From the Nanny State to the Bully State

During the course of this decade we will witness a global battle over the fate of the nascent Bully State. The Bully State will be this decade's “bad cop” to the Nanny State's “good cop” of past decades.

The past generation of welfare statism saw the unduly protective Nanny State bleed into every sinew of our daily lives. Sociologist David Marsland explains that, “Once you have a big welfare state in place, the excuse for state nannying is infinite in scale”, he says. “This ... continues the process of reducing self-reliance and handing responsibility for ourselves to external bodies.”

Yet, just when you thought things could not get worse, they did. Two years ago, Oxford University's Nuffield Council of Bioethics published a seminal report that provided the international public health establishment with the explicit rationale for a dramatic change in the relationship between the citizen and the State.

Of course, the implications of the Nuffield Report extend far beyond health. Given the expansive way in which health is now defined, the state's power to enforce behavioural change on individuals reaches considerably beyond the current notion of what falls within health care.

The key assumption of the Nuffield Report - and of the respective Australian, British, Canadian, and American public health establishments that have begun to implement, at different speeds and with differing emphases, its policy prescriptions - is that the provision of health information, whereby the state provides citizens with information useful for making informed personal decisions, is a failure.

According to the Nuffield Report, public information often fails to persuade individuals to take the appropriate actions to keep themselves healthy. Primary examples of this failure include alcohol use, poor diet, lack of exercise, and smoking. This means that, as the Nuffield Report put it, “more invasive public policy may be needed”.

Several additional assumptions drive both the Nuffield report's recommendations and, subsequently, Western governments' public health thinking. These assumptions are:

• Most of the health care burden is driven by disease that results from lifestyle decisions.
• Most of the health care burden is therefore, in theory, preventable.
• The cost of most lifestyle-related disease is not recovered from the individuals with such diseases or from the industries whose products contribute to these diseases.
• Individual autonomy cannot be the paramount value in health care.
• Individual choice as a basis for health is “too simplistic”.
• Individual freedoms may have to give way to the coercive power of the State.
• Interventions, including coercive actions, to change behaviour may proceed in the absence of evidence of their effectiveness.
• Individuals have a clear responsibility to refrain from lifestyle decisions that lead to disease and, consequently, treatment can be denied to those who refuse to change their behaviour.

The authors of the Nuffield Report term their approach an “ethic of stewardship”, which they (with straight faces) describe as a new liberal approach to health, individual responsibility, and the state. In truth, it is an extreme, and an extremely dangerous, form of nannying dressed up in stewardship clothing. It is really bullying rather than nannying, threatening people rather than merely nudging them in the appropriate direction.

As the noughties drew to a close, it was clear that state-sponsored lifestyle hectoring was out; state-sponsored coercion was in. The Nanny State had become the Bully State.

In most Western countries, the state's post-World War II health care role has been three-fold: the provision of information; health promotion, and the universal provision of service. In contrast, the Bully State's “new liberalism” promises health stewardship and the state as health sovereign.

The evidence presented by our new, self-anointed health stewards in defence of their assumption that the provision of information alone is a failure is the demonstrated inability of so many in today's society to lead healthy lives. The “fact” that there are so many alcoholics, gamblers, smokers, and fat people provides the necessary proof that the classical liberal rationale for respecting individual choice is untenable.