Oliver William Morriss
Cambridge, England

A potentially fatal crisis in the contemporary world threatens the very foundations of public health, in that what were formerly known as “diseases of affluence,” namely stroke, cardiovascular disease, and diabetes, have become a global phenomenon affecting individual lives as well as national economies. Respect for autonomy is fundamental to bioethics; but unfettered liberty to make unhealthy choices does not support a coherent healthcare policy response. If individuals have a responsibility to make prudent lifestyle choices, can some degree of paternalistic interference by governments be justified where autonomous decisions are made irresponsibly?

The most problematic and delicate facet of this question is the sanctity of our rights as citizens to be free from a “nanny state.” Our liberty of self-determination is compounded by notions of autonomy which emphasizes the belief that “I, and I alone, am ultimately responsible for the decisions I make, and the consequences of those decisions.”¹ From a similar perspective, Susan Wolf proposes that autonomy is ultimately a highly strung tension between freedom and responsibility.² If such thinking is unerring, should there exist a corresponding (socio-legal) obligation to make responsible choices? Egalitarian Ronald Dworkin proposes that: “in principle . . . individuals should be relieved of consequential responsibility for those unfortunate features of their situation that are brute bad luck, but not those that should be seen as flowing from their choices.”³ If this is so, might this dichotomy between “bad luck” and “choice” be used to distinguish between those diseases that develop as a result of genetic defects, such as Type 1 diabetes, and those arising from individual lifestyle choices, such as Type 2 diabetes? Considering the staggering financial burden of prolonged and expensive treatments for diseases related to diet and lifestyle, should individuals who make a conscious decision to consume unhealthy diets be held responsible for the consequences of that choice?

Whilst theoretically alluring at first blush, making such a distinction proves manifestly unhelpful and ethically lamentable when applied to complex and real life circumstances. Consider the facts of the English case R (on the application of Condliff) v North Staffordshire Primary Care Trust,⁴ where the illness in question was caused by both bad luck and autonomous choice. Mr. Condliff had Type 1 diabetes. After beginning to use insulin, he developed an insatiable appetite and became morbidly obese, with a BMI of over 40 kg/m². He had renal impairment, hypertension, and obstructive sleep apnea, became depressed, immobilized, and incontinent, and completely dependent on the care of others.

Does framing the issue as one of “bad luck” or “choice” aid in determining the rights of individuals in cases such as this? Where there is an amalgamation of chance and autonomous decision making, how are we to balance the respective contributions to the overall development of disease? To deprive an individual of the right to medical treatment purely on the basis of “bad choices” would be to antagonize and mercilessly abandon individuals in a time of need, and to rely on an antiquated moral philosophy which Orwell once referred to as a sort of “moral nose.” The pursuit of such unduly moralistic “nasal reasoning” often culminates in people simply “sniffing a situation and detecting wickedness,” a phenomenon that has historically invoked stigmatization and feelings of disgust by “the sight of Jews, black people and, indeed, women being treated as equals.”⁵ Instead of framing the issue in a way that questions whether individuals have developed their illness as a result of “bad luck” or “choice,” might the issue be framed in a way which asks whether our unfettered respect for autonomy induces a state of dependency?

In Mr. Condliff’s case, can it plausibly be supposed that he retained his autonomy given the debilitating nature of his illness? Gostin appears to answer this question in the negative, positing that “when a person becomes seriously ill or disabled, the adverse effects on his or her autonomy, let alone full enjoyment of life are palpable.”⁶ Consider the Greek epic poem The Odyssey, where Ulysses commanded his crew to tie him to the mast of his ship and to refuse his orders to cut him loose when confronted by the perilous allure of the Sirens’ song. The crew, despite Ulysses’ demands, did not permit him to exercise his choice, interfering with his liberty in order to safeguard his ability to enjoy that liberty in the future. Might the same case be made for some degree of interference in the context of chronic lifestyle diseases?

Paternalistic government interference with the autonomy of individuals is amenable to philosophical contention, namely, whether and to what degree government can modify human behavior, even if it does so in the name of public health.⁷ Indeed, the oft-invoked “nanny-state” metaphor has become a hallmark of the anti-paternalist advocate and theorist, who has become an expert in framing health interventions as not only an affront to the intellect of ordinary people,⁸ but also as expounding the worrisome risk of inducing a slippery slope, culminating in a trespass upon the freedom of individuals to choose what they eat.⁹ The prospect of such an infringement does not sit well with the core tenets of Mill’s seminal “harm” principle, which contends that: “the only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others.”¹⁰

