This is a long read. Sorry.
Read this as a Toolkit to counter the guff you often hear about the nanny state.
1 introductory thoughts
Nothing inflames a debate on what “public health should do / not do” more than a good old ding dong about “the nanny state”. People disparage nanny as “social engineering” – and intimate this is “wrong”. Is it any “wronger” than the engineering corporates do to encourage us to buy more of their stuff that we might actually need. Or would have done with on incentives – accessibility, price, advertising etc. So one might say all nanny is doing is trying to counter the influence of commercial sector.
I’ve already written a bit on this – some (academic) rebuttal arguments to the nanny state line. It is mainly a reading list of academic pieces on this. Of particular note in the first blog is the Hastings Centre series on the Bloomberg NYC era.
The Institute of Public Affairs (which I can only assume is akin to the IEA in this country) published a list of 75 policies or institutions it would like to see abolished & 150 examples of heinous intrusions on personal freedom. In response Simon Chapman published a list of 150 ways the nanny state is good for us. It’s somewhat of a classic:
Given that nanny is quite hot again, with very clear public support for regulation in recent Kings Fund work on the future of the NHS, I ought to update my thoughts.
2 It’s important to not forget history. This issue is an old one
All regulatory interventions are controversial at the time they are introduced…but they are accepted. Vaccination, sanitation etc… Would certain people argue against sanitation now? I suspect not but the Poor Law was hotly debated at the time.
This was London in 1952 – Just before the nanny state intervened in your free choice to breathe air that killed kids
3 What about the public, what is their view.
The Kings Fund analysis for NHS70 included new polling data exploring who is responsible for keeping us healthy. It argues that the success of the smoking ban and early evidence that the soft drinks industry levy has led to manufacturers reducing the amount of sugar in their products suggests that tax and regulation can be an effective part of a strategy for improving the population’s health.
The research with the public finds that a majority support stronger Government action on public health, including the soft drinks levy, minimum alcohol unit pricing and restricting junk-food advertising.
The research also concludes that while most people accept they have a responsibility to contribute to their own health and wellbeing, the most important influence on people’s health is the economic, physical and social environment in which they live. The obvious implication of this that a supportive and enabling environment is important to supporting individuals to look after their own health. Supportive is often conflated with “nanny”.
The polling data suggests that the public are more receptive to such interventions than politicians often suppose.
An additional resource is a recent British Social Attitudes survey, which highlights support for so-called nanny state policies HT @policyrelevant. His view is that the BSA study is interesting [at least to me] in illustrating the false dichotomy between individual / [nanny] state. People tend to have much more nuanced views of the concept of responsibility, which include broad support for regulation
This by Grunseit is well worth a look – Nanny or canny? Community perceptions of government intervention for preventive health
- The nanny state conceptualisation was not dominant in either the survey or focus group data.
- Qualitative data analysis highlighted alternative conceptualisations, namely government as a: canny investor; leader on positive health behaviour; partner or facilitator for health.
- Respondents’ level of support for specific interventions overlaid these general conceptualisations with considerations of the target population and risk factor, intervention mechanism and government motives.
- Community perceptions regarding prevention therefore reflect more thoughtful and complex interpretations of preventive actions and policies than suggested by nanny state
- advocates and legislators should not allow debate around preventive measures to be restricted to the nanny state–libertarian continuum, but engage the community in more collectivist considerations of future health costs, beneficiaries, equity and likely outcomes of both action and inaction in order to garner community support and identify information gaps
@BWDDPH recently highlighted clear evidence the #nannystate can make the world a better place for us all. This was on the plastic bag tax. This is a clear state interference in our free choices to use plastic bags (we seem to have accepted it readily)
4 Here are 10 pertinent examples of why nanny is good
The last time I had serious dealings with this one I asked folk as I came across them over the space of a few weeks what they thought the nanny state had ever done for them. The responses were interesting. Ive written them up here:
1. “The nanny state ensured your children use seat belts.”. Is that ok.
