LIFESTYLES AND PUBLIC HEALTH

The people of every nation would be healthier if they adopted healthier lifestyles. Ninety percent of those who die of lung cancer would not have contracted the disease if they had not smoked. Exercise, sensible diet, and compliance with treatment for high blood pressure can, and do, prevent countless episodes of cardiovascular disease. Practicing safe sex reduces the risk of contracting AIDS. Use of seat belts and motorcycle helmets lowers the chance of injury from accidents on the road.

The prospect of improving health and reducing illness through changes in living habits rather than through curative healthcare is attractive on a number of grounds. Since it is preventive, it avoids the distress of disease; side effects and iatrogenic consequences may be fewer; cost may be lower; and the healthier ways of living may be rewarding in their own right. For these reasons, any government that failed to promote healthy lifestyles could be faulted on ethical grounds.

Nevertheless, the encouragement of healthier lifestyles has drawn moral criticism in the literatures of bioethics and health policy. The chief concern is that governmental (and even private) attempts to bring about changes in living habits will encroach on personal liberty or privacy. A second complaint is that lifestyle-change programs may have the wrong motives, and may have undesirable social and psychological effects.

Health versus Liberty

INTERVENTION: WHAT JUSTIFICATION? Nearly everything we do affects health in some way, if only because the time spent could be devoted to exercise or other health-enhancing behavior. The notion of unhealthy lifestyles, however, is typically associated with a small number of habits. Smoking, the leading killer in the United States, always takes first place, closely followed by alcohol and other drug abuse, lack of exercise, and being overweight. Other risk factors affected by individual choice veer toward the medical, including behavioral change intended to control serum cholesterol and hypertension, perhaps including compliance with doctors' orders. Construed still more broadly, a "healthy lifestyle" would include living in a region not plagued by pollution or recurring natural disasters; avoidance of unsafe jobs; and purchasing the safest cars and appliances.

Attempts to change unhealthy behavior through education and exhortation are relatively unproblematic from the moral point of view. But these measures are less likely to be effective than programs that seek to influence behavior more directly through penalties, taxes, restrictions, or prohibitions. These, however, involve or border on coercion, and in some cases, as with sexual behavior, they necessarily intrude into a person's most private domains.

The fact that good health may be valued by every person does not by itself justify these interventions, since for some people the health risks seem to be less important than the benefits derived from the risk-taking behavior. Few would seriously assert that eating rich ice cream or smoking falls within the category of fundamental human rights, but each encroachment on individual autonomy is commonly regarded as standing in need of justification, especially in the United States, which has a cultural history marked by an ideology of individualism. Three kinds of justification have been offered for programs aiming to change lifestyles: (1) paternalist concern for the person's good; (2) protection of others from burdens involuntarily imposed by the risk-taking behavior; and (3) the public's stake in the nation's health.

PATERNALIST JUSTIFICATIONS. In the United States, paternalist justifications are rarely provided as such. Though exceptions and counterexamples abound, lip service is still paid to the tradition of John Stuart Mill's On Liberty. It is easier to argue for motorcycle helmet laws as a means of reducing the costs of medical care than as a means of protecting human life, despite the greater importance of the latter. When paternalism is explicitly defended, however, it is usually on the grounds that the choices the paternalistic policy prohibits are not fully voluntary ones: Bad habits, such as smoking and overeating, may be sustained by addiction or genetic predisposition. This "soft" paternalism avoids the need to argue for the "hard" paternalist view that even fully voluntary choices may be overruled if the state concludes that the individual might benefit.

For many unhealthy habits, the argument that the behavior is not fully voluntary is easy to make. The individual choice may be determined by chemical, psychological, or social causes. Once a person is addicted to nicotine, it is extremely difficult to stop smoking, as millions of unhappy smokers know; the same holds true for alcoholics and those addicted to legal or illegal drugs. The original decision to try cigarettes, alcohol, or drugs is often made during adolescence, when the individual's ability to resist peer pressure is typically weak.

Nevertheless, the soft paternalist argument faces a number of objections. Not all unhealthy choices are obviously involuntary. The decision to engage in unprotected sex, for example, may be the result of partner coercion, or inner compulsion or denial, but it may also stem from the individual's dislike of condoms or not having a condom. Moreover, even the person whose behavior is shaped by an addiction may be capable of deciding to seek professional help in breaking the addiction. The decision to forgo seeking help, a "second-order" choice about choice, is not necessarily rendered involuntary by the "first-order" addiction. In these instances, paternalistic intervention will be of the hard variety, which involves the authorities acting on the principle that their goals for the individual should be imposed on the individual's own goals.

