Public Health - should evidence always dictate policy?

Do preventative health initiatives risk becoming moralism in disguise, or are they simply a responsible way of stopping people harming themselves?

In the Green Paper A Healthier Nation, Prime Minister David Cameron declared ‘many of our most severe health problems are caused…by wrong personal choices’. From the national smoking ban in public places, to local authorities designating certain streets and parks booze-free zones, the urge to legislate against ‘wrong personal choices’ has grown ever stronger in recent years. While some saw such Nanny State-ism as peculiar to New Labour, the new coalition has announced that it too will encourage the public ‘to make the right choices about what they eat, drink and do in their leisure time’. Despite the language of right and wrong, we are reassured that this is not moralism. Policy-makers are simply responding to what the latest research shows. But the type of evidence cited, and the conclusions drawn, reflect a broader change in the role of public health. Where once it was about society-wide schemes such as mass vaccinations or sanitation, now its focus is on micro-managing individuals’ lifestyle choices. As primary health care has shifted away from diagnosis and treatment towards managing patients’ behaviour to prevent future illnesses, GPs are often on the front line of delivering endless evidence-based ‘advice’ as to how patients should live.

Critics object that in this context, medical evidence has become politicised. Indeed, Richard Smith, former editor of the British Medical Journal, and one of the experts responsible for government recommendations on how many ‘units’ of alcohol we should drink, has admitted the figures were ‘plucked out of the air’. When research published in April showed the much-vaunted ‘five a day’ (portions of fruit and vegetables) confers only marginal health benefits, campaigners insisted the advice should be promoted anyway, to drum home a wider message about obesity and junk foods. And while politicians have embraced ‘evidence-based policy’, when government advisor David Nutt went off-message on drugs policy, he was punished for overstepping his jurisdiction.

How far can evidence go in deciding what is a ‘right’ or ‘wrong’ choice? The consensus seems to be that healthy means good, regardless of anything else. Healthy, clean-living restraint may appeal to some, but others may feel more sympathy for Clement Freud’s famous quip that in giving up life’s irresponsible pleasures, ‘You don’t actually live longer; it just seems longer’. Do preventative health initiatives risk becoming moralism in disguise, or are they simply a responsible way of stopping people harming themselves? Are politicians offloading responsibility and avoiding debate over contentious policies by variously citing and blaming scientific evidence? With advances in medical technology, might we find cures and treatments for conditions caused by ‘unhealthy living’, saving us the trouble of changing our behaviour? What role should the latest evidence play in forming public health policy?

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