Lifestyle choices—beyond the medical sector and in the private realm

As with other lifestyle choices with health implications, such as physical activity, diet, sexual protection, car driving, place of dwelling (city/country), hobbies (such as dangerous sports), or occupation, certain factors come into play around government intervention to promote or protect health that are not necessarily relevant to policy decisions in other areas of public health. These factors are more pronounced with the governance of HUOT of addictive products than with the other lifestyle choices mentioned above. Lifestyle choices have also been held up by many political and philosophical thinkers as sacred and to be defended against intervention or manipulation, especially where the consequences of the choice are primarily seen as affecting only the individual, and not third parties. This dates back to James Stuart Mill’s anti-paternalist injunction that ‘his own good, either physical or moral, is not a sufficient warrant’ for the state to impose an intervention to make a person healthier (Mill, 1859).

Many areas of public health decision making are strongly rooted within the institutions of medical practice, for example immunization programmes or restrictions on the transmission of epidemic diseases. These areas may require legislative enforcement and so ultimately invoke the coercive power of the state, but such legislation basically gives medical and paramedical practitioners the authority of state power to request or require strongly certain behaviours (childhood vaccinations or isolation to prevent infection), without intruding much on other aspects of the individual’s relation with the state. In facing the problems of HUOT of addictive products, a much wider range of the machinery of government is necessarily involved. These include:

  • ? The healthcare system at all levels. Because of the high level of comorbidity of HUOT with other diseases, patients with heavy use may present to primary healthcare providers or to those in emergency hospital facilities for treatment of other injuries or diseases but unwilling to recognize or are unaware of HUOT as their primary problem. This implies, first, that ethical principles for intervention on HUOT (or other lifestyle factors) in medical settings have to encompass a wide range of medical situations; and, second, that the importance of addressing HUOT as significant risk factors in the development or prognosis of comorbid conditions may be accepted by health professionals as justifying intervention even when the problem is not recognized by patients themselves. More specialist levels of medical care have to face ethical issues such as whether it is justified to prioritize a liver transplant for an alcohol-using patient given the risk this lifestyle factor poses to his or her new liver. Healthcare professionals in non-medical settings (e.g. schools, prisons, or workplaces) are also brought into play in public health measures to reduce harm from HUOT.
  • ? The criminal justice system. If a substance is legally banned (as a number of addictive and intoxicating drugs are in different countries), then police, courts, and prison and probation systems become heavily involved, with attendant consequences for ethical considerations around human rights, civil liberties, and equality. As a method of (extreme) social control, the ethical considerations of working at this intersection between public health and criminal justice, i.e. depriving those who use addictive products (majorly, those whose behaviour constitutes HUOT) of their liberty or exacting fines, are further explored in Section 3.8.)
  • ? The regulation of commerce. Some addictive products (tobacco, alcohol) are legally traded in many parts of the world, but in almost all countries these products are subject to various degrees of special regulation (only sold on licensed premises, restrictions on sale to minors or proximity to schools, restrictions on sales hours, limitations on advertising, etc.) Historically, restrictions may have been set in place on grounds of acknowledged social goals (e.g. restrictions on the strength and hours for the sale of alcohol were introduced in the UK during the First World War because it was thought that lunchtime drinking was damaging the productivity of munitions workers (Berridge, 2014)). More recently, the justification for these restrictions are framed in terms of the high costs to society of HUOT and a growing awareness of the psychological processes and mechanisms that lead to greater and greater consumption of these products (which will be further addressed in Section 3.8).
  • ? The tax system. In many countries, the most important intervention in the commerce of legal addictive products is heavy taxation on their sale. Like many other taxes, this has two purposes which may sometimes be in conflict: to raise the maximum amount of revenue to support government activities (including health and social services needed to address the consequences of HUOT of such products), and to discourage behaviours that the government wishes to reduce (in this case, substance use). Another policy that has been proposed is to set a minimum unit price (MUP) for alcohol (Holmes et al., 2014), which would have similar effects on the consumer to taxation (raising the price relative to other goods) but with the difference that the increased income goes to the traders or producers rather than to the government. Despite this, the alcohol industry has actively opposed and successfully lobbied against the introduction of MUP in several countries that have considered the measure to reduce alcohol-related harm (Gornall, 2014).
  • ? The role of corporations. The manufacture and supply of legal addictive products (alcohol and tobacco) is very big business, indeed, controlled primarily by large and powerful multinational companies. These companies have strong interests which they vigorously pursue against the restriction of their trade, and against public health initiatives which alert the public to the damaging effects of their products (see Chapter 9). Ethical considerations include the role of government to protect citizens from corporate manipulation through marketing and policy interference, which will be discussed further in Section 3.9.
 
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