Intervention aimed at altering lifestyle choices on paternalist grounds may overemphasize the goal of health at the expense of other goals. If the paternalist justification is strongest when the unhealthy choices are least voluntary, these may also be the occasions when the choices are most difficult to influence, and the degree of coercion required may be objectionable in itself. Smokers subjected to very high excise taxes, for example, may suffer from the taxes without giving up cigarettes. Finally, the behavior in question may be difficult to change without considerable meddling in the individual's culture and milieu, whether these champion "wine, women, and song," or risk taking and violence, or quiet (and unathletic) contemplation. The life of the fitness-loving moderate is not for everyone, even if it is most conducive to long life and good health.

FAIR DISTRIBUTION OF BURDENS. Mill's principle of liberty sought to limit intervention to the protection of others from the effects of one's own actions; "self-regarding" behavior is thus the domain of the individual, while others have a say in the regulation of "other-regarding" behavior. Critics have long noted that the boundary is indistinct; nearly everything we do has effects on others. Sexual behavior, the most private of acts, is not at all self-regarding in the era of the AIDS epidemic. And since few people pay all their healthcare bills out of pocket, any behavior that necessitates care will impose a financial burden on other parties.

If these behavioral choices are to be protected, they will have to find some shelter other than Mill's principle. In the case of AIDS, an argument might be made that intrusive regulation would violate a right of privacy, where "private" does not mean "self-regarding" (AIDS transmission is anything but that) but "intimate" or "personal." This right might not be defensible in light of the seriousness of the AIDS epidemic, however; and in any case, other unhealthy habits and choices—for example, smoking, which incurs risks to others through passive smoke inhalation—fall out-side of this personal zone. Since there is no general right of liberty when our choices affect the lives of others, the individual's prerogative to maintain unhealthy practices must be decided on other grounds.

Paternalist arguments aim at justifying interventions that seek to curb unhealthy behavior. Arguments that point to the burden of unhealthy behavior for other people, however, may or may not share this aim. They may indeed seek to justify curbs on the behavior in order to forestall the imposition of burdens. But this can also be accomplished by requiring the individual to pay his or her own way, perhaps through excise taxes, without any diminution of the unhealthy behavior. Finally, the individual whose choices result in illness may be made to pay for his or her own healthcare, or to forfeit any claim on the resources of others, or, at the least, to be placed at the end of the line when resources are scarce.

These steps represent a particular understanding of distributive justice. They seek to impose the true costs of choices on the one who chooses, so that these costs will be taken into account at the moment of choice. Those who believe that the welfare state should assist its citizens in meeting their basic needs, in this view, should not regard all needs as equal. Unhealthy lifestyles create avoidable needs, and individuals should be held responsible for these choices. Those who refuse to take care of themselves, in this view, forfeit at least some of the liberties (to individual choice) and the entitlements (to help, on an equal footing, in time of need) that others deserve.

As with the paternalist justification for intervention in lifestyle choices, this argument concerning the fair sharing of burdens faces a number of objections. One might argue that distinguishing between patients with similar healthcare needs on the basis of personal responsibility for illness introduces a concept of fault more at home in the legal world than in the system of healthcare. Treating all patients according to need, without regard to such factors as status, ability to pay, or fault, is a powerful way of affirming the importance of those aspects of people in virtue of which they are equal, relative to those that divide, distinguish, and rank us. This equality is important both to us as patients and to doctors and other healthcare providers, whose first instinct should be compassionate response to human suffering.

On more technical grounds, the burden-sharing argument rests the case for intervention into unhealthy lifestyles on the outcome of an economic calculation: that the habit in question incurs a net cost. The problem is that those who die prematurely because of unhealthy habits avoid burdening others with the cost of maintaining them in their old age. Economists have long debated whether smokers burden others or relieve others of a financial burden of care; the answer may vary by country, depending on such variables as the cost of healthcare and the cost of living. If there are places in which smokers actually save society money, the burden-sharing argument would entail penalties for those who do not smoke.

Care must be taken, moreover, in stating the burden-sharing argument. Insurance, including health insurance, protects against risk, but it also can make risk taking less unwise. Those Americans who play football, for example, can regard America's healthcare system as a partial safety net; the sport would be too dangerous for many without it. In this light, the burden-sharing argument might succeed in justifying special and higher insurance premiums for risk takers, but unless the risk takers refused to pay these fees, it would not justify curbs on the actual risk taking. Even the special fees would be unjustified if there were rough equivalence in the degree of risk taken by a large number of coinsureds, one person's motorcycle riding offsetting another's sedentary library dwelling.

