Human Liberty and Human Health

Human Liberty and Human Health – Lecture presented 28th October 2004 to the Public Health Forum of the Manchester Medical Society as the Presidential Address of DR. STEPHEN WATKINS

Director of Public Health for Stockport, Council Member of the British Medical Association, Council Member of the Medical Practitioners’ Union/ MSF, Chairman, Transport and Health Study Group.

SUMMARY

In this lecture Stephen Watkins asserts that liberty is not just the absence of constraint, but that it is a matter of positive empowerment, of the rights of human beings to control their own destinies.

Using as an example the Tragedy of the Commons (the situation where rational individual decisions add up to a consequence that nobody wants, and only a collective decision can empower people to reach the desired end) he points out that often people will only be able to control their destinies if they can make collective decisions about their environment. Such decisions are an exercise of liberty, not a constraint upon it.

Applying this concept to four different public health issues he challenges the idea that public health measures are an assault on human liberty.

He asserts that

• a ban on smoking in public places is justified not only by the rights of non-smokers to be protected from passive smoking, but also by the rights of the majority of smokers, who want to give up, to be helped in that decision by not being required to give up their social life with their cigarettes
• controls on advertising of unhealthy food and measures to require food manufacturers to make healthy food available are necessary to allow consumers a proper choice. There may be a freedom to harm yourself but there is no freedom to persuade somebody to harm themselves if you are motivated only by commercial motives
• fluoridation of water supplies is an entirely legitimate collective choice as there can be only one composition of the public water supply and it is a legitimate proposal to advocate that the composition of a natural mineral within it should be adjusted to that level which has been shown to be optimal for health
• road traffic is a classic Tragedy of the Commons situation

Dr. Watkins then discusses the concept of a free market and draws attention to situations in which market theory itself would suggest that an unregulated market will not work. Several of these are relevant to health. Health care falls into three of the exceptions, as a commodity which raises issues of social justice, as a commodity where the transitional consequences of a market adjustment may be unacceptable and as a commodity where the consumer is dependent on the advice of the supplier. Many environmental issues raise issues of externalities, of the Tragedy of the Commons or of the need for a collective consumer. Poverty is a public health issue and the distribution of income is an issue which the market is unable to handle adequately as the market distribution of the value of individuals’ skills does not necessarily correspond to an acceptable distribution of consumer power. Health-damaging commodities create an externality issue unless the flow of information is regulated so that the consumer is properly informed.

Dr. Watkins then discusses the problems of central planning pointing out that chaos mathematics sets limits to our capacity to predict the outcome of interventions in some systems and that organisational theory explains why large monopolistic organisations malfunction.

Finally Dr. Watkins emphasises the importance of dissent as a protection against error and the difference between promoting safety and becoming risk-averse.

HUMAN LIBERTY AND HUMAN HEALTH

There is currently a major political debate about the fundamental nature of public health.

On the one hand there is a view that the problem is one of human beings choosing unhealthy lifestyles and that the solution is to persuade them to choose differently. This view is called libertarian by its advocates, and victim-blaming by its detractors. It is individualist in its solutions. It is often, although not invariably, associated with right-wing political attitudes, although whether that explains its acceptance by the current Labour Government is an issue I would not wish to comment on.

On the other hand there is a view that the task is to create physical and social environments in which human beings will be protected from unnecessary hazards and in which it will be easier for them to choose healthy lifestyles. This view is called “promoting health as a social value” by its advocates and “creating a nanny state” by its detractors. It is collective in its solutions. It is often, although not invariably associated with left wing political attitudes, although its most vociferous current exponents appear to be the Liberal Democrats and the British Medical Association.

I have tried to find quotations which summarise these two points and have found the following.

The individualistic right wing viewpoint is best illustrated by a quote from Lenin:

“The health of the people is the concern of the people themselves”.

The collectivist left wing response is best illustrated by a quote from Disraeli:

“The health of the people is the first concern of Government”.

I believe that Disraeli was right. Yet I am also, to my very core, a libertarian. The main thrust of this presentation is to argue that the so called libertarian vision of public health is not in fact a libertarian vision at all. It is indeed a vision which fundamentally misunderstands the nature of human liberty and seriously undermines it.

