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Exercise, Population Health and Paternalism

Written by Rebecca Brown


The NHS is emphatic in its confidence that exercise is highly beneficial for health. From their page on the “Benefits of exercise” come statements like:

“Step right up! It’s the miracle cure we’ve all been waiting for”

“This is no snake oil. Whatever your age, there’s strong scientific evidence that being physically active can help you lead a healthier and happier life”

“Given the overwhelming evidence, it seems obvious that we should all be physically active. It’s essential if you want to live a healthy and fulfilling life into old age”.

Setting aside any queries about the causal direction of the relationship between exercise and good health, or the precise effect size of the benefits exercise offers, it at least seems that the NHS is convinced that it is a remarkably potent health promotion tool.

It is perhaps surprising, therefore, how little is done to ensure people take more exercise. Office for National Statistics data from 2019 showed around a third of adults in England were considered either fairly inactive or inactive. Yet health promotion efforts to increase physical activity rarely reach further than providing encouraging messages on the NHS website and a few attempts at encouragement by opportunistic doctors faced with a physically inactive patient. Compared to other public health interventions – banning smoking in public places, requiring food retailers to display nutritional information on labels, hassling people to attend large scale cancer screening programs, prohibiting multi-buy offers on alcohol sales, imposing minimum unit pricing, and so on – the efforts to encourage physical activity look half-hearted.

What more could be done? Much has been made of the potential for ‘nudges’ to improve public health. These involve changes to the physical and social environment that make it easier (and more likely) that people will make ‘healthy’ choices. Nudges seek to walk the line between intrusive, liberty restrictive interventions that force behaviour change, and efforts at persuasion which have limited impact. In the physical activity context, nudges include stairs featuring motivational messages (or even calorie counts), placing lifts or escalators in a less visible position (though making sure they’re still available for those who need them), or mHealth technology that provides feedback on people’s activity levels (such as step counters). But clearly more could be done if there was greater willingness to enforce coercive legislation in this context. For instance, efforts to encourage active travel, although increasing, have generally been limited in the UK (particularly in comparison with some of our European neighbours). Cars continue to dominate roads and cycling infrastructure, even in cities where cycling is reasonably popular, is minimal and of generally poor quality. In particular there is an apparent unwillingness to commit to making non-active travel inconvenient and less appealing, along the lines of smoking and binge drinking. 

Such interventions are, presumably, paternalistic (if motivated by a benevolent attitude to make people healthier). There is a longstanding disdain towards paternalism in medical ethics, but this has largely been articulated in the clinical context. The translation of anti-paternalism to public health contexts is trickier. As James Wilson (2011) points out, two key features of paternalism which are supposed to make it problematic in individual contexts – interference with liberty and lack of informed consent – are endemic to many public health interventions. Paternalism, Wilson argues, should not be offered as a general objection to public health interventions. Instead, we must consider whether the infringements of liberty involved in a (paternalistic) intervention are justified.

There is a general preference to use the ‘least restrictive alternative’ when it comes to public health interventions. A less remarked upon but still relevant consideration is whether we are obligated to use a more restrictive alternative if this is needed to bring about some important benefit. For instance, it might be unethical to fail to have a smoking ban in place if the harms of smoking are sufficiently severe. A very non-restrictive intervention (e.g. the NHS creating a webpage that says exercise is good for health) is of no use if it has no effect on physical activity. The policy options seem to be to either 1. make no attempt to encourage physical activity; 2. use non-restrictive methods to encourage physical activity (e.g. gentle persuasion); or 3. use more restrictive methods to increase physical activity (e.g. hard and soft regulation). Given the failure of the second approach to have much of an impact on physical activity (at least insofar as the UK population is increasingly inactive) and the pronounced enthusiasm of health promoters for exercise as a tool for better health, it is surprising that more intrusive methods for increasing physical activity have not been implemented.

Perhaps one explanation for this is that such interventions would involve intentionally making life less convenient for people. But this is where the bullet must be bitten: if physical activity really is believed to be as good as the NHS suggests when they declare it a “miracle cure” supported by “overwhelming evidence” then it is surely neglectful to continue to allow people to shorten and worsen their lives through failure to be more active? After all, there has been a huge (and successful) effort to reduce smoking rates in the face of robust evidence of serious harm. Few people think that restrictive regulation of tobacco smoking is inappropriate. Of course, if the messaging from the NHS is exaggerated – perhaps as a tool to try to encourage more physical activity via persuasion – then intrusive regulation would not be warranted. But in such a case, neither would such vigorous claims for exercise as a wonder ‘drug’ be justified.

