Introduction

Freedom is possibly the most enticing concept in the western political tradition. At the very least, freedom is necessary for us to make important choices about our lives. Although being free does not necessarily make us powerful, without freedom our power as individuals is almost certainly diminished. It is debatable, however, whether our freedom consists in being able to do whatever we wish, or whether it relies upon us doing those things that are good for us and allow us to develop as individuals. Should we be free to consume as much alcohol as we like for as long as we like, or does our freedom rely upon us placing limits upon what we drink so that we can develop other interests and skills? Are those people who smoke thirty or forty cigarettes a day free, or are they slaves to their habits? To those who want the freedom to indulge their habits, health promotion can be seen as a potential threat to the life-style decisions they have made for themselves. Knowing this, it would seem important for governments to find ways to communicate their public health messages without alienating those deemed to be most at risk.

An increasing amount of attention is being paid to health promotion and this is starting to challenge the ways in which we view the responsibilities of the state for the provision and direction of health care. The apparent move towards health promotion has been driven largely by financial concerns. Rather than rely primarily upon treating the sick, governments and medics have favoured earlier intervention in the hope of preventing illness and thus relieving pressure upon the scarce resources marshalled by state-funded health care systems. This early intervention does, however, raise serious questions about the power of the state and the freedom of the individual. It is far from clear whether health promotion enhances or detracts from individual freedom. Libertarians could view health promotion as one of the many methods used by the government to regulate individual behaviour and to enhance its own power at the expense of individual freedom. We should remember that whilst health promotion is sometimes focussed upon tackling the health problems of vulnerable groups, it is also often aimed at relatively healthy people and that such intervention could do significant things to undermine the sovereignty that many people seem to feel that they have over their own bodies. Paternalists might see health promotion as necessary to protect us from ourselves and in so doing enhance our ‘real’ or ‘true’ freedom. But the choices do not end here. It could be that the state can help to empower people to assume greater responsibility for their own health and thus to rely less upon the input of the state. This ‘third way’ approach, characteristic of current Labour Party policy in Britain, places health promotion at the centre of a campaign to reconcile the conflicting priorities favoured by libertarians and paternalists respectively.

Health Promotion

Health promotion is generally concerned with finding ways to improve the health of the individual and the community. Health promotion goes beyond traditional methods of curing illness and seeks to improve well being by helping people live more productive and fulfilling lives [29, pp. 133–134]. Although it could be argued that people should be sufficiently mindful of their own well being to make healthy choices without having to be prompted, this fails to take into account the range of social and individual factors that shape the health we enjoy or endure. Simply leaving the individual to his or her own devices would be heartless at best and would neglect to give due weight to the importance of individual health for the general health of society. Although it is always possible that governments could be motivated by philanthropic concerns, it is often the case that governments intervene in social affairs because of dire need. In Britain, the government turned in earnest to health promotion campaigns following the problems it had recruiting for the Boer War. When it had to turn down 40 per cent of recruits on health grounds, the government began to take health care seriously. This led to the creation of new services (including hospital care) for pregnant women and to the development of hospitals to deal with infectious diseases [9, pp. 62–63].

There are a variety of strategies used in health promotion. Lifestyle campaigns are used to warn people about such things as the dangers of smoking. The government might also intervene directly to improve the health of the population by regulating levels of acceptable pollution or by increasing taxation on harmful substances. There is also a range of preventative measures that can be put in place to improve general levels of health. Primary prevention might include introducing laws to prevent dangerous behaviour. Secondary prevention includes such things as screening services and tertiary prevention could involve measures to minimise the effects of a disability or to provide extra care for vulnerable sections of the community [29, pp. 134–136]. Although medics might have an important role in health promotion, it is unlikely that they can do everything themselves without the cooperation and support of the state. Nordenfelt [17] argues that the responsibility for health promotion lies outside of the medical professions and that the government must have some involvement in the provision of health-enhancing facilities (like gyms) and in restricting health-damaging activities (like smoking) [17, pp. 18–23]. This is not simply because those who manage the machinery of the state want to increase its functions, but because it makes sense in light of a long-standing commitment by governments to defend public health.

Health promotion has become increasingly important in debates on the future of health provision in Britain. It could be argued that this should have a central role in public provision of health care and that it should not be viewed as an optional bolt on. We should remember that one of the original aims of the National Health Service (NHS) was to promote health and well-being rather than simply provide medical care to the unwell but that it was not until the 1970s, in response to escalating demands upon the NHS, that the government began to look again and take seriously the pledge to improve the health of the nation. From the mid 1970s onwards, Labour and Conservative governments have stated that more resources need to be diverted towards health promotion [9, pp. 64 & 82; 29, p. 137]. Governments have recognised that public funding of health care is expensive and that public demands upon government-funded health care are close to insatiable. Frightened of escalating taxation and further crises in the funding of welfare services, many governments are looking for ways to reduce our expectations and push us to be more responsible for our own well being. Rather than provide more health care to more people, we are encouraged to live in healthier ways. As governments attempt to place limits upon direct public provision of health care, it would appear that health promotion attains increasing significance.

