Part of the aim of these essays is to engage with topics that 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 conversations that make us better at holding a mirror up to ourselves toward a more effective pursuit of health. With this in mind, here is a topic that is certainly touchy and challenging, while at the same time essential to the work we do to generate a healthier world. That topic is paternalism.
I have previously defended paternalism in public health, arguing that it is simply an extension of the notion that we need to 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, and that balancing the needs of the collective with the autonomy of the individual should lie at the heart of all we do. This suggests 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 practically apply this definition to ensure our actions are no more or less paternalistic than needed?
To answer these questions, here are two examples.
First, 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? 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, it is likely true that if every car driver wore a helmet, the 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, we can 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, and 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 have also been conversations 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, toward 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 that 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.
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 (saying there are some drugs that no one is allowed to use) is well worth it to maximize positive liberty (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.
A version of this post also appears on Substack.
A Balanced Use of Paternalism as a Tool to Support Health
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17.04.2024
Part of the aim of these essays is to engage with topics that 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 conversations that make us better at holding a mirror up to ourselves toward a more effective pursuit of health. With this in mind, here is a topic that is certainly touchy and challenging, while at the same time essential to the work we do to generate a healthier world. That topic is paternalism.
I have previously defended paternalism in public health, arguing that it is simply an extension of the notion that we need to 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, and that balancing the needs of the collective with the autonomy of the individual should lie at the heart of all we do. This suggests 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 practically apply this definition to ensure our actions are no more or less paternalistic than needed?
To answer these questions, here are two examples.
First, take the example of helmet-wearing while riding a motorcycle. In many states, it is required that........
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