Wilson, James. “Why it’s time to stop worrying about paternalism in health policy.” Public Health Ethics 4.3 (2011): 269-279.

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4 Comment on this post

  1. As I remember there was a GP practice in Peckham that incorporated a gym and more. I presume that this closed . Medical policy has been dictated by surgeons and physicians believing in pharmaceutical solutions. Exercise has been left to the local authorities whose budgets have been squeezed till dry.

  2. One problem is that the moral rightness of an action does not translate straightforwardly into the moral authority of any given agency to insist on it. Except on the extreme consequentialist view, for example, one can believe that adultery is morally wrong without holding that any action that prevents adultery is by the same fact morally right.

    Here, it’s reasonable, of course, to argue that the outcome of taking exercise is good and that by the same fact it is morally permissible. But without retreating into an extreme of consequentialism that even Bentham would have found uncomfortably narrow, that alone isn’t enough to explain why it would be morally permissible for the government or the NHS to force people to do it. The authority–if any–of government and NHS to force behaviour change needs a separate explanation. Given that both are societal constructs, surely the source of their authority is what society has agreed they should be for.

    The NHS certainly should NOT force behaviour change. The source of its moral authority is an agreement on the part of individuals in society to pay into a common pot, knowing that most of the time the beneficiaries are other than oneself while also knowing that at any time one might need to draw on it. The NHS exists, in short, to repair people when they need to be repaired; its moral authority to change their behaviour is restricted to circumstances under which such change is a necessary part of the repair.

    You could argue that a democratic government does have the authority to force behaviour change, providing that were part of its manifesto. The source of the government’s moral authority is (more or less) its electoral mandate, and if society has agreed through that to authorise government to force health-related behaviour change then perhaps that is all the authority it needs. As stated, that is a bit unlikely, though. It’s hard to imagine the electorate voting to be forced to do something they don’t want.

    Fortunately, ways to effect behaviour change are not dichotomous between being laissez-faire in the name of autonomy on the one hand, and forcing the issue in the name of better health outcomes on the other. Those are merely the anchor points of a spectrum that also includes (for example) educating, advising, persuading, nudging and coercion. That brings some forms of influence within the authority of the government. The electorate are unlikely to vote to be coerced or forced, but they might be willing to give the authority to be educated or advised.

    But we also have to remember that, once again, a moral obligation on the part of government to educate and advise does not of itself translate into a moral obligation on the part of individuals to be educated or to act on advice. And if they don’t want to do so, and become ill as a result, they are absolutely entitled to expect the NHS to pick up the pieces. That, after all, is the function for which society maintains the NHS, and for which it invented the NHS in the first place.

  3. The Government and NHS force behaviour change all the time when it suits it, for example most of the targets the Government and the NHS itself have set necessarily require behaviour change. Considerations of paternalism are no where to be seen when it comes to these sorts of initiatives, they only seem to becomes an issue, when it is suggested that individuals actions may have consequences that are deleterious to their health. These arguments are frequently employed by those who benefit from the current status quo (the pharmaceutical, tobacco and food industry and the so called “Think Tanks” that they fund, to name a few more obvious examples),

    A health service that is there simply to ” repair people when they need to be repaired” is a National Illness Service not a comprehensive health service. Indeed there is a certain paternalism in the notion that the NHS is only a rescue service and has no role in health promotion……..more ill health not only benefits health care providers in privatised health care provision, but it also does so in the NHS (albeit less directly).

    Brown, Webb and Hain all touch on the need for health promotion. Surely health promotion needs to return as a core function of the NHS, by co-production with the populations it serves, not handed down in tablets of stone from producer to consumers.

  4. The point is that at the moment the individuals who constitute society and who pay for the NHS do so in the expectation that it will repair health damage, not forcibly prevent it. Since that societal expectation is the only defensible source of its moral authority, the NHS must not take it upon itself to enforce behaviour change or to penalise poor health behaviour. That is not what it is there for.

    Health promotion does not represent such enforcement but comes under the head of ‘education and advice’, which society does expect from the NHS. Health promotion remains a core function of the NHS just as it always has been (at least, as it has been ever since I joined as a medical student in 1981).

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