Defending public health against ‘nanny state’ accusations: we need to talk about freedom

Vikki Entwistle, Stacy Carter & Miles Little | November 28, 2016 | Blog


Accusations of ‘nanny statism’ are often levelled against initiatives that aim to improve people’s health by, for example, taxing tobacco, alcohol and fatty or sugary foods, or limiting the places and ways in which these products can be advertised, sold and used. Recent examples of ‘nanny state’ language in UK news headlines are shown below:

Revealed: Britain is third worst country in EU for nanny state regulation. …The 2016 Nanny State Index, published today by the Institute of Economic Affairs, gave every EU country a score out of 100 according to how it regulates private lifestyle choices on alcohol, food, soft drinks, tobacco and e-cigarettes. (Headline and extract from article by Michael Wilkinson, The Telegraph, 31 March 2016)

The relentless march of the nanny state. Sugar is set to take its place among the UK’s sin taxes. (Headline and first sentence from article (no byline), Financial Times, 26 March 2016)

Dawn of the nanny state? The government certainly seems to be on a mission to get people in England healthier, if the flurry of recent announcements is anything to go by. … For a Conservative government that has traditionally rallied against the so-called nanny state, it represents a remarkable change in tack. In the early years of the coalition, there was a much more hands-off approach… (Headline, first sentence and extract from article by Nick Triggle, BBC News Online, 28 March 2016)

Nanny state has gone too far’ anger as new smoking laws come into force TODAY.

(Headline from article by Vickie Oliphant, Sunday Express, 20 May 2016)

Health chief attacked over ‘nanny state’ alcohol guide that says a single glass of wine a day raises cancer risk. (Headline from article by Sophie Borland/Kate Pickles, Daily Mail/Mail Online, 25 August 2016)

‘Nanny state’ accusations can function as powerful rhetorical weapons against interventions that are intended to benefit people. This blog, based on our recent academic paper, offers suggestions both to help public health advocates develop effective defences against nanny-state accusations and to ensure that public health interventions are well justified.

What are nanny state accusations about?

Many nanny state accusations are politically, commercially or ideologically motivated. They are often rather vague, and the particular concerns that lie behind them are rarely clearly explained by the accusers. In general, however, as the examples in the box illustrate, they allege undue interference by governments or other agents in people’s lives. They also imply that the solution to the alleged problem is to drop the interventions they object to in order to safeguard individual freedom or autonomy. (Autonomy, roughly speaking, is a matter of shaping and controlling one’s own life rather than have it shaped and controlled by others. We’ll say a little more about it below).

Sometimes nanny state accusations are simply flippant pejoratives – attempts to discredit interventions without any thoughtful critique. When the accusations have substance, however, it is important to note that they have two parts. First, the accuser alleges that an intervention entails some important undermining of people’s freedom or autonomy. Second, the accuser recognises that the intervention is made ‘for the good of’ the people whose freedom or autonomy is allegedly undermined – for example, to increase their health. Interventions that limit freedom or autonomy do not always do so for the good of the people constrained. When people with infectious diseases are quarantined, for example, this is usually for others’ benefit. Interventions like quarantining rarely attract nanny state accusations because they don’t fulfil the second part of those accusations. Nanny state accusations are typically reserved for interventions that are considered paternalistic on the grounds that they both limit people’s freedom and are done for their own good.

When critics make ‘nanny state’ protests about public health interventions, they are not usually saying that health is unimportant, or that the interventions will be ineffective for improving it. This is important to note. Public health advocates have often tried to respond to nanny state objections by explaining how much health gain the contested interventions could generate. Such responses miss the central point of the accusations. To successfully respond to charges of nanny statism, public health advocates need to address the accusers’ concerns about freedom or autonomy.

It will be important, then, to establish why the accusers think the interventions they object to are problematic for people’s freedom or autonomy. If they have cried ‘nanny state’ simply as a flippant pejorative, they will probably have little to say, and the shallowness of their objections can count against them. But it will still be useful for public health advocates to be able to recognise and engage with the ideas about freedom and autonomy that are associated with nanny state objections to their interventions.

Thinking about freedom and autonomy

Nanny state accusations generally focus on one broad kind of freedom: freedom from interference by the state or other people. This kind of freedom is sometimes referred to as ‘negative liberty’. It is emphasised in what political philosophers call libertarian thinking.

