Paternalism- what a tangled web
August 6, 2013
“IT IS NOT TOO MUCH TO REQUIRE THAT WHAT THE WISEST OF MANKIND, THOSE WHO ARE ENTITLED TO TRUST THEIR OWN JUDGEMENT, FIND IT NECESSARY TO WARRANT THEIR RELYING ON IT, SHOULD BE SUBMITTED TO BY THAT MISCELLANEOUS COLLECTION OF A FEW WISE AND MANY FOOLISH INDIVIDUALS, CALLED THE PUBLIC.“ (Mill, 1999).
“TO BE A POOR MAN IS HARD, BUT TO BE A POOR RACE IN A LAND OF DOLLARS IS THE VERY BOTTOM OF HARDSHIPS. HE FELT THE WEIGHT OF HIS IGNORANCE, NOT SIMPLY OF LETTERS BUT OF LIFE.” (DuBois, 1903)
“SOBERING REALIZATION OF PROGRESS” (DuBois, 1903)
Back in February 2013, I posted a short tribute to Ronald Dworkin, the famed political legal scholar, upon his passing (http://wp.me/p32X8n-9H). The most salient piece written by Dworkin continues to resonate for me has to be his piece in the Monist, entitled “Paternalism”. I had been exposed to principles of paternalism while a graduate student in African American and African Studies at The Ohio State University. In the African American Leadership course taught my dear mentor, Dr. James Upton, I was asked to lecture as an adjunct to his class of upperclassmen. I stood at a lectern quoting legal scholars while framing paternalism with The Souls of Black Folk by DuBois. Mind you, these students of Afrocentricity often discussed the disparities in racial realities using thinkers such as W.E.B. DuBois and Booker T. Washington. These students advocated through critical engagement. When was the last time health professionals took a step back from our R21’s to do that? I am by no means advocating for a departure from evidence based research (post-positivism). Nope, not me. In an effort to “cast (our) buckets”, Dr. Upton gave me an outlet to further devise a way to explore disparity in a way that suited me…as a scholar. Low and behold, I decided that the way that I would serve society would be as a public health professional in a MPH Program (again as a Buckeye). But instead of being drawn to relative risks as the others, I was hanging on the every word of Dr. Kenneth Steinman. Dr. Steinman had his students dive into Dworkin as a core perspective to understand “public health”, a work that most likely felt foreign to many, but not me. Maybe a little sumthin’ could be learned from a Negro spiritual repurposed by DuBois to emulate “double consciousness” of race or a nice, friendly soft paternalism debate in the light of human fallibility. Just maybe.
Published in 1859, John Stuart Mill penned On Liberty. The basic premise of his work posed the position that the essence of man is to defend the individual rights to think and act for him. According to Mill (1999), action would be wrong when it acts contrary to the greatest happiness for the most people. So how is his stance against paternalism (known as Mill’s principle) counter to the basic tenet of public health? This pareto efficiency is achievable ONLY through the protection of personal autonomy by means of ”protest against external authority” (Mill, 1999). Oops, public health acts through such “external authorities”. In line with utilitarianism,
“OVER HIMSELF, OVER HIS OWN BODY AND MIND, THE INDIVIDUAL IS SOVEREIGN” (Mill, 1999).
People, according to Mill (1999), base decisions on “personal preference”. If we in health are to evoke the power to infringe on the personal liberty of an individual, Mill (1999) said that we only have that right when the burden of proof suggests that “preventing harm to others” is the only justification.
“HIS OWN GOOD, EITHER PHYSICAL OR MORAL, IS NOT A SUFFICIENT WARRANT” (Mill, 1999)
What is made quite evident is the warring of the ideals of maintaining personal liberty with the maximization of social utility. What is the acceptable tipping point before we topple too far to the side of autonomy while undermining social welfare? Dworkin (1972) in response to Mill wrote that paternalism “will always involve limitations on the liberty of some individuals in their own interest but it may also extend to interferences with the liberty of parties whose interests are not in question.” Mill sets an unreasonably high threshold for achieving “paternalism”. This certainly is not unusual with such sweeping pronouncements. In light of the impossible achievability of Mill’s requirements, Dworkin (1972) said that what is at work in reality is “impure paternalism”. As impure paternalism is followed, a disenfranchised class’ needs are met by way of subjugating the requirements of an unaffected class (Dworkin, 1972). Someone has to give up liberty so others can gain. But who wants to be the “perceived” loser? If the argument remains as a question of personal liberty, yes, someone will shoot craps. However if the framing of reference becomes that the public’s health will improve which may:
1. Reduce the burden on taxpayers to subsidize services of the underserved in order bring more parity to community.
2. Population based mortality and morbidity may be reversed- If I give a little, I may gain a better quality of life in the end. My insurance premiums are pooled based on the outcomes of all of those insured as a collective. My community will thrive.
It is getting over the immediacy of the personal loss of liberty that stings. We in public health cannot make promises that for each loss of liberty there will be a “recognizable” gain in health status that people may be able sense. People live by the concreteness of their own experiences. Unfortunately, this is often to the disadvantage of public health to get buy-in of impact. But it is perhaps the impurity of human experience that makes the work of public health the most noble of all. It is just so darn hard to lose while “gaining”.
Du Bois, W. (1903) The Souls of Black Folk. Chicago: A.C. McClurg & Co.;
[Cambridge]: University Press John Wilson and Son, Cambridge, U.S.A., 1903; Bartleby.com, 1999. http://www.bartleby.com/114/.
Dworkin, G. (1972). Paternalism. The Monist. 56 (1): 64-84.
Mill, J. (1999). On Liberty. London: Longman, Roberts & Green, 1869;
Franklin, J. (1965). Three Negro Classics. New York: Avon Books. I suggest this version which includes the full texts of The Souls of Black Folk & also Up from Slavery (Washington). Elegant foreword by the preeminent black historian, John Hope Franklin, is not to be missed.