THE NATURE OF HUMAN LIBERTY

A first shot at a definition of human liberty might perhaps be something like:

“Liberty is the absence of constraint”.

Once upon a time there was a household which comprised one human being, three mice and a cat. The human being firmly forbade the cat to harm the mice. Then one day the cat proposed that the household adopt a libertarian constitution. All would be free, and able to pursue their own destiny. This was agreed. At which point the cat ate two of the mice. When the other mouse and the human being protested, the cat said that it was free to eat whoever it wanted. The third mouse protested at the infringement of the rights of the mice that had been eaten. But the cat pointed out that they too had been free to eat whosoever they wanted. They could have eaten him. They had not chosen to do so, but he had chosen to eat them. At this point he ate the third mouse as well.

Libertarians have always recognised this problem. So the definition has to be modified to something like:

“Liberty is the absence of constraint, except to protect others from harm”.

But this too raises questions. What kinds of harm are prohibited? If I choose a chocolate biscuit from the biscuit plate might I not harm somebody else who might have chosen the same biscuit? Why should I drive on the left hand side road if I would rather drive on the right? It is argued that this is to protect others, but if they all drove on the right there would be no problem. Why should the minority who want to drive on the right have to comply with the oppressive demands of those who choose to drive on the left and expect everybody else to follow suit.

Where does the ban on fox hunting fit in? Does the fox have rights, in which case the ban is legitimate? Or is it only humans who have rights, in which case the ban prohibits an activity which harms nobody?

So perhaps we might adopt some kind of definition like:

“Liberty is the absence of constraints, except for those constraints that are voluntarily agreed or that are imposed by law for a valid purpose, namely the protection of the fundamental freedoms of others, or the protection of others from harm (other than harm occasioned by fair competition) or the enforcement of those arrangements necessary for the proper operation of shared infrastructure or the protection of the rights of other species (to the extent that society chooses to recognise those rights)”

The definition has now lost some of its original resonance. It is hard to see it being inscribed on a banner.

The fundamental problem with each of these definitions is that they view liberty as a negative – the absence of constraint. Liberty is actually, in my submission, a positive.

This is the definition I would propose:

“Liberty exists to the extent that human beings are free to control their own destiny. It is a state of positive empowerment, not merely the absence of constraint.”

Once liberty is defined in these terms, it is possible to see that it can be present to a greater or lesser degree. It becomes possible to talk of its distribution – to ask, for example, whether poverty leaves people so disempowered that they are no longer free. It also becomes possible to recognise that the protection of liberty is not a simple matter of leaving things alone – it requires action to be taken to empower the disempowered. The most important step forward, however, that this definition makes is when you realise that to control important areas of their destiny human beings must act together. The protection of liberty therefore requires the creation of the mechanisms that allow them to do so. In some circumstances this may require the establishment of constraints.

For a start this gives us the answer to why we don’t have the freedom to drive on the wrong side of the road. The large majority of human beings want everybody to drive on the same side of the road. This isn’t just because they are control freaks who want everybody to be alike. It is because everybody driving on the same side of the road significantly enhances their chance of living until tomorrow. This is a legitimate aspect of the control of their own destiny. So they have the right to decide that they want to live in a society where everybody drives on the same side of the road, and that right can only be collectively exercised.

If we are to control our own destiny we must have the right to make collective decisions about the general state of our environment. Those decisions are not a constraint upon liberty but a genuine exercise of it. This principle is of great importance in a set of situations called the Tragedy of the Commons. The Tragedy of the Commons is named after a hypothetical situation where there is a common which can only support the grazing of twelve cows. There are twelve commoners each with a right to graze a cow. Each of them is grazing a cow and each of them is considering whether to graze a second. Each of them reasons that if they graze a second cow they will get all the extra produce and yet they will lose only one-twelfth of the consequences of the overgrazing. So each of them rationally decides to graze the extra cow. Even if they realise that others are making the same decision it is still rational for them to graze the extra cow. They are going to suffer the consequences of the overgrazing anyway – why should they alone lose the benefits. The common is now seriously overgrazed. But it is still in the interests of each commoner to add a third cow. And so it goes on until the common is destroyed and the cows die. To prevent this happening the commoners must get together and agree bye laws for the common. None of them alone can bring about what each of them wants – the preservation of the common. If each of them makes their own rational decision in their own self interest, what will result is what none of them want. To be able to control their own destiny they must have the freedom to make a collective decision and impose the constraints that secure their collective choice.

