The Unintended Consequences of Public Health Policy
Is it necessary for the government to protect public health? There are many principled issues that are public health concerns: protection from harm, lifestyle freedom, and fairness in society’s health concerns. If we evaluate these goals of public health relative to the outcomes of government action, I believe we can conclude that the only legitimate role of government in public health is that of a referee.
First let us look at protection from harm. In order to believe the government has a role in achieving this ideal, we need to evaluate the efficacy of public health policy. While the state can definitely try to protect people and avoid harm by passing laws, it is less obvious that these actually have the desired effect. Take for example the criminalisation of marijuana in the name of protecting people from harm. This has lead to disproportionate criminal sentencing of minorities and those individuals from poorer backgrounds. Similar to banned substances, strict underage drinking laws have not reduced underaged drinking, but have forced it to be clandestine and uncontrolled, increasing the likelihood of consuming counterfeit or dangerous goods. On the legal side, regulations from institutions such as the FDA have made it difficult to introduce innovative drugs through regulations meant to protect patients. In a few cases, though, such as with the smoking ban in public spaces, they seem to have better consequences. From this it can be seen good intentions do not necessarily lead to good consequences. On a case by case basis I believe it is clear that the unintended negative consequences outweigh the positives.
This leads us to the second point: in those cases where government interventions truly have had a positive impact on public health, are there any further factors that need consideration? Public health should not violate an individual’s lifestyle freedom, which is the purpose of good health. Very often, however, public health initiatives limit freedom of choice. This is problematic for two reasons, it is inconsistent with what public health means and it goes against the democratic presumption of choice. Firstly, public health is concerned with citizens enjoying healthy lives. However, in the political sphere, leading a healthy life is a right, never a duty (whether or not it is a moral duty, and I believe it is, is irrelevant for the present discussion). As for the democratic presumption, which is not only intuitively appealing but also essential for a free and open democracy, as opposed to a tyranny of the majority, it can be stated as: people should be at liberty to make their own choices according to their values, even when the majority does not accept those choices and values, as long as they do not threaten or harm others in so doing. By forcefully trying to achieve an improvement in someone’s health without their consent, we are violating this presumption. Clearly, there is a trade-off, and not a trivial one, whenever we want the state to impose measures whose aim is, in principle, to protect public health.
How could we prevent this trade-off? We should first realise that the alternative to government actions is not non-action, but non-government action. As a result of market pressure, virtually all soft drinks manufacturers commercialise zero-sugar versions of our favourite drinks, non-alcoholic beer is readily available at any supermarket, and the demand for healthy foods is so high that customers are even willing to pay more for them. Furthermore, human ingenuity never stops to come up with new alternatives that encourage healthy choices, or reduce the use of harmful substances; this is what is happening with vaping, a reduced harm replacement of dirty tobacco smoke. In general, the desire of many people to have healthier lives pushes others to deliver what they want in a peaceful synergy of consumer-driven progress, and all without need for the government to spend any resources on it.
This leads to the concern of fairness, which is somewhat connected to the already discussed importance of not limiting freedom. Calls to government action aimed at safeguarding public health also have to consider whether it is just to impose specific values or visions of what a good life looks like on other people. How can it be fair to force others to bear the consequences of decisions not their own? Think of the ban on marijuana for medical or recreational purposes because it was deemed socially undesirable by some; think of someone unable to enjoy a glass of wine because the State had already chosen for them; think of someone dying from overdose because the marginalisation of some substances made it impossible to have appropriate quality standards. To ensure fairness, the proper role of government would be to step out of conscious and consensual actions and to make sure that, as with everything else, there is accountability and transparency, that responsibility is returned to us. If everyone has fairness in their health, it requires that they are free to live lives that they see as personally healthy.
We can therefore conclude that the government might legitimately act to protect public health, but only in those cases in which its ends line up with its means, and its consequences with its intentions. I believe that due to market forces encouraging improved health, the role of the government is that of a referee, to ensure that the market in health can function properly. Other actions beyond this are not only unnecessary, because there are alternatives, but also undesirable, because of the unintended costs associated with failure. If we address the public health issue through voluntary cooperation, if the government couples its function as arbiter with letting civil society step up, if innovation and entrepreneurial creativity are allowed to provide a solution, then we can reach and will reach an equilibrium between effective protection of public health and higher levels of personal freedom, democratic respect, and tolerance towards diverging values.
This article was a contribution to the SpeakFreely Essay Contest on Public Health. The above piece was awarded the 2nd prize.
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