifestyle decisions that lead to disease and, consequently, treatment can be denied to those who refuse to change their behaviour.
The authors of the Nuffield Report term their approach an ‘ethic of stewardship’, which they (with straight faces) describe as a new liberal approach to health, individual responsibility, and the state. In truth, it is an extreme, and an extremely dangerous, form of nannying dressed up in stewardship clothing. It is really bullying rather than nannying, threatening people rather than merely nudging them in the appropriate direction.
As the noughties drew to a close, it was clear that state‐sponsored lifestyle hectoring was out; state‐sponsored coercion was in. The Nanny State had become the Bully State.
In most Western countries, the state’s post‐World War II health care role has been three‐fold: the provision of information; health promotion, and the universal provision of service. In contrast, the Bully State’s ‘new liberalism’ promises health stewardship and the state as health sovereign.
The evidence presented by our new, self‐anointed health stewards in defense of their assumption that the provision of information alone is a failure is the demonstrated inability of so many in today’s society to lead healthy lives. The ‘fact’ that there are so many alcoholics, gamblers, smokers, and fat people provides the necessary proof that the classical liberal rationale for respecting individual choice is untenable.
Consequently, the case for state interventions to change the health environment and individual behaviour is, it is claimed, an unassailable one. During the past couple of years, therefore, Western nations have been introducing a myriad of case studies representing health stewardship‐in‐action. These have included regulations, taxes, and programme addressing obesity, alcohol, gambling, and smoking.
This is the point in the story line where, one may reasonably assume, one of the characters poses the perfectly reasonable question, what does the evidence say? Sadly and perplexingly, rarely has that happened. But, if it did, what would a balanced reading of the research literature tell us?
It would inform us that:
Providing health information has not failed. What has failed is the state’s expensive attempt to instill fear in the minds of its citizens about many of their dietary and recreational choices. Serious health warnings are diluted when consumers are deluged by ‘warnings’ about every imaginable item, ingredient, and eventuality. There is already evidence that consumers are confused by warning labels, for example. Clearly, most of these labels should come with their own warning: ‘Caution: Bureaucrats at Work’.
Prevention has failed to ward off lifestyle illnesses for the fundamental reason that such illnesses are multifactoral and, therefore, it is clinically impossible to identify the sole cause of a disease. Consider, for instance, the multiplicity of risk factors for both lung cancer and heart disease‐thirty for the former and over three hundred for the latter.
Consequently, health promotion has failed as a policy tool. Since Canada’s then‐Health Minister Marc Lalonde articulated the health promotion philosophy in 1974, the central tenets of health promotion have remained two‐fold, namely, that (1) science clearly shows that, if people are to be healthy, they must change their lifestyles, and (2) it is the public health establishment’s role to see that this change takes place, either voluntarily, or, if necessary, through various modes of coercion.
There is little compelling evidence, however, that multifactoral diseases can be prevented, particularly through lifestyle interventions. Respective governments’ specific policies on obesity, alcohol, gambling, and smoking are unjustified and unsuccessful because they are based upon evidence‐free arguments. These policies never stood a chance of success.
The standards of scientific evidence required to justify public health interventions are far, far higher than those employed by policymakers. Evidence‐light, photo‐op policymaking often makes for good media coverage and, at times, good politicking, but it rarely makes for good public health.
In addition to a dissection of the health paternalism mantra underlying the Bully State, what is needed is a robust articulation of the case for individual autonomy. Such a case would flesh out the following points: individual autonomy is the core value of a democratic society; there is an inherent trade‐off between individual autonomy and public health under health paternalism; and the abandonment of individual autonomy in health policy poses a threat to our other freedoms.
One need not be an American libertarian or a European classical liberal to appreciate the stewardship ethic’s threat to a democratic society. Rather than the product of an ideological agenda, a plea for personal choice as the foundational value of public health is, in stark contrast, a plea for both common sense and morality in policymaking.
As Bully Staters do not want us to smoke cigarettes, gamble, drink alcohol, or gain weight, they will ratchet up their campaign to shame and coerce those who rejoice in the individual’s right to pursue pleasure. Under the Bully State, the real bully is Nanny the Policy Nurse, who dispenses regulatory ‘cures’ for all manner of alleged social ills, from smoking to simply having fun.
Thankfully, there will be dramatic growth in people’s unwillingness to be bullied out of, and into, particular habits. This will create an opportunity for the first politician who stands in front of the Bully State’s regulatory march yelling, ‘Stop!’ By the end of the decade, it is entirely possible that most Westerners will be actively rebelling against their respective Department of the Domestic Bully.
Appropriately harnessed, such a popular groundswell may demand a scaled‐down state in the public health arena. This would ensure a focus on the legitimate role of government in health‐ care policy: providing credible information, refraining from propaganda and persuasion, and funding evidence‐based care.