THE ISSUE OF SMOKING BANS

The case for smoking bans can be made even in the terms of a definition of liberty which permits constraints only where they protect others from harm. Such a case would be rooted in the harm occasioned by passive smoking. It is a powerful case even on the most traditional definitions of liberty. Why should people have a right to poison others? Do people not have a right to be protected from being poisoned at their place of work or at the place where they go for their recreation?

When we define liberty as the right for human beings to control their own destiny another equally important issue arises. Most smokers want to give up. They have become addicted to tobacco in their youth when they were ill informed of its long term consequences and now that they know the consequences, and wish rationally to avoid them, they find it very difficult to do so because of their addiction.

This addiction is a constraint upon their power to control their own destiny. We would enhance their liberty if we made it easier for them to implement the decision they wish to make. We do the exact reverse of helping them if we tolerate a situation where the vast majority of pubs and clubs permit smoking. If would be ex-smokers, who wish to avoid the reinforcement of their addiction, must give up most of their social life along with their cigarettes their liberty is diminished.

THE ISSUE OF HEALTHY FOOD

Clearly people must have the right to choose to eat unhealthy food. It is the most fundamental principle of liberty that it must include the right to be wrong. If there is no right to be wrong then no freedom is meaningful. It is a travesty of libertarian thought to use that statement as the end point of the discussion. Do people eat unhealthy food because they choose to? Is food so labelled that people can easily distinguish healthy from unhealthy food? The food industry is bitterly resistant to such labelling. Is healthy food as readily available as unhealthy food? It is certainly very difficult to find low salt processed foods and such as do exist are often found only in large stores, often accessible only to those with access to a car.

What about the power of persuasive advertising? Far more money is spent persuading people to buy unhealthy products than is spent on informing them about their hazards. This is said to be the “commercial freedom” of the manufacturers. This concept deserves examination. It is one thing to say that people have a right to choose to harm themselves – quite another to argue that businesses should have the freedom, for purely commercial reasons, to try and persuade them to do so.

Tackling these issues is not interference in the people’s freedom to choose. On the contrary these issues must be tackled if that freedom is to be meaningful. Australians, a group probably not dissimilar in their tastes from the English, believe they have a right to choose to eat low salt foods and so they have placed constraints upon the freedoms of food manufacturers so as to ensure that that right is meaningful. In doing so, they demonstrate a more sophisticated understanding of human liberty.

THE ISSUE OF FLUORIDATION

It is odd that the opponents of fluoridation speak of freedom of choice, for there can only be one composition of the public water supply. There can be freedom of choice in bottled water and indeed you can argue a case for saying that steps should be taken to protect that choice by ensuring that where the public water supply is fluoridated, unfluoridated bottled water should be available, and conversely where water is unfluoridated there should be a supply of fluoridated bottled water. But the choice as to the composition of the public water supply can only be a collective decision. That is a simple factual point. What is so special about unfluoridated water that those who want to drink it believe that their right to be supplied with it should outweigh the wishes of the majority? What is wrong with the American view that, in the home of the free, people have the right to drink fluoridated water? The lovers of tooth decay, of course, present the argument in terms that fluoride is an alien addition to water. In fact fluoride is one of the natural minerals normally present in water. Like all natural minerals it has an optimal level and outside that range it causes harm – too much of any mineral will poison you, too little will give you a deficiency disease. Why should we not adjust the level of fluoride in our water supply to that level which generations of experience of natural water supplies has shown us to be the one that is optimal?