2. “The nanny state means that young man is less likely to drive down the street where my son plays at 50mph”
3. “The nanny state meant I stopped spending hours picking windscreen glass out of peoples faces the day seat belts became compulsory”
4. “The nanny state meant that orthopaedic wards started to fill with young men when they brought in compulsory crash helmets.”
5. “The nanny state means that because of the smoking ban – tens of thousands of people NOT being admitted to hospital because of a heart attack or asthma”
6. The nanny state means we could begin to close coronary care units. Who would have thought
7. “The nanny state means that my daughter (who works part time in a bar) isn’t forces to breathe in somebody else’s class a carcinogen”
8. The nanny state ensures some form of pension and a health care system free to all, regardless of ability to pay.
9. The nanny state educates your kids, and ensures safe clean drinking water. Are these things not ok?
10. Is it ok that the state intervenes to close down butchers that are selling contaminated meat – this restricts your choice to buy meat from where you want to.
All these things are to some extent interfering with your free choice and true market forces.
Of course you could say that you want to go back to a time when the pesky nanny state wasn’t interfering and you should be free to choose whether I drink clean or filthy water without that pesky nanny state, interfering in my free choices. It’s an interesting line that underscores the silliness of the line of argument.Social, economic and environmental cues are simply the modern equivalent of pump handles and sewers etc
5 Who opposes nanny & what lines to use in response.
a) Industry opposition is mostly commercial, or dressed up as ideological.
Obviously industry doesn’t like nannyish interventions, and lobbies hardest against these. This isn’t based on ideology, but on commercial concerns.
Rumour has it that sugar spend $30 per voter, or $10m, lobbying against the Berkely soda tax whilst supporting individual level education interventions. I’m told the food industry spent in excess of €1billion opposing food Traffic Lights in EU law, and Tobacco spend $A 50m opposing Oz #PlainPacks law. I will leave you to draw your own conclusions about what industry might know about the relative effectiveness of behavioural interventions focused on individuals versus structural policy interventions, and the impact on sales.
It never ceases to amaze me that nobody sweats around state intervention around say pensions, education of your kids, universal health care, air quality, poor housing…. but when commercial interests at stake. Double standards? or the ideological opposition is naught but a cover for commercial opposition.
This might be seen as what makes funding libertarian think thanks such an effective political strategy for commercial sector actors. The ideological commitments of an organisation like the IEA help to insulate business interests from the being seen to promote narrow economic interests. It is salutary to read this modern classic
“Big tobacco, the new politics, and the threat to public health“. An assidous takedown of a lobby group that is disguising the commercial interests of its (non declared funders) in ideology.
This thread is also interesting. Who funds the IEA, the TPA, the ASI; who are they doing their ‘thinking’ on behalf of. Ask the IEA who funds them and watch the tumbleweed – “The rightish wing ‘free trade’ thick tanks advocating tax havens, “freedom” (no regulations like workers’ rights or environmental protection), no welfare (no tax & no free healthcare). Basically, “Only the wealthier survive” philosophy?”
Fortunately Gornall seems to have sorted all this out in this spectacular bit of journalism documenting the funding base of the IEA
The Taxpayers Alliance also consistently argue against regulatory interference, and again, are “somewhat murky” about their funding base.
b) Common lines I hear and thoughts in response
“We should delay regulation until we have better evidence”.
The desire to do no harm needs to realise that doing nothing in this debate can be harmful. By continuing with business as usual, we are harming people in other places and other times” Jim McManus. Watch the delay put in by USA food industry for calorie labelling. Watch for the delay being asked for on lowering the max stake on FOBT. Whilst we have delayed interventions, too much sugar kills folk. 184k annual deaths from sugary soft drinks! Doesn’t quite square with the image of fun and youth does it.
People promote ineffective but plausible approaches – promoting “responsible” drinking, or “we should focus on self regulation”, or “focus on those who are highest risk, or “it’s just a few that cause harm”.