Libertarian thinking reflects and reinforces a view that almost all government (and much other) intervention in people’s lives is unjustified simply because it is interference. It takes freedom from interference to be more important than any other consideration. Libertarian thinking thus seems to render the vast majority of public health interventions unjustified. But there are good reasons not to accept it. What libertarian thinking implies about freedom and autonomy simply does not fit with what we know about human life.

In what follows, we will use several basic points about freedom and autonomy to expose some key weaknesses in many nanny state accusations and to encourage public health advocates to think carefully about the implications of their interventions. The basic points, in general terms, are that:

  • There are different kinds of freedom and different aspects of autonomy, and although people will vary to some extent in terms of which of these they value most, some are widely regarded as more important than others.
  • Freedom and autonomy rely, at least in part, on social arrangements, including laws, policies, cultural norms and what what goes on in social groups and interpersonal relationships; and
  • Some (state imposed and other) limitations on freedom are widely accepted and can be well justified.

Some freedoms are more important than others

The strong emphasis on freedom from interference that is central to libertarian thinking seems to imply that everything (including other kinds of freedom) that might be saved by freedom from interference is equally important. But this does not fit with the widespread recognition that some freedoms are much more important to us than others. Freedom from torture, arbitrary arrest and detention, and freedom of thought and belief, for example, are so widely recognised as worthy of protection that they have been accorded the status of human rights. In contrast, some of the personal freedoms that nanny state advocates seem keen to protect, including freedoms to buy cigarettes in branded packets, or to avoid being told by government what levels of alcohol consumption are considered safe, are not so highly regarded. They are not the kinds of freedoms that matter most in people’s lives.

Important freedoms and autonomy depend on social support

A strong emphasis on negative liberty seems to imply that people are most free when they are completely independent of both government and other people. But few people want to live remote and isolated lives, and sustained self-sufficiency is, for the vast majority of us, impossible. We cannot escape the fact that we live in networks of social relationships and take advantage of the services and supports offered by state and local cooperation (or, indeed, are disadvantaged by their lack, as we will say more about shortly).

Freedom from government or other public health intervention cannot secure all the freedoms that matter to people. Indeed, some interventions can be crucial for important freedoms, such as freedom from discrimination in relation to employment and housing, and freedom from disease through access to clean water and safe and effective medicines.

Neither can freedom from intervention by government or others secure the personal autonomy that people value. The idea that personal autonomy requires social support has been particularly well established by feminist philosophers. Their so-called relational theories of autonomy recognise the importance of some negative liberties, but also stress that to shape and control their own lives in any meaningful sense, people need a broad range of opportunities, skills and forms of recognition that depend in various ways on the societies they live in. Catriona Mackenzie, for example, argues that personal autonomy is a matter of being self-determining, self-governing and self-authorising. She points out that to be self-determining, people need social structures such as laws and policies to provide opportunities for them to make and act on important choices about their lives (e.g. who to marry and what kind of work or career to pursue); to be self-governing, people need socially supported opportunities to develop the skills and capacities to be able to regulate what they do in line with who they want to be; and to be self-authorising they need recognition from others to develop the self-respect, self-trust and sense of self-worth that will enable them to take personal responsibility for what they do.

Relational theories of autonomy thus highlight various ways in which public health and other interventions can positively support and increase people’s autonomy, as well as various ways in which they can undermine it. They offer richer and more demanding ways of considering the implications of public health interventions for freedom than the simplistic libertarian thinking that underpins some nanny state accusations.

Insights from relational theories of autonomy can support the defence of some public health interventions against nanny state accusations. They can be used to point out, for example, that taxing high sugar-content drinks or putting cigarettes into plain packaging is unlikely to significantly impair people’s autonomy because they do not undermine their opportunities for self-determination, self-governance or self-authorisation. On the other hand they can also raise the standard that might be required of public health interventions, including media campaigns that aim to promote healthier lifestyles. For example, they suggest that campaigns that perpetuate negative stereotypes of people with obesity as lacking in self-control, or campaigns that rely on arousing disgust or fear, can undermine autonomy because they fail to support self-governance and perhaps undermine self-authorisation.