ROAD TRAFFIC

For years the stock argument of anybody who wants to do something irresponsibly risky has been to say that it is safer than crossing the road. It usually is. I always wonder how long it will be before we accept the true logic of that argument and start to do something to make it safer to cross the road. We could save most pedestrian road accident deaths if we had more safe crossings of main roads and we drove at 20mph when we left the main road. Since few places are more than a mile from a main road, few journeys will involve more than two miles off main roads. The difference between travelling two miles at 20mph or at 40 mph is three minutes. We are killing our children to save less than three minutes on our journeys. This is not a legitimate exercise of freedom.

Road traffic is one of the most important current examples of the Tragedy of the Commons. Car users congest the roads thus destroying the benefits that they thought they had acquired with their car, whilst public transport users face a declining system. It would be in everybody’s interest if everybody used their car only when they really needed to. Then the roads would be free of congestion and available to car users when needed and public transport would be more frequent and more extensive in response to the increased demand for it. But nobody can bring that about alone. Unless we act together our individual decision will be to add to the congestion. The idea that we cannot constrain that individual decision takes away from all of us the greater freedom to act collectively to stop the rot and bring about the better situation that the overwhelming majority would prefer. Once again an over simplistic idea of liberty disempowers. It is this disempowerment which is the true affront to liberty.

SO WHERE DOES REGULATION STOP?

So is there no end to the regulation that I am prepared to advocate in the name of human health, justifying it as libertarian in the name of empowerment? Yes of course there is. The concept of liberty that I am putting forward sets that limit. Regulation stops when it no longer gives people a collective power over their own environment that makes a greater contribution to their control of their own destiny than the lesser individual freedoms they give up. Until that point regulation is empowering and is an assertion of liberty. Beyond that point it starts to become an affront to liberty. Where people are making collective choices, or they are removing barriers that prevent them making healthy choices, or are changing social norms so that the healthy choice becomes the natural choice, or are ensuring that the flow of information is not distorted by commercial pressures for people to harm themselves then there is an act of empowerment that libertarians should support. If those areas are properly addressed then I do not think we have any reason to see liberty as likely to be a threat to health. Our species would not have survived millions of years of evolution, many of them in conditions of great adversity, if it were equipped with a deep-seated instinctual drive to harm itself.

IS LIBERTY GOOD FOR HEALTH?

So far I have addressed the issue of liberty as a barrier to health improvement and have concluded that it is unlikely to be such a barrier if we recognise the need for liberty to be viewed as empowerment rather than just the absence of constraint. I now wish to address the question of whether liberty is in itself beneficial to health.

It is biologically plausible that liberty could be health promoting. The stress reaction is produced when an organism faces a threat to its well being of sufficient severity to challenge something which the organism perceives as being of central importance to it. The reaction is designed to support fight or flight and if used in measures to counter the threat is entirely healthy. But if there is nothing that can be done to counter the threat, and it remains hanging over the organism for a prolonged period of time, then the reaction persists inappropriately and this causes health damage as some aspects of the stress reaction, such as the raised blood pressure, raised blood cholesterol, reduced gastrointestinal motility and reduced immune system reactions, are health damaging, leading to heart disease, cancer, gastrointestinal problems and increased susceptibility to infection.

It is plausible that an empowered individual will be more likely than a disempowered individual to respond to a threat positively by addressing it, and that liberty will therefore be a health benefit.

There is not a great deal of evidence either way on this part. The work of Alfreddson et al has shown that people who have control of their own work experience lower mortality than those who do not, and this finding has been replicated in other occupational studies, but it remains possible that it is a spurious association resulting from confounding factors. There has been a randomised controlled trial of an educational instrument intended to increase personal autonomy in handling chronic diseases and it showed improved outcomes but it is possible that this was not the effect of the autonomy but of other aspects of the instrument – it could indeed have been a Hawthorne Effect. So we have a biologically plausible relationship and some suggestive evidence but no compelling proof. (Note: – During discussion of the paper several members of the audience drew attention to other evidence supportive of such a relationship, including evidence linking perceived locus of control to improved health outcomes and evidence that autonomy affected prognosis in mental illness).

