Private choice, public health. Fall 2006 was a perfect time for a scholar interested in the ethics of health promotion to arrive in New York City, which has been experimenting with some of the nation's more innovative and controversial policies to improve population health. Many of these policies alter the environment in ways that affect health—for example, by eliminating trans fats from fast foods and cigarette smoke from public places and by creating bike lanes and parks. If New York City Health Commissioner Thomas Frieden prevails, sodium levels in packaged foods will be next.
This approach to health promotion aims to shift the behaviors of a community through policy and structural changes. In contrast, typical U.S. health policy educates people about some health-relevant risk factor, such as cholesterol. Both approaches attempt to alter people's behavior, but while the former remakes the environment to promote healthy habits, the latter relies on informed individuals to remake themselves. Herein lies one facet of the controversy stirred by some of the broad-based health initiatives in New York City and other progressive municipalities and states. Critics believe such measures are paternalistic, overreaching the state's authority and imposing a particular view of the good life.
These measures may indeed convey a strong message about the putative value of "healthy living," but it is less clear that they are paternalistic in a morally problematic sense. Strong paternalism occurs when interventions aim to protect individuals from themselves against their own free and informed choices. To decide when a policy is paternalistic, then, we have to look at the voluntariness of choices and the reach of harmful consequences. Bike lanes and safe parks expand, rather than limit, people's transportation and recreation options. If smoking bans are justified by the harm of second-hand smoke and by nicotine's addictive power (raising questions about voluntariness), then they are not paternalistic in a strong sense.
The ban on trans fats in restaurants looks more like strong paternalism, at least if we assume that people's food choices are informed and voluntary (a view some argue against) and that foods that contain trans fats harm only those who choose them (one could argue that parents choose fast, cheap meals not only for themselves but also for their young children, extending the harm to those not yet able to consent to the risk). But even with these assumptions in place, bans on trans fats differ from public health measures such as seat belt laws, which trump personal choice by penalty of law. The ban on trans fats neither polices nor penalizes the private culinary practices of committed trans fat consumers. It frustrates the pursuit of their preferences, but it also eliminates a health-harming ingredient from fast, cheap meals, which many fast food consumers may welcome. These bans, to use economist Richard Thaler's and legal scholar Cass Sunstein's phrase, "nudge" us in the direction of healthier choices.
Just how far and by what criteria states should nudge their citizens toward healthy choices merits spirited debate. Epidemiology is an imperfect science, and health is not the only good we care about. For two years I took part in such a debate as a Robert Wood Johnson Foundation Health and Society Scholar at Columbia University. This past October I relocated to The Hastings Center and have brought that debate with me.