Health-damaging behaviors, particularly tobacco use, lack of physical activity and poor eating habits, are major contributors to the leading chronic diseases such as heart disease, cancer, stroke and diabetes.
The importance of interventions to address these behaviors in an effort to prevent or delay the onset of major chronic diseases is well-documented. However, what interventions to implement is less clear and raises important philosophical, ethical and practical questions relating to issues such as individual freedom, personal autonomy and paternalism.
Another issue is whether the intervention is based on voluntary or mandated compliance when the behavior is limited to the individual and causes no immediate or direct harm to others.
A case in point is the implementation of smoke-free or tobacco-free initiatives on college campuses and elsewhere. There is strong public support to eliminate exposure to secondhand smoke that also may ban “vaping” or the use of electronic cigarettes.
Given that tobacco use, and not just smoking tobacco, is the leading cause of preventable deaths in the U.S., many campuses also have instituted tobacco-free policies that include all smokeless tobacco products by anyone, including smokeless tobacco in private vehicles parked on campus property. Currently, there are more than 2,200 100 percent smoke-free campus sites. Of those, more 1,900 are tobacco-free.
While well-intended, there are important issues that need to be considered.
One is autonomy, which is the freedom to act or function independently without external controlling influences. Respect for autonomy is one of the fundamental principles of health care ethics. This includes allowing patients to make their own decisions about what care they receive or not receive.
However, autonomy is not without limitations. One is the Harm Principle, when power is exercised over an individual to prevent harm to others. Smoke-free laws, policies or rules impose limitations on smokers due to the demonstrated risk and harm caused to others from secondhand smoke. Because of the potential harm, there is strong public support and high voluntary compliance.
However, tobacco-free is inconsistent with personal autonomy when imposed in the absence of demonstrated harm to others such as using chewing tobacco or smoking alone in a vehicle.
Another ethical issue arises between the concepts of paternalism and autonomy. Paternalism is the policy or practice of people in authority to restrict the freedom of those subordinate to them in their best interest. Violations can range from admonition, fines or loss of privileges. It restricts a person’s freedom “for their own good.”
Paternalism involves a judgment that the person is not able or willing to decide for themselves how best to pursue their own good.
Examples include laws that require seat belts or wearing a motorcycle helmet. While understandable to support efforts to reduce secondhand smoke, the same does not appear to be justified with respect to supporting mandated tobacco-free policies. It is paternalistic and inconsistent with autonomy.
Strong public support for smoke-free and tobacco-free policies is, in part, due to the vast majority being nonsmokers. In 1965, 42 percent of the adult population smoked. Recent data show the smoking rate at an all-time low of about 14 percent, a 67 percent decline since 1965.
Given the dramatic reduction, it is easy to see why smoke-free and tobacco-free would have public support. However, does that justify mandating tobacco-free policies when the harm is to the individual user and not the population? If so, consider the following situation.
Just as campuses have gone tobacco-free, should there be a mandated program to reduce obesity on campuses? Obesity is a well-documented public health problem. One study reported that during four years of college, the percentage of students overweight or obese rises from 23 percent to 41 percent — a 78 percent increase.
Given its prevalence in the population, obesity could be a greater health problem than tobacco use. Some health risks associated with obesity include heart disease and stroke, high blood pressure, diabetes and some cancers. Given this challenge, should campus residence halls, using accepted measures to determine obesity, mandate nutritional practices such as food choices and quantities for obese individuals? Should obese people be enrolled in mandatory programs promoting healthy eating and activities? What corrective action, if any, should be implemented? Fines for non-compliance? Probation for repeat offenders? Given concern for a healthy campus environment, should these mandates be expanded to include employees? Should there be a loss of benefits or pay reduction for noncompliance?
Nonsense you say. The previous example shows that mandating any behavior limited to the individual can be a slippery slope without priority to respecting personal autonomy and freedom of choice while avoiding paternalism.