Some state-imposed restrictions are widely accepted and necessary for important freedoms

If the strong emphasis on negative liberty that lies behind many nanny state accusations is followed through consistently, it tends to negate the possibility of all but the most skeletal government. Yet as the points made above suggest, an absence of government intervention is unlikely to ensure the kinds of freedom and autonomy that people most value. It is also not what most people seem to want.

Some state-sanctioned constraints are widely accepted, and at least implicitly recognised to be important for the preservation of valued freedoms. It is generally uncontroversial, for example, that all children should receive at least a basic education, that all drivers should follow certain rules of the road, and that all products marketed as medicines should pass at least basic tests of their safety and effectiveness. These create more valued opportunities than they constrain. Some interventions are, of course, contested because they shift the balance of trade-offs between different freedoms. Recent bans on smoking in public places, for example, limited some smokers’ freedoms in terms of where they could smoke, but increased their and other people’s freedoms to engage in social activities in smoke-free environments. Not introducing these bans would not have ensured everyone was in all important respects more free.

This is just one example of how the status quo sometimes limits important freedoms and opportunities – at least for some people. States are often uniquely positioned to ensure people have the kinds of freedoms and opportunities that really matter, so when important freedoms and opportunities are threatened, for example, by the adverse effects of absolute or relative poverty, social oppression and exclusion, or by commercial practices that contribute to these, a state that does not intervene is arguably limiting freedom more than one that does.

 

Rebutting nanny state claims

When faced with accusations of nanny statism, then, public health advocates might reasonably start by asking the accusers to explain what exactly they are concerned about and how they believe the intervention might limit important freedoms or personal autonomy. This should provide opportunities for rebuttal based on the points made above. It invites debate about questions such as: How important to people are the freedoms that the accuser focuses on? Will the intervention meaningfully limit people’s ability to shape their own lives? And on what grounds are these claims made? Public health advocates can also draw attention to the broad range of freedoms and opportunities that people do care about, suggest that it is a reasonable role of government to ensure some freedoms and opportunities, and point out that doing so can increase rather than impair the autonomy of citizens. They can position discussions about particular interventions as part of a larger conversation about whether and why different kinds of limitations on freedom can be considered justifiable and legitimate.

Assessing public health interventions more broadly

Our analysis is in some respects more demanding than nanny state thinking for assessments of the implications of public health interventions for people’s freedom and autonomy. It maintains the requirement that public health interventions that limit important freedoms need to be carefully justified (think here again of quarantine) and draws attention to various other ways in which freedom and autonomy can be undermined. In terms of health promotion in particular it suggests some important limits to the way that public health agencies interact with citizens. As noted above, communication campaigns that encourage disgust, disrespect or disdain towards, for example, people who are heavier than most, or people who smoke, can be criticised for their tendency to undermine autonomy. They might even be deemed unjustifiable despite their potential to lead people to eat more vegetables or smoke less.

Conclusion

Dealing well with nanny state criticisms requires opening up a conversation about what freedoms and opportunities matter, how much, to whom and why. It will take public health advocates into debates about which freedoms should be protected and which are less important. These might be difficult conversations, but they must be had. If nanny-state accusations are allowed to dominate public discourse, many attempts to improve public health will be framed as unjustifiable, and the benefits of interventions that both promote health and support important freedoms and personal autonomy will not be realised.

 

This post is based on our article ‘Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions’ published in Public Health in 2015 (Vol. 129, No. 8.)

About the authors

Vikki Entwistle

Vikki Entwistle is Professor of Health Services Research and Ethics in the Health Services Research Unit at the University of Aberdeen. She has a broad interest in the ethical aspects of health care delivery, including the challenges of providing ‘person centred care’.See all posts by Vikki Entwistle

Stacy Carter

Stacy Carter is Associate Professor at the Centre for Values, Ethics and Law in Medicine at the University of Sydney. Her interests relate broadly to ethical aspects of public health and she is currently particularly focused on concerns about “too much medicine”.See all posts by Stacy Carter

Miles Little

Miles Little is Emeritus Professor at the Centre for Values, Ethics and Law in Medicine, which he founded in 1995 at the University of Sydney. Miles works in various ways to help keep medicine in touch with its moral base.See all posts by Miles Little