All are lines we often heard from industry or those with commercial interests (or those in their pay). We have enough evidence that self regulation doesn’t work in the field of alcohol, food, smoking and likely other areas.
and Mary Bassett: trailblazer for health in New York City (“Low life expectancy among some groups in New York is not about poor choices—it is about too few choices”). Also see the spectacular evidence base on evaluation of the PH Responsibility Deal developed by Petticrew and others.
There’s a well developed set of materials documenting the fairly common playbook used by those who oppose you. Look at Tobacco Tactics.
Merchants of Doubt sets out both the ideology and it’s commercial backing very carefully. The central premise is that regulation can make a large impact on profits and that by strategically sowing doubt those opposed can avert that loss of profits. The book documents this over acid rain, climate change, tobacco and other areas. Also documented is the effort to alter the political context and background against which such debates happen, to reframe or relocate the debate away from a path of regulation. This has the effect of further dampening political will for regulation.
This wide ranging review https://link.springer.com/content/pdf/10.1007%2F978-3-030-05325-3_57-1.pdf of the space that is the commercial determinants of health by Luke Allen has some excellent counter arguments in it.
But….“It’s manipulation of the free market and corrupts free choices”.
I’m all for the free market, lots of buyers and sellers, easy entry and exit, externalities corrected for. But…… To what extent does your food choice feel “free” from those nasty corporations control your “free” choice
The food companies that control “choice architecture” – consumer choice is only a secondary capacity #obesity but Big Food has the advantage in keeping them out.
“Taxing things can be regressive – it affects the poor the most”.
This may be true, but the harm from the thing being taxed also hurts the poor most. A standard response is “if you think a soda tax is regressive Try diabetes – that’s definitely regressive”.
The slippery slope
There are those who deploy the slippery slope argument to invoke fear of control by the overbearing state
2 counter lines I often use1) “has it occurred to you there is a continuum of views and your slippery slope line seems a little shrill”2) is that unlike the commercial interests that would dearly love control of our purchasing patterns
Dom Harrison also points out that We have already slipped right down the slope of culture/legislation/behaviour being controlled in the interests of big businesses…worth remembering-‘the state’ is not them, its actually ‘us’ …!
Industry self regulation is sufficient
Many (in industry in the main) will say that the PH Responsibility Deal can achieve similar gains to mandattion and legislation
Flipping it, one can use this to quantify the harm from continuing industry self regulation approach compared to a counterfactual of stronger regulation
The views of the liberal group are mostly quite forthright. I’ve not included some things that have been said about “my type”, on account of there being some very rude words.
The libertarian dialogue on PH is characterised by personal, vindictive and spiteful put downs (swivel eyed loons) to those who hold contrary views
I’ve often been called a government sock puppet by those who oppose the nanny. It is true I am employed by (local) government.
@COPDdoc, myself and others are thinking of using the same forms of rhetoric reversed! IEA = food, tobacco, oil, booze sock puppets. Have a look at this – Tobacco industry sock puppets? And this. Some suggest this is not reversed but restored to its original use – corporate spin and astroturfing etc. How about using the same forms of rhetoric reversed! IEA = food, tobacco, oil, booze sock puppets. Have a look at this – Tobacco industry sock puppets? And this. Some suggest this is not reversed but restored to its original use – corporate spin and astroturfing etc.
• Often the ethical assessment around personal responsibility are often about a desire to penalize those who engage in stigmatizing behaviours.
• Instead of focusing on the wide range of cases in which individuals knowingly put their health at risk – including dangerous sports or hobbies, stressful jobs, and elective surgeries – these arguments are concerned only with a small subset of individuals who knowingly contribute to their negative health outcomes – smokers, heavy drinkers, those who engage in drug use, those who attempt suicide.
• This narrative completely ignores, and here’s the deal, the wider environment people make those decisions. We are product of our environments.
• There are differences in causal responsibility, moral responsibility, or culpability.
• what’s really at play in these discussions is a tendency to blame individuals for engaging in socially undesirable behaviours, while neglecting others who are just as responsible.
