OPINION: Back off my burger! Protection vs. personal choice
Jacob Sullum, a senior editor at Reason magazine, is the author of "For Your Own Good: The Anti-Smoking Crusade and the Tyranny of Public Health."
Campaigning for president last September, Barack Obama made "a firm pledge" that under his administration "no family making less than $250,000 a year will see any form of tax increase - not your income tax, not your payroll tax, not your capital gains taxes, not any of your taxes."
Two weeks after taking office, Obama broke that pledge by signing a bill that raised the federal cigarette tax to help pay for an expansion of the State Children's Health Insurance Program.
The 156-percent tax hike, from 39 cents to $1 a pack, was highly regressive, since people of modest means are more likely to smoke and, when they do, spend a bigger percentage of their income on cigarettes than affluent smokers (such as Obama) do.
On the face of it, this was an odd revenue choice for self-styled progressives to endorse, but it was not an isolated incident. As Democratic legislators consider ways to pay for new medical subsidies, one of the options on the table is another regressive consumption tax: a levy on sugar-sweetened beverages.
In the eyes of their supporters, these taxes are good not despite but because of their disproportionate impact on the poor, who will benefit if higher prices drive them to quit smoking or reduce their caloric intake. Those options are available to them even without the taxes, of course, but the fact that they continue sucking Marlboros and guzzling Mountain Dew shows they do not attach sufficient value to their own health. Hence the government must realign their incentives until they start making the right choices.
A similarly dim view of people's capacity to choose what's good for themselves is leading Nassau County legislators to consider requiring the conspicuous display of calorie counts in fast-food restaurant chains. Suffolk County is in the process of implementing a similar rule. Since this information is already available to consumers who want it, making it impossible to avoid amounts to government-mandated nagging.
Such is the logic of what passes for "public health" nowadays.
It was not always so. The traditional focus of public health was protecting people from dangers imposed on them by others: disease carriers, polluters, purveyors of quack remedies or tainted food.
In the last half-century or so, public health increasingly has focused on protecting people from dangers they willingly accept, such as those posed by smoking, gluttony, sloth, drinking, illegal drug use, gambling, playing video games or riding a bicycle without a helmet.
When it comes to justifying the use of force (which government action always entails, directly or indirectly), there is a crucial difference between these two kinds of risks. In the case of external threats, even those who believe that government should be limited to protecting individual rights can see a strong argument for intervention. In the case of voluntarily assumed risks, intervention can be justified only on paternalistic or collectivist grounds.
It's important to keep this distinction in mind, but not always easy. Consider the new acetaminophen restrictions the Food and Drug Administration is considering. An advisory committee recently urged the FDA to reduce the maximum dose of acetaminophen allowed in over-the-counter analgesics like Tylenol and to ban prescription painkillers like Vicodin and Percocet that combine acetaminophen with narcotics.
These changes, aimed at preventing liver damage caused by acetaminophen overdoses, might look like an attempt to protect unwary consumers from hidden drug risks. But they actually are aimed at protecting people who deliberately or carelessly exceed the current dose recommendations. The proposed restrictions therefore would sacrifice the interests of consumers who follow instructions for the sake of consumers who don't.
Similarly, laws prohibiting smoking in bars and restaurants superficially resemble laws regulating air pollution, which fit within the traditional public health mission of protecting people from external threats. But because secondhand smoke in bars and restaurants is both conspicuous and confined to private, enclosed spaces that people can easily avoid, it is a voluntarily assumed risk - like smoking itself, which is the real target of these laws.
Bans on the use of e-cigarettes in public indoor spaces, such as the one recently passed by the Suffolk Legislature, are even harder to justify, since these devices do not emit smoke.
Another way to blur the boundary between private and public health is by claiming that risky behavior imposes medical costs on taxpayers - an argument we can expect to hear more often if Obama is successful at increasing the government's role in health care.
The first problem with this argument is that some unhealthy habits actually save taxpayers money. A study reported last year in the journal PLoS Medicine, for example, found that smokers and obese people incur higher annual medical costs than thin nonsmokers do, but generate lower lifetime costs because they tend to die sooner. A more fundamental problem with the fiscal argument is that it provides an open-ended rationale for government intervention, transforming every private decision that might raise the risk of disease or injury into a public matter.
The mission of protecting people from themselves has become so mixed together with the mission of protecting people from each other that many public health practitioners do not even recognize the distinction. Thomas Frieden, the former New York City health commissioner recently appointed by Obama to head the U.S. Centers for Disease Control and Prevention, embodies the CDC's shift from illnesses caused by microbes to illnesses caused by lifestyle choices.
He is an infectious disease specialist who is known mainly as an enthusiastic advocate of broad smoking restrictions, heavy cigarette taxes, trans-fat bans and mandatory calorie counts on restaurant menu boards.
Shortly after the Sept. 11 terrorist attacks, The New York Times reports, Frieden said smoking would be his biggest priority as health commissioner, since "bioterrorists are not going to kill more New Yorkers than tobacco is."
For contemporary public health officials, it's all about the numbers. The aim is to minimize total morbidity and mortality, whatever their cause. This collectivist calculus leaves no room for freedom of choice.