THE FREE MARKET

The use of market mechanisms to operate the economy is attractive to libertarians because it depends on the interplay of the activities of individuals rather than on any decision making body and it is therefore less susceptible to authoritarian interference. It is important therefore that we understand market mechanisms. The critical point of market theory is the effect of supply and demand. If supply is insufficient to meet demand then the price rises. This makes it more profitable to produce the good in question. For a transitional period windfall profits are made but these attract new suppliers which results in an increased supply to correct the imbalance. The market corrects the imbalance more efficiently and quickly than any alternative. This is an attractive idea and across much of the economy it actually works. But there are areas where it doesn’t and where attention to market theory would itself predict that it wouldn’t. These areas can be found described in the footnotes of economic textbooks but are often ignored when practical decisions are being made. Many of them are of significance to health and it is important that as public health professionals we are aware of them.

Situations where an increased price cannot produce increased supply

If an increased price cannot produce an increased supply then the supply and demand relationship cannot do its job. This applies when

• The amount of the commodity in question that can be supplied cannot be increased – an example would be land

· The commodity in question is purchased because it marks status or confers advantage and it is this relative position that matters not the absolute – an example of these positional goods would be education which can be sought for its own sake but is far more often sought for the status it certifies

• ·The commodity in question is sought after because it is rare. Collector’s items would be an example.

· Market entry costs may create a natural monopoly in which it is difficult for new suppliers to enter the field. Infrastructure would be a good example – we cannot have competing public water supplies because they would be too expensive to construct.

Situations where relevant factors do not impact on the market mechanism

Sometimes there are important factors which do not impinge on the market mechanism

·Externalities, where part of the costs fall on third parties, are an important category. Pollution is a good example. The market can only work properly if somehow these are brought into the equation – hence the interest in the “polluter pays” concept

·The Tragedy of the Commons has already been described

Situations where the market needs to be tempered by social justice

Sometimes market mechanisms may produce consequences which are so unjust that they cannot be tolerated

• There are some commodities, such as legal justice and health care, where there would be a sense that it would be wrong if people could only have them if they could afford them
• The transitional consequences as the market operates to produce balance may be unacceptable. Even if selling food at grossly inflated prices were the most efficient way to bring a famine to an end (by creating a powerful incentive to import food) the transitional situation, in which those unable to pay the price die, is unacceptable. Many IMF prescriptions for developing countries are open to the criticism that they create unacceptable transitional consequences and these play a major role in the health crises of the developing world.
• The market uses the income that a person receives for their labour in two ways. It uses it as the price of the labour in the labour market. It also uses it as the consumption power that that individual has to meet their needs and this is the prime input into the market’s function of meeting human needs. Market theorists who suggest that the market will effectively meet human needs overlook the key problem in this dual use of the one item. The prime consumer input into the market should be based on the distribution of human need coupled with some variation in the capacity to meet those needs associated with reward and sufficient to allow a market in labour to operate. There is absolutely no reason to suppose that that distribution will correspond to the unmodified market distribution of the value of individuals’ skills. Indeed it seems highly unlikely that it would.

Situations where individual consumer sovereignty cannot drive the market

Market theory assumes that individual consumer decisions will send the “demand” messages that drive the supply and demand nexus.

There are two situations where this is not the case

• Where a good is enjoyed collectively not individually a collective consumer needs to be created. Many environmental benefits fall in this category
• Where the consumer cannot judge their own need, for example in the case of professional services such as health care where the consumer is advised about their needs by their supplier, the supply/demand nexus is no longer a balance but is driven by the supplier.

· If important matters which consumers should take into account are concealed from them (e.g. the healthiness of the commodity) they will be unable to take them into account in their purchasing decision

The Health Significance of These Problems with Markets

These problems with markets are significant for health in a number of ways. Health care falls into three of the exceptions, as a commodity which raises issues of social justice, as a commodity where the transitional consequences of a market adjustment may be unacceptable and as a commodity where the consumer is dependent on the advice of the supplier

Many environmental issues fall into one or more of these problem areas. Land use is an area where there is a need for regulation because the supply/demand nexus does not work properly as the supply cannot be increased. Pollution is a major externality. Environmental improvements often require a collective consumer. Transport is a Tragedy of the Commons situation. So is waste disposal.

Education is another area where there is a legitimate health interest and where the supply/demand nexus does not operate properly because it is a positional good

Poverty is a public health issue and the distribution of income is an issue which the market is unable to handle adequately

Health-damaging commodities create an externality issue unless the flow of information is regulated so that the consumer is properly informed.

