Ealing PCT’s new campaign to ‘help’ smokers quit goes to the heart of a debate too-often ignored: the proper limits of state intervention in the name of public health.
The PCT has gone one step further than the smoking ban, the warnings blazoned across cigarette packets and advertising campaigns by what it calls a ‘new direct action approach’. Over the next six weeks, smokers in Ealing will have nowhere to hide, as the Stop Smoking Team trawls the streets challenging smokers to take a CO2 monitor test and take up counselling support to give up for good.
Who is stopping to ask if this is a step too far? Is it not yet another unwarranted infringement on civil liberty? Some will say not; if civil liberty is narrowly defined as freedom of association, assembly, religion, speech and to due process and fair trial we may have little qualms with it; no-one is forcing the smoker to take any tests or counselling. They can easily say no.
But then isn’t civil liberty also about the right to privacy; and about setting limits to government action so that it cannot abuse its power and interfere with the lives of its citizens? If so, the position becomes much more precarious. Surely the person who does not know that smoking damages your health must be something of an anomaly; the warning on the front of every cigarette pack they buy makes it pretty clear. People make perverse decisions, persisting in smoking, drinking, eating to excess, and taking little exercise, despite being aware of the risks to their future health. Why should they be hassled by government-sponsored public health workers when nipping out of work for a relaxing smoke? What comes next? Picking on those that are fat, those that choose to drive rather than walk, or those that sit in the pub after work on a Friday having a few beers?
Of course, many smokers may want to quit, but is Ealing PCT’s strategy really the best way to go about it? No distinction is drawn between those that do and those that don’t. I am reminded by a story told by Dr Mike Dixon, a GP and chair of the NHS Alliance, to illustrate what he called ‘the marshy bog land of real life’ at a recent debate Civitas held:
“This morning I saw a patient who for ten minutes talked about such the issues he wanted to talk about. The computer said he had about a 25 per cent chance of having a heart attack in the next five years. We fiddled with the knobs and found out that he had a simple choice. To get down to a 16 per cent chance he either had to give up smoking or go onto statins.
Yet he didn’t want to go on statins and giving up smoking was a difficult option because his partner, who had a tendency to depression and psychosis, was on lots of tables and as a chain smoker would find it difficult to help him through that.
These are the real choices that make a difference to a person’s life expectancy; choices that depend on very human things like relationships, trust, integrity and things like how you can motivate people or perhaps even persuade them.”
Quitting smoking is a long-term process that surely requires a trusting relationship, support and confidence from the outset, not sending a market research team up to people in the street. Would not making stop-smoking advice much more easily available on a voluntary basis – setting up a stand in the street that people could approach themselves – be a better idea?
Self‐determination, dignity and autonomy are likely to be important components of a wider definition of health that many would do well to remember. In his essay, In Defence of the English Professions, the LSE professor and former European Commissioner, Ralf Dahrendorf wrote:
‘There is a fundamental difference between countries in which government had to wrest powers from autonomous social units [the UK and the US] and countries [in continental Europe] in which all rights of citizens had to be wrested from an all-powerful state.
The burden of proof is very different in those countries in which there is a general presumption in favour of a self-governing society, as against those in which the presumption is always in favour of the state. Another way of putting this is to say that to countries of the former tradition, notably Britain and the United States, freedom comes naturally; whereas in the latter, including most of the European continent, it always has to be fought for.’
It is alarming that there is not even a shard of public debate about the progressive erosion of this principle in health care. We must decide whether we want a health system that is essentially there for the individual, or that is essentially utilitarian and paternalistic. Everyone dies, but at least they stopped smoking and lost a bit of weight before doing so.
