Reevaluating paternalism

Sometimes we must curtail certain liberties so we can support the freedom to live a healthy life. But how much constraint is too much? How much is not enough?

Part of the aim of these essays is to engage with topics which may be challenging, reflecting the importance of having difficult conversations that advance progress. If we find that nothing we say causes us to feel a bit uncomfortable, it is hard to think we are truly having the kinds of conversations that make us better at holding a mirror up to ourselves towards a more effective pursuit of health. With this in mind, I will today address a topic that is certainly touchy, challenging, while at the same time being essential to the work we do to generate a healthier world. That topic is paternalism.

Merriam-Webster defines “paternalism” as:

“a system under which an authority undertakes to supply needs or regulate conduct of those under its control in matters affecting them as individuals as well as in their relations to authority and to each other”

By this definition, paternalism is inextricable from the work of public health, much as it is from the work of all policy. Public policy is the business of allocating resources (supplying needs), typically through the passage and enforcement of laws (regulating conduct). The policy process is a central means by which we work to shape a world which is optimized for the living of rich, full, healthy lives. Even when policies aim to create opportunity paths towards health, they often necessarily entail creating structures that amount to constraints on what we can and cannot do. We nevertheless pursue these policies because we regard them as a net positive for the health and wellbeing of communities.

In doing so, we should have the honesty to acknowledge that policymaking, as an action for health, is often paternalistic.  A fair proportion of policies place limits on what we can do, for the good of all. It is precisely because policies often constrain that we aim to make policy through a process that is relatively transparent, slow and deliberative, and accountable to voters. By facing the fact of what policy is, we can begin to shape polices which do what they need to do for the purposes of supporting health without tipping into an undue infringement on the liberties we hold dear. As an aside, it is worth briefly noting what we should mean by “liberty.” There is a temptation to equate the idea of liberty with, say, red hat-wearing motorcyclists defying sensible guidance against congregating in large crowds during a pandemic. When this is our image of the people who care about liberty, it can be easy to forget that liberty is central to the work of health. I have written before about our commitment to supporting autonomy as part of our broader commitment to human rights, and what is autonomy if not liberty? This suggests that liberty is actually what we in health should be surfacing all the time, because what we do is all about human autonomy and dignity. 

Now, there is a view sometimes heard in health circles that, in the name of liberty, there are some who simply will not accept any policies which seem to mean constraint. I do not think the facts fully support this view. Certainly, there has been some reflexive rejection in the US of anything that seems paternalistic. But there are also many forms of restraint which are widely accepted because they are understood by just about everybody to be in the interest of the common good. From seatbelts and traffic laws, to food safety standards, there are plenty of areas where constraint is broadly accepted in the name of the public good. It is perhaps not so much rules that chafe as it is a sense that rules are being applied dishonestly, haphazardly, or with undue heavy-handedness. It is when we make rules that curtail freedom while insisting that they do not, or when we make rules that seem to go beyond what is necessary, while downplaying or dismissing any objections to them, that some people take objection. For this reason, it is all the more important that we are forthright about our engagement with paternalism, that we recognize it for what it is—the exercise of power—and that, as such, we temper this engagement with the understanding that power can cause us to overstep and so we should proceed, always, with humility and a sense of balance.

I have previously defended paternalism in public health, arguing that it is simply an extension of the notion that we need to somehow create a healthier world, and doing so eventually has to involve some people making decisions for all of us. However, I have also been clear that such decisions should be made within reasonable bounds, that balancing the needs of the collective with the autonomy of the individual should lie at the heart of all we do. This suggests some questions: what is “the right amount” of paternalism? How do we define how much is necessary and how much is too much? How do we then practically apply this definition to ensure our actions are no more or less paternalistic than they need to be?

Let me begin to answer these questions by offering two examples.

Let us first return to those motorcyclists to take the example of helmet-wearing while riding a motorcycle. In many states it is required that one wears a helmet when riding a motorcycle. Why? Because data show clearly that the risk of serious injury in a motor vehicle accident is so high for those not wearing a helmet that we have come as a society to largely accept the paternalism inherent in requiring helmet-wearing, even if a rider may prefer to feel the wind in her hair. Conversely to this, it is likely true that if every car driver wore a helmet risk of injury would be lower in car accidents. But we do not require a helmet while driving a car in any state. Why? Because decreased risk due to car helmet-wearing is not, given the many other safety features of a car, sufficient for us to tip into the paternalism that would then cause us to require a car helmet.