If an individual’s own good is not sufficient to justify coercion, a logical inference might be drawn that the individual is himself the greatest proponent of his own interests and welfare. An oft-cited principle of economic thought is that one is never worse off for having more choice, as one may always simply decline to avail oneself of that choice. However, such individualistic philosophy is principally hinged upon the assumption of homo economicus,¹¹ or “economic man,” which envisages that man is entirely rational in the pursuit of his subjectively-determined goals. Whether such an idealistic notion crystallizes in reality is highly questionable. As framed by Fitzjames Stephen in Liberty, Equality, Fraternity, it is unsubstantiated to suppose that the “mass of adults are so well acquainted with their own interests and so much disposed to pursue them, that no compulsion or restraint put upon them by any others for the purpose of promoting their interest can really promote them.”¹² In their seminal book Nudge, Thaler and Sunstein postulate that there are two facets of human nature which render the homo economicus fallacy untenable: temptation and mindlessness.¹³ Temptation has been a recurring affliction of human nature since the serpent tempted Adam and Eve to eat fruit from the forbidden tree, and continues to torment the self-control of even those with the strongest resolve. Mindlessness is perhaps best demonstrated by the work of Wanksink’s “Bottomless Bowl” study, in which fifty-four participants were given a large bowl of tomato soup. What they did not know, is that the bowls of soup were housed in a modified restaurant-style table, which continually refilled the soup bowls as the contents were consumed. Despite consuming 73% more soup than those who consumed soup from normal bowls, the participants did not believe that they had consumed more.¹⁴ With this combination of temptation and mindlessness, people seem to slip into “automatic pilot,” often eating whatever is placed in front of them. It would thus appear that despite Mill’s belief in the unwavering rationality of the “economic man,” people do not always make choices in their best interests, and despite a plethora of evidence that an unhealthy diet is a preeminent risk factor in the development of chronic disease, a tremendous number of people continue to consume highly-processed and energy-dense diets.

So if we accept that human nature is not compounded by homo economicus invulnerability, but by inherent frailties which are amenable to “nudges,” it is really a question of which “nanny” we prefer—accountable governments “nudging” us towards healthier lifestyles, or profit driven food corporations “shoving” us towards ill health. If the former is deemed considerably preferable, then an unfettered formulation of autonomy is wholly utopian, and incompatible with confronting diet-related disease. The sacrifice of some values in the interest of preserving others is a sacrosanct characteristic of society’s enduring function. But salient as such considerations undoubtedly are, to perceive the issue as solely the denouement of individual autonomous choice is far from compelling, and allows the very corporations who cater to, and profit from, the aforementioned human frailties, to scapegoat individuals who consume unhealthy diets as exercising informed and free choice. With this caveat in mind, policy responses must be premised upon a holistic approach, and cannot be decontextualized from the complex and highly intertwined systemic political, legal, social, and economic forces which facilitate the globalized marketing of health-harming foods.

References

1. J R. Lucas, Principles of Politics, (1st edn, Clarendon Press 1966)
2. S Wolf, “Sanity and the Metaphysics of Responsibility” in F Schoeman, Responsibility, Character, and the Emotions: New Essays in Moral Psychology, (1st edn, CUP 1987)
3. R Dworkin, Sovereign Virtue, (Harvard University Press 2002)
4. R (on the application of Condliff) v North Staffordshire Primary Care Trust [2011] EWCA Civ 910
5. J Harris, Enhancing Evolution: The Ethical Case for Making Better People, (1st edn, Princeton UP 2007)
6. L O. Gostin and K G. Gostin, “A broader liberty: JS Mill, paternalism and the public’s health”, (2009) 123 Public Health 214-21
7. M Lalonde, “A New Perspective on the Health of Canadians”, (1974) Ottawa, Ontario: Minister of Supply and Services Canada
8. R Magnusson, “Case studies in nanny state name-calling: what can we learn?”, (2015) 129(8) Public Health 1074-82
9. D Resnik, “Trans fat bans and human freedom”, (2010) 10 American Journal of Bioethics 27-32
10. J S. Mill, On Liberty, (1st edn, John W. Parker & Son, 1859)
11. J S. Mill, “On the Definition of Political Economy, and on the Method of Investigation” in J M. Robson, Collected Works of John Stuart Mill (Toronto, University of Toronto Press 1967)
12. J F. Stephen, Liberty, Equality, Fraternity, (Liberty Fund Inc 1993)
13. R H. Thaler and C R. Sunstein, Nudge, (Penguin Books 2009)
14. B Wansick, Mindless Eating: Why We Eat More Than We Think, (Hay House UK 2011)