PUBLIC HEALTH. The third justification for intervention on behalf of healthier lifestyles points to the collective health of the public as a common good. In material terms, a healthy population enhances economic productivity and the nation's capacity to defend itself. General health also provides some degree of protection from the spread of infectious disease. Theorists of public health have contended, moreover, that the public health, meaning the sum of each person's health, constitutes a further goal of public policy that can be distinguished from both the paternalist and the burden-sharing arguments.

Another feature of the public-health perspective is the "prevention paradox," the observation that many critical prevention policies affecting lifestyles produce large aggregate savings in lives but little demonstrable benefit to each individual. For example, seat-belt policies may save thousands of lives nationally but only marginally reduce the risk for each individual who drives. Similarly, changes in fat intake will strongly reduce the number who die prematurely from heart disease but affect the chances of each individual only slightly.

The prevention paradox thus arises from the fact that even small changes in the behaviors of tens of millions of individuals involved in low to moderate lifestyle risks avert thousands of deaths. The prevention paradox further underscores the emphasis in public health on rates of disease and deaths averted, and the difficulty of producing mass changes in behaviors through voluntary measures alone.

Far more important than the government's stake in a healthy work force is the centuries-old tradition of governmental responsibility to protect the health and safety of the public, construed as a public or common good. The public-health perspective is rooted in the democratic and constitutional tradition of assigning to elected officials and members of executive agencies responsibilities for protecting the common good, where this has been interpreted by courts as involving the protection of health and safety (and morals as well, which accounts for the long entanglement of public health and moralism). The public-health or regulatory power of government has long been justified on the grounds that reasonable restrictions on liberty and property, as weighed by the legislature, to promote the common good are the very essence of the regulatory power. This tradition is rooted in theories of government and the duties of citizens that antedate the rise of concerns with paternalism and Mill's famous essay.

Motives and Effects of Intervention Programs

The preceding discussion of arguments for intervention in unhealthy lifestyles has taken the arguments at face value. Critics, however, have suggested that the real motivations for these policies are usually unannounced. The actual motivation, in this view, is moral—or, to be more precise, moralistic, proceeding from a rarely examined and rarely defended set of moral premises. Once these are made explicit, according to the critics, both the motive and the policies are rendered less attractive.

One sign that lifestyle intervention has a moralistic motive, according to critics, is the selectivity of targets. Many kinds of behavior have negative health effects that are not equally addressed. Promiscuity, lack of exercise, and being overweight are merely the medieval vices of lust, sloth, and gluttony. These habits have negative effects on health, to be sure; but so do other kinds of behavior not viewed as vices. Childbirth, for example, presents a certain level of risk to every woman and a decided risk for some; but because it is socially approved, there is no thought of penalizing, taxing, or discouraging the behavior. The burden-sharing argument presents itself as a neutral act of accounting; but, in the critics' view, it is actually concerned with the costs of behavior deemed undesirable on moral grounds while it tolerates behavior of which it approves, no matter how costly.

The moral perspective from which lifestyle intervention is urged, moreover, has been criticized as healthism, a parochial view that elevates health from a self-interested goal to a virtue. In this light, "personal responsibility for health" stems not from the need to avoid burdening others with the costs of one's care but from the conviction that healthy people (at least, those who choose health) are better people, morally speaking. This perspective is also said to be linked to an ideology that emphasizes the degree to which one's state of health is a function of choices one makes, rather than the whims of nature or the safety of one's environment and workplace.

One of the most frequent complaints about the lifestyle debate is that it is used to "blame the victim" and undercut the justification for collective action. Thus, those who wish to restrict in various ways the availability of alcohol or tobacco, to limit overall use of these risky products, meet counterclaims that these are not problems of regulation but of individual responsibility and education. The advocates for regulation, in effect challenging the motivation of this view, argue that their opponents do not really want to see a well-financed campaign against smoking and drinking but want no official action at all. Instead, they want wider acceptance of the view that these are problems that will be resolved only when people take more responsibility for their own health and safety.

Conclusion

Though this entry has dwelt on the difficulties in making a convincing case for intervening in unhealthy lifestyles, the collective weight of such lifestyles should not be exaggerated. Much of the bioethical literature on lifestyles indicates that the choices posing the greatest problem for public-health authorities are those which involve personal or intimate behavior, are entirely self-regarding, and represent fully voluntary behavior. Little in our behavioral repertoire falls in this narrowly defined category, however, and those who wish to pursue this promising avenue to health can enter the argument on an even footing.

daniel wikler

dan e. beauchamp (1995)

bibliography revised

SEE ALSO: AIDS; Autonomy; Coercion; Economic Concepts in Healthcare; Freedom and Free Will; Healthcare Resources, Allocation of; Justice; Paternalism; Public Health Law; Responsibility

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