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Moving beyond the Nanny State debate in public health

The debate last night between public health advocate Professor Mike Daube and former health minister Tony Abbott – Welcome back nanny? Civil liberties vs the public good – was much tamer than I’d been anticipating.  I have written a piece about the Nanny State for today’s Crikey bulletin.

But here is an extract from Daube’s speech that I thought might be of interest to Croakey readers.

It is a section where he cites recent considerations by Sir Kenneth Calman and the Nuffield Council on Bioethics of issues around the relationship between the state’s authority and that of the individual, from the extremes of libertarianism to the collectivist views at the other end of the spectrum.

“They developed what they saw as a proposal to capture the best of the libertarian and paternalistic approaches which they described as ‘the stewardship model’.

This argues that liberal states have responsibilities to look after the important needs of people, both individually and collectively; therefore they are stewards to individual people, taking account of different needs arising from factors such as age, gender, ethnic background or socio-economic status, and to the population as a whole. In their view, the notion of stewardship gives expression to the obligation on states to seek to provide conditions that allow people to be healthy, especially in relation to reducing health inequalities.

What does this mean?

It means that public health programs should:

*    Aim to reduce the risks of ill health that people might impose on each other

*    Aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health – from clean air and water and safe food onwards

*    Promote health not only by providing information and advice but also to prevent and assist people deal with unhealthy behaviours

*    Seek to ensure that it is easy to lead a healthy life

*    Recognize that for many of them there is currently no real choice about how they can live healthily or avoid misinformation.

*    Ensure appropriate access to medical services

*    And pay particular attention to protecting the health of children and vulnerable groups and reducing inequalities.

In that context, we should recognize that we:

*    Cannot coerce adults other than where there is a clear cause (such as drink-driving)

*    Should minimise interventions that are introduced without the consent of those affected or without procedural justice, and

*    Should seek to minimise interventions that are perceived as unduly intrusive and in conflict with personal values.

If those principles are broadly accepted, there is then an intervention ladder, starting with doing nothing or monitoring, moving through approaches such as providing information or enabling and offering choices, moving on to restricting choice – for example through removing unhealthy ingredients from foods, as Mayor Bloomberg has done with transfats in New York, and finally moving through to the hardest forms of action – constraint, as with eliminating tobacco advertising, or elimination of any choice – such as compulsory isolation of patients with infectious diseases.

Stewardship also recognizes that it is often the role of the State to make choice a genuine option.

The concept of stewardship recognizes the need to act carefully and deliberately, but also places the onus fairly and squarely on decision-makers to act in the public interest – at times to move to those hard forms of action – and to recognize the consequences if they fail to act.”

Presumably Daube is hoping that the stewardship model might supplant the more simplistic debate that we so often hear around the Nanny State.

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