Beyond the ‘nanny state’: Stewardship and public health

BACKGROUND: Some public health measures restrict personal freedom more than others, and deciding what type of measure will be appropriate and effective has long been a problem for policy makers. Existing bioethical frameworks are often not well suited to address the problems of public health. METHODS: The Nuffield Council on Bioethics set up an expert working party to examine the ethical issues surrounding public health in January 2006. Following evidence gathering and a public consultation exercise, the Council published its conclusions and recommendations in the report ‘Public health: ethical issues’ in November 2007. RESULTS: A spectrum of views exists on the relationship between the state's authority and the individual. The Council set out a proposal to capture the best of the libertarian and paternalistic approaches, in what it calls the ‘stewardship model’. This model suggests guiding principles for making decisions about public health policies, and highlights some key principles including Mill's harm principle, caring for the vulnerable, autonomy and consent. An ‘intervention ladder’ is also proposed, which provides a way of thinking about the acceptability of different public health measures. The report then applies these principles to a number of case studies: infectious diseases, obesity, alcohol and tobacco, and fluoridation of water supplies. CONCLUSIONS: The idea of a ‘nanny state’ is often rejected, but the state has a duty to look after the health of everyone, and sometimes that means guiding or restricting people's choices. On the other hand, the state must consider a number of principles when designing public health programmes, and justification is required if any of these principles are to be infringed.