Water supply requires a collective consumer because it is impossible to have competing supplies.

The Overall Significance of These Problems with Markets

These various problem areas represent a much wider range of human economic transactions than is apparent from their footnote status in economic textbooks. If we imagined a state which meticulously confined its intervention in the economy to those areas where market theory alone would suggest that a market cannot operate, but vigorously pursued its role in those areas, we would have a state which was providing or regulating education, healthcare, transport and infrastructure, was regulating land use, the market in luxury goods, and professional services, was operating redistributive taxation, was controlling advertising of health damaging products and was using its tax system to account for externalities. Although operating entirely within the principles of market theory such a state would undoubtedly be attacked as excessively interventionist. It would be characterised by its opponents (and many of its supporters) as socialist, although some of its supporters would resist that title.

If the market cannot operate with internal legitimacy (i.e. legitimacy in terms of its own theory), except in a state which could be characterised as socialist, then capitalism is a market distortion. I appreciate that many will read that as an ideological statement but I do not intend it to be such – I put it forward only in a value free academic way as the logical implication of a careful analysis of market theory.

CENTRAL PLANNING

Marx presented central planning as the solution to the difficulties of capitalism.

He did so in an overtly libertarian rhetoric – “Man is born free but is everywhere in chains” and “Man is the master of his own destiny but not in the circumstances of his own choosing”.

Before central planning had been tried, and before the developments in mathematics and in organisational theory which would demonstrate its difficulty, it is easy to see how this could have seemed the best way forward. In fact it did not produce the great improvement in human empowerment and in productive efficiency that Marx predicted. It produced the exact reverse.

Organisation theory now provides us with clarity about why the organisations needed to operate central planning will not work well

Large monopolistic organisations will become risk averse. Those who make mistakes will fail to progress professionally so only the risk averse will reach the top. As the Pennine saying goes “Them as meks no mistakes meks nowt else either”

Large monopolistic organisations will discourage dissent and will fail to receive adequate feedback about their errors. Bad news will not be passed on for fear of punishment. Criticism will be sotto voce. Ultimately Groupthink (in which any dissent is automatically characterised as wrong-minded and probably malicious) will take hold and will lead to major blunders.

If targets are set people are less likely to exceed them (Selznick’s dysfunction) so excellence is discouraged

If targets are set and people’s careers depend on meeting them they will be met if possible, even if this is sometimes by means of a distortion.

As well as the difficulties of creating an organisation capable of carrying out central planning we have in the last few decades discovered mathematical reasons as to why the task is in any case impossible. Central planning depends on the belief that if all relevant information is gathered the steps can be taken which will produce the appropriate outcome from the system. Chaos mathematics tells us that this isn’t so – that some systems are stable and predictable but others are by their nature unstable and unpredictable.

In its terminal state the Soviet planning system showed the following symptoms of its failure

• Double think in which apparatchiks were thoroughly familiar with two different realities – the actual one that they worked in and had to make decisions about, and a different one which was given to the public
• Dual statistics – an official set and an operational set
• Bad news not passed on for fear of punishment
• Risks not taken for fear of punishment
• Vicious destructive personal attacks on dissenters
• Services distorted by artificial methods of meeting targets, such as running empty goods trains in large circles to meet the train-miles target
• Public services seeing it as their prime role to promote the interests of the governing party.

In 1992, whilst there was still a Conservative Government in place, I first pointed out that all of these characteristics were appearing in the NHS. I suggested that as the Soviet system collapsed a group of Gosplan apparatchiks, realising that their careers would not progress as their agency was collapsing, took up new identities, learned English (or at any rate a language that approximated to it) and acquired key roles in what was then the NHS Management Executive. Twelve years on the attempts to solve the problems of the NHS by the methods that destroyed the economy of the Soviet Union have continued. So are they showing the same adverse consequences? Nobody would dispute that the NHS is dramatically improving but this is in response to a very large investment of funds. We used to be the most cost-effective health care system in the world and we dreamed of what we would be able to do if we were adequately funded. What we are delivering with the funds is less than we used to dream of. Is this a sign of a serious decline in efficiency? If so does this result from the planning system that successive Governments have used?