Now, it is possible to imagine the inclination some may have to dismiss this example. “It is all well and good,” one might say, “to talk about helmet-wearing. But helmet-wearing is so obviously safer, so well-established as beneficial, that to compare its benefits to the relatively minor pleasure of feeling the wind in one’s hair is to put forward a straw man representation of what causes people to resist paternalism and when we might reasonably decide to overrule this resistance.” Let us take, then, an example that is perhaps harder, more complex—the paternalism of laws that ban psychoactive substances. We have laws that make psilocybin, heroin, other non-prescription opioids, cocaine, and its derivatives illegal. The history of why these drugs are illegal is checkered, and much of it has involved the harming of people and communities of color more than others. Reflecting this, there is an arbitrary quality to some of our drug laws. In some cases, the reasons for different drug policies are clear, with certain drugs being more dangerous than others. But, in some cases, the picture is more complex. There is, for example, a growing body of research about the potential uses of psychedelics for treating trauma and mental illness, yet in many places the law continues to classify them with substances that offer no benefits and substantial risk. There has also been conversation about whether criminalization may do more harm than good in the work of constructively addressing addiction. All this has led to a reevaluation of the legal structures around drugs, towards addressing the paternalism inherent in telling adults what they can and cannot put in their bodies. As a result of this reevaluation, there has been a loosening of drug criminalization laws in some states. The result of this has been mixed. In some cases, this has opened the door to the taxation of these substances, and broader access to drugs that have provided therapeutic benefits. But in other places, an easing of restrictions on drugs has led to widespread substance misuse and dependence, overdoses, and breakdowns in public order, conditions which in Oregon recently prompted a return of restrictions that had been rolled back. This has informed a conversation in which measures which could be described as paternalistic have been reevaluated, as communities have tried to balance concerns for individual liberty and the complex roots of drug policy with the consequences of rejecting paternalism too comprehensively, opening the door to unintended consequences which can pose challenges for the health and social cohesion of communities.

What do these examples teach us about the role of paternalism as a tool to improve the health of populations?

First, they teach us that paternalism is, for better or worse, an essential tool for creating a world that keeps us healthy. While the very idea of paternalism may make us uncomfortable, a level of necessary, judiciously applied constraint is what creates a world that maximizes our freedom from poor health, allowing us to live rich and satisfying lives, supporting positive liberty at the expense of negative liberty.

Second, the degree of paternalism we deem acceptable—the “right amount” of paternalism—is a matter of the risk we are trying to mitigate, as balanced by the cost of the interventions we consider. A helmet may not be much of an imposition if we are aiming to reduce a substantial risk of motorcycle death, but it is probably too much of an imposition if we are asking people to wear it when they are already protected by the outside of a car. Likewise, decriminalizing drugs would be a less complicated matter if it did not intersect with the toll that substance misuse and dependence can take on the well-being of individuals and communities. There are no easy answers in our efforts to strike this balance. We should not retreat from our responsibility to take actions that could be seen as paternalistic when these actions could help support health. We also should not be taking these actions, or any action, without thinking carefully about the tradeoffs involved.

This leads to a third point: paternalism should be considered skeptically, as should any constraint on individual autonomy and dignity. We should make this consideration, however, with the understanding that the effect of refraining from a measure of paternalism can be arguably worse than the thoughtful, balanced use of paternalism as a tool to support health. At the end of the day, we are trying to balance freedoms, and some constraint on negative liberty (i.e. saying there are some drugs that no one is allowed to use) is well worth it to maximize positive liberty (i.e. making sure as many people as possible can live a full life not hampered by drug misuse). In this way, paternalism can be understood as a means of safeguarding and broadening access to the liberty—the freedom that comes with not being sick—that is at the heart of the project of health.

This topic is, in my assessment, at the heart of the work that we do in health. It is a difficult topic, but one that, as with many difficult topics, is best served by conversation, by careful deliberation. Without that, we would all be wearing helmets while walking down the street—safer, perhaps, but also less reasonable in our approach to health.

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Also this week.

A new publication in npj Mental Health Research with Salma Abdalla, Catherine Ettman, Samuel Rosenberg, Ruochen Wang, and Gregory Cohen about the influence of the Covid-19 pandemic on the mental health and well-being of US adults.

Thoughts with Michael Stein on the perils of scientific disengagement in the latest Observing Science.