- see @ContraPoints on free speech youtu.be/IBUuBd5VRbY. Excellent stuff
This by Vicki Entwistle is also excellent – relational conceptions of paternalism. Key points:
• ‘Nanny-state’ accusations can function as powerful rhetorical weapons against interventions intended to promote public health.
• largely accusations of paternalism. They conjure up emotive concern about undue governmental interference undermining peoples’ autonomy.
• autonomy can be understood in various ways. conceptions of paternalism implicit in nanny-state accusations generally depend on libertarian conceptions of autonomy.
• These reflect unrealistic views of personal independence and do not discriminate sufficiently between trivial and important freedoms
• Relational conceptions of paternalism incorporate relational conceptions of autonomy, so recognise that personal autonomy depends on socially shaped skills, self-identities and self-evaluations as well as externally structured opportunities. They encourage attention to the various ways that social interactions and relationships, including disrespect, stigmatisation and oppression, can undermine potential for autonomy.
• While nanny-state accusations target any interference with negative freedom, however trivial, relational conceptions direct concerns to those infringements of negative freedom, or absences of positive freedom, serious enough to undermine self-determination, self-governance and/or self-authorisation
See this by Coggon. Excellent
1. Aim to deny nanny state accusations: explain how protecting autonomy requires legislative and regulatory interventions to defend our interests and freedoms.
2. Respond to nanny state claims by challenging the premises and practices of those who make them: expose hidden interests and challenge the motivations and effects of their assertions.,
3. Embrace the idea of the nanny state: “reclaim” it, rather than allow it to be a viable smear.
I’d suggest a fourth strategy – draw parallels to other spheres of life where we seem perfectly comfortable accepting state intervention to achieve good outcomes. Education, policing, pensions, even military investment.
6 Discussion points. Some points that may help your arguments.
- No choice is made in a vacuum – in fact choices are really responses conditioned by the environment we live in. The extent of individual choices is very much determined by how much educational, social, financial power we have.
- JS Mill, in On Liberty made the case we should be free to make choices, who would disagree. But our collective choices about health behaviour have consequences on others pressure on NHS system as a result of NCDs Is that what Mill envisaged?? Are choices really “free”.
- Much of state regulation is about limiting the influence of big corporations, or correcting market failure and thus extending the limits of personal choice for the people who have least of it. It’s also about extending choices/freedom for people with less power by curtailing freedoms of those who have more – eg curtail my choice to drive my car at 55mph down your inner city residential street which means you can exercise the freedom to let your kids play out. and if its about ideology… then taking the evidence the “anti nanny stance” is sort of saying “I’m prepared to see children unnecessarily die in order to maintain my ideological beliefs”. Nanny state is about recovering freedom that has been taken from people (through hard-sell / addiction / affordability) and thus introducing more equitable access to ‘living well’ and reasonable decision-making.
- Some like “nudge”. Nudge is essentially from same continuum of approaches. Nudge is usually less “persuasive” than Nanny. Arguably nanny is conscious act to correct market failure. Market perfectly designed to achieve what it gets – over consume booze, cigs, poor diet, under consume exercise. Adam Oliver has extended nudge to ‘budge’ and ‘shove’ see some of the diagrams in here– which call on all the systematic mistakes we make as individuals when thinking about health which government/policy can help correct
- We keep looking at public health from wrong end telescope. Individual choices are shaped by massive political choices. Stop blaming individuals for the current lack of which addresses systematic problems
- What makes downstream behavioral interventions so terribly appealing is how little they demand of the intervener (@jchyip)
- we seem to accept it is right to shape people’s behaviour to help them make better financial decisions? …We generally think its ok whats different about health
- On free will arguments, since smoking mostly starts as a childhood addiction even the ‘free will’ argument is a bit bogus & ‘responsibility’ is an unevenly applied construct that is contingent on false notions of full agency for everyone (@harryrutter)
- As Dave Buck has pointed out to me, if you ask the public do you want a nanny, and who is responsibly for your health – then they will say no. If you ask them specifics about how govt can help they will most likely say yes.
