A Tyranny of Health?

by Theodore Dalrymple

The dream of a society so perfect that no one will have to be good (as T.S. Eliot put it) is a beguiling one for intellectuals, perhaps because they think that they will be in charge of it, as a recent article in the Journal of the American Medical Association titled “The Moral Determinants of Health” well illustrates.

In this article, which has the merit of being clear and logical, no single instance of individual conduct is mentioned as being necessary for, or conducive, to health. In the healthy society envisaged by the author, who is a public health doctor in Massachusetts, no one will have to try to behave well—not drink or eat too much, refrain from smoking or taking drugs, not indulge in hazardous pastimes, take recommended but safe exercise and so forth—because everything will come as a matter of course to him. Living in a perfect society, he will behave perfectly. The author’s means of achieving these ends are entirely political, and wildly impractical examples of progressivism without practical wisdom—and as such, unremarkable.

More troublingly, in the author’s view, at least implicitly, health is the goal of goals to which all other considerations ought to be subordinate. It is perhaps natural for a doctor to think this, concerned as he is, day in, day out, with the health of others, but nevertheless this is a very reductive view of life.

It goes almost without saying that health is desirable; no one would actually prefer to be unhealthy than healthy, though a considerable number do prefer to claim to be unhealthy, or unhealthier than they are. But we should remember that a life is not well- or badly-lived according only to its length. Mozart died at thirty-six, but would anyone say that his life would have been better-lived had he survived to seventy-two but without having composed any of his music? People, moreover, sacrifice their lives for any number of reasons, from the noblest to the most ignoble. Would anyone say that Martin Luther King lived badly because he exposed himself to assassination, which a nice quiet life would not have done? As is known, assassination is bad for the health; we do not say, therefore, that people who tell the truth despite threats are bad because they betray the cause of health and thereby lower (albeit infinitesimally) life expectancy in their society.

Let us take the word determinant and examine the case of cigarette smoking. In Britain, as in America, there is a decline in life expectancy as one descends the socio-economic scale (though even the poorest have a life expectancy half as great as members of the British Royal Family in the middle of the 19th century). A very considerable proportion of the difference is accounted for by the prevalence of smoking, much higher in the lower classes than in the upper.

Why is this? It was not always so. However, when it was proved beyond reasonable doubt that smoking caused lung cancer, and then a variety of other serious diseases, the richer and better-educated portions of society abandoned smoking as a pleasure and a habit. The lower classes did so to a lesser extent (though still to some extent).

It is not that the lower classes do not know that smoking is bad for their health. In getting on for half a century, I have never met anyone of any class who did not know this. Many, however, say that they wish to take their chances; the pleasure or relief provided by smoking is such that they deem the risk worth it.

We cannot say that they are necessarily wrong, though it is not a choice we ourselves would make. I have indulged in many risky behaviours in my life, that nevertheless seemed to me worth the risk.

Now the author of “The Moral Determinants of Health,” who writes solely of poverty, inequality, racism, etc., would either have to take away the choice of people who choose to smoke, thus setting himself up as a dictator, or he would have to admit that there are individual determinants of health related to the choices people make. Correlation is not cause; the fact that more poor people smoke than rich is not the same as saying that poverty causes smoking. Men are not billiard balls whose direction is determined in a purely mechanistic way by the impact of a few physical forces.

One does not have to go to the opposite extreme and claim that there are no social influences at all, and that men are total masters of their fate in all circumstances. Take the question of obesity: it is a sad fact that fat mothers have fat children because they overfeed them (quite apart from any genetic influence). Fat children are more likely to be fat adults: it is harder, though not impossible, for them to be otherwise. It is certainly not fair that fat children should have to struggle more than thin not to be fat in adulthood, but this again is not the same as saying that there is no moral dimension whatever to their individual body mass index, nor is it the same as saying that, if there is such a dimension, they should be denied all sympathy or assistance in trying to do something about their obesity. As Dr. Chasuble said to the morally exigent Miss Prism: “Charity, Miss Prism, charity, we are none of us perfect. I myself am peculiarly susceptible to draughts.”

The author of the article in JAMA is unaware that his opposition to mass incarceration actually undermines his argument, for it is a fact—a sad and horrible fact, but a fact nonetheless—that imprisonment decreases the death rate among prisoners compared with their peers outside. I worked it out that a prisoner is just over half as likely to die in prison in Britain as are his peers outside. If the avoidance of death were all-important, we should be imprisoning more, not fewer, young men. I presume that no one thinks this.

According to the figures provided by JAMA, over 100,000 people have read the article on-line. I would imagine, though I don’t know, that most of them are doctors. In the comments, there is not a single dissent from the premises of the article. Whether dissent would be censored, I do not know, but I very much doubt it.

I think, then, that it is possible that a dictatorship of virtue would not be abhorrent to at least a large section of the population.

First published in the Library of Law and Liberty.