SO WHAT ECONOMIC SYSTEM DO I ADVOCATE?

Having dismissed both capitalism and Marxism, I could legitimately be asked what system I do advocate. I believe markets should be used where none of the objections to their use arise. Where it is relatively easy to correct the distortions, for example by taxing externalities, or by creating a collective consumer to purchase things that are collectively enjoyed, that should be done. Where markets cannot work we should not attempt to create them but should nonetheless try to find some mechanism for using small, locally accountable, purposive organisations.

SAFE OR RISK AVERSE?

Risk taking is central to human progress. It is important that we distinguish a safe society from a risk-averse society. In a safe society people who climb mountains check the weather, take the right equipment, make sure they are trained in its use, make sure they know the route they are taking, carry a means of communication such as a mobile phone, tell people where they are going and when they should be back, and support the mountain rescue service. In a risk-averse society people do not climb mountains. There are many areas where the distinction between advocating safety and being risk-averse is not clearly drawn and silly decisions are being taken in the name of safety. Rail safety is definitely an area where risk-averse behaviour and bureaucratic safety regulations have taken over from the determined common-sense commitment to safety which made the railways the safest transport system. The Health & Safety Executive appears to have lost touch with reality in some other areas as well. The litigation culture which has made it impossible to buy hot drinks in the United States has spread to this country.

As public health professionals we need to oppose this trend.

• It will discredit public health measures and lead to people becoming antagonistic to safety messages. The danger is that when the backlash comes it will not just attack the silly messages but it will attack genuine safety messages and measures as well.
• It will stop many valuable public health measures being taken – a hysterical attitude to rail safety has so increased the cost of rail projects that its greatest effect will be to stop people being taken off the roads. It is questionable whether it will save any lives on the railways but it is certain that it will cause deaths on the roads.
• A risk-averse society is not safe. People who are trying to avoid all risks ultimately lose the capacity to evaluate risk and become less safe not more. I believe that the Paddington rail disaster happened because the people who should have done something about a signal being passed repeatedly at danger were too busy writing safety cases about a plethora of minor risks.

I am very much afraid that medical practice is becoming risk-averse, driven by protocols and rules rather than by experience and judgement. 80% of medical practice is indeed capable of being managed and regulated and we should do our best to improve it. But 20% isn’t and it is a very important 20%. We must always recognise the need to treat the exception exceptionally.

THE VALUE OF DISSENT

Never confuse loyalty with obedience. If you are unsure of the difference imagine you are about to make a major blunder. Those who are obedient will assist you in doing so. Those who are loyal will do their utmost to stop you. Some of the most serious blunders have occurred in conditions of Groupthink where a group of leaders came to believe that they were morally superior to their opponents and that anybody who disagreed with them was automatically wrong and probably pursuing a self-interested agenda. Dissent is our only safety valve against our own errors.

When we stop valuing it we take ourselves a further step away from understanding reality.

THE CULTURAL CONTEXT OF LIBERTY: THE PROBLEM OF THE ENGLISH APPROACH

The slogan of the French revolution was “Liberty, Equality, Fraternity or Death”. Interestingly, if we do indeed accept that liberty is good for health, this could be viewed as an evidence-based epidemiological statement since we already know that poverty is bad for health and that strong social networks promote health. The Founders of the United States spoke of the right to life, liberty and the pursuit of happiness. In contrast English philosophical discussions about liberty have tended to focus on the rights of people to make decisions that are harmful to them. So the French link liberty to fraternity and equality, the Americans link it to the pursuit of happiness and the English link it to self harm.

It seems that an English version of liberty has it that if somebody wants to sell unhealthy food to you, you should just buy it and eat it so that you don’t interfere with their commercial freedom and that if somebody wants to pollute the atmosphere of your local pub with poisonous smoke you should just breathe it in so that you don’t offend against their freedom. O Liberty, what have the English done to you?! You speak to them of human hope and of the rights of human beings to shape their destinies. And they make of you a well mannered deferential defender of the status quo.