- The lesson for us all is to be specific not conceptual. The public gets used to things – we’ve looked back at attitudes to smoking ban etc and tipping points. Consider the above points re air quality.
- We have strong status quo bias around most things including public health intervention. Status quo is not without harms.
- The obesity plan, chapter 2 goes further than we thought it would in regulation terms. Is this a special case of children and them having no agency? Or could this be a tipping point for change, a door that needs some shoving but is no longer locked
- Especially important are the immediately invertible arguments people throw against nanny state -freedom and equity: Freedom for who, equity for who. Equity of what – choice or outcomes.
- Is there a ‘nanny state’ intervention where we legally compel somebody to do something health-wise and it has no impact on anyone other than the individual. I’m not sure we ever do? A challenge then, to make sure we keep abreast of our critics: ‘How can you nannies legalise cannabis whilst illegalising tobacco?’ … Not presuming anyone’s position and all for alternative yet similar arguments to throw in.
Anna Purdie and others have suggested that Syntax is more appropriate framework for considering this than Sin Ta. It’s not about “what the evidence says” it’s about manipulation of public and thus political support for a certain one of thought; and the important role that discourse and framing play in determining public opinion on interventions to promote and protect population health.
The blog suggests we take cues from the experiences of both the plastics industry and the burgeoning sustainability agenda of the fashion industry, we should highlight the harms caused by overconsumption, and the ways that it, too, can curtail “freedom” of choice. It also highlights the importance of rebuttal of prevailing narratives and work to build stronger counter-narratives and communications campaigns that portray health regulation as something aspirational, beneficial and equalizing.
7 .Summing up. There are some commonly recurring issues
i) individuals make poor choices over long-term decisions such as investing in health,
ii) this is worse the poorer you are, not because of any intrinsic characteristic of ‘you’ but because of poverty, and the effect of poverty is to force your hand and limit your choices even more
iii) producers/retailers maximise (private benefits – private costs) and who can blame them, without being incentivised to internalise social benefits and social costs most (some exceptions e.g. some mutuals, some socially minded private orgs) . Who could blame them, its what their shareholders expect.
Ultimately nanny is also about protecting the wider population from individual choices. The obvious example that you have mentioned is passive smoking in public places. …but this also applies to other things e.g. seatbelts – when this was first brought it this was about protecting front seat passengers from the impact of people in the back being thrown forward.
Acknowledgement to those who I have taken inspiration from ideas from – too many to mention, but specifically Harry Rutter, Dave Buck, Mark Petticrew, Nick Hopkinson, Jim McManus. Many others who I’ve forgotten about
I recently added this set of thoughts on reframing the nanny state
The way this gets framed is always negative and about “interference” in peoples lives. Here is an alternative take
- We react and respond to cues and influences in our world: social, economic, financial
- Our ‘free’ choices are shaped by this.
- Some of these are very powerful influences
- We act rationally – most of the time we live for the moment and maximise our utility now. Consequences for us in the future and others now and in the future are mostly seen by us as “someone else’s concern”
- The consequences ARE the problem – to the NHS, the economy, social justice, environment and climate. People with more income have more means and opportunity to exercise choice
- The ‘free market’ seeks to shape our choices. It doesn’t build in the externalities into the cost or consequences, arguably it doesn’t care about the consequences – “someone else’s problem”.
- The investment of some industries to shape and influence our ‘free’ choices is vast. Look at the marketing budget of many companies that sell us stuff that isnt terribly healthy for us.
- That influence is also pervasive, insidious, often covert. Often seek to influence government approach to policy and regulation. That isn’t inherently wrong or evil – it is about those companies seeking to maximise return to shareholders
- So yes, you can frame PH or environmental groups as the “nanny state”. Equally you can frame it as levelling the playing field and increasing truly “free” choices
- So yes, let’s encourage and enable ‘free’ choices but let’s make that a truly ‘free; choice – with all of the costs and consequences built in