It has been argued that health promotion provides an effective way to tackle problems of poor health. For those actively involved in health promotion, a health service that ignores preventative measures creates real long-term problems for itself. According to the Health Development Agency in Britain interventions to assist individuals in changing their own behaviour are often cost-effective. The Health Development Agency, which is now part of the new National Institute of Health and Clinical Excellence, points in particular to the success of anti-smoking campaigns and those campaigns designed to promote safe sex; both of which targeted young people [11, pp. 1–2]. It is recognised, however, that individual and collective action and commitment is necessary for health promotion to be effective. In a House of Commons [12] report on health, it was noted that individuals are often engaged insufficiently in improving their own health and the health of the community. Although it was recognised that it is very difficult to influence people simply by telling them that their behaviour might pose serious risks to their health, it was considered important to find ways to encourage people to take responsibility for their own health and well being. This does not mean that it is all down to individual effort. The British Department of Health has argued that there should be a collective sense of responsibility for public health and that it is important to involve individuals and community groups in combating health problems. The Department of Health acknowledges that the government should be responsible for providing services to treat the sick and that it should also help to protect health by minimising the social, environmental and behavioural factors that can damage the health of both the individual and the community [6, pp. 5–8, 21 & 42–43]. It would appear that health promotion is not simply a service that people can choose to consume or ignore. Social and political agendas are set regardless of personal indifference and it is these agendas that might be seen to threaten or enhance individual freedom.

Health Promotion and Negative Liberty

If we are to understand the implications of health promotion for the freedom of the individual, we need to be clear about the nature of freedom. Perhaps we should start by drawing attention to the distinction between negative and positive liberty and by acknowledging that the current section will deal with negative liberty or the freedom to do as we wish. Isaiah Berlin [3] claimed that negative liberty is having freedom from interference. In particular, it was thought to involve us being able to act without being obstructed by others and he argued that we are coerced when we are prevented from acting by the deliberate interference of others. There must of course be some limits to this form of freedom because if people are free to do exactly as they wish, the strong might victimise the weak. It was therefore recognised that there must be ‘… a certain minimum area of personal freedom which must on no account be violated’ [3, p. 36]. In this way, a line is drawn between personal life and public authority. It is far from clear, however, where this line should be drawn. Supporters of negative liberty tend to see the state as an enemy of individual freedom and are therefore predisposed to look for ways to place limits upon the authority of the state.

One of the most important advocates of negative liberty is John Stuart Mill. In Mill’s view, the community should only interfere with the conduct of the individual so as to prevent harm to others and that in purely personal matters we should have total independence. According to Mill, the adult individual should have sovereignty over his or her own mind and body. He believed that in order for us to be free we need liberty of conscience, thought and feeling, liberty of lifestyle and the freedom to unite with others. Our freedom depends upon all three being respected and observed [15, pp. 13–16]. Mill knew, however, that no individual could claim to be a totally isolated being and that we cannot harm ourselves without hurting those close to us. All deterioration in the physical or mental faculties of an individual harms dependants, prevents an individual from contributing to the good of the community, and can create a burden on society [15, pp. 80–81]. If our actions ‘violate’ our obligations to others, then these actions are open to censure or ‘moral approbation’. The case of intemperance, for example, would fall into this category. Intemperance might lead to an individual being unable to support or educate his or her family and incur debt. This would be a failure to fulfil our duties and we could be punished. Mill thus believed that there should be definite limits to the authority of the state. It should not have a right to intervene in self-regarding conduct. He believed that the personal sphere of self-regarding conduct should be protected from public intervention. The only grounds for public intervention are when it can be shown that the actions of somebody threaten to harm the interests of others. Even then, Mill was careful to warn us to look out for those who would seek to restrict liberty by evoking the idea of the public good whilst simply imposing their own tastes on others.

It could be argued that health promotion, especially when this means providing un-solicited advice and attempting to control individual behaviour, can be a threat to the freedom of the individual. Using this definition of freedom, arguments could be constructed to defend the freedom of the individual to consume the recreational drugs of their choice. If limits are to be placed upon these individuals, it could be argued that such limits would only be legitimate if it could be proved that the freedom of these individuals damaged the freedom of others. Even if we did not want to take the arguments this far, a convincing case could be constructed against the state intervening in health promotion. Sheaf [23] argues that by attempting to create a culture to influence behaviour, health promotion can be seen as a form of social control and health promoters can be criticised for attempting to impose their own values on the general public. Health promotion or preventative care can increase victim blaming, it can extend the jurisdiction of medical officers over the lives of the population and it can lead to increased demand (at least in the short run) for health resources [23, p. 87]. It is clear that for supporters of negative liberty the individual must be free to make decisions (and mistakes) for themselves without the state intervening inappropriately. Indeed, they would tend argue that individuals should find ways to protect their privacy from the over-arching authority of the state. It could be argued that if the state is to function effectively it needs definite limits to the range of functions it performs. Without these limits, the potential for the abuse of state power might be far too great.

Health Promotion and Positive Liberty

Although it might be tempting to regard health promotion as a threat to the freedom of the individual, this would only seem to apply if we hold onto a negative view of liberty. For many people, freedom does not consist in having license to do whatever we wish but in developing and progressing as individuals. Supporters of positive liberty have argued that individuals should overcome their base desires and listen to their ‘higher selves.’ For example, Taylor [26] argues that the idea of negative liberty places far too much attention on the coercive powers of the state and fails to give due consideration to the ways in which ignorance and inner fears can stand in the way of true freedom and of individual development. For Taylor, we need to find ways to gain control over our own lives and to push aside immediate pleasure and convenience in the interests of fulfilling our long-term aims and interests. This view of freedom tends to allow far more room for the state to intervene in the lives of the individual [3]. Indeed, it could be argued that state action is essential if individuals are to be made aware of the potential barriers that exist to their freedom and development. State intervention in the provision of health care, education, housing, benefits and so on could thus be justified on the grounds that it contributes towards the positive liberty of the individual.

The state could intervene in a variety of ways to modify the behaviour of its citizens. The British liberal T.H. Green, for example, believed that positive liberty would be served by placing limits upon the sale of alcohol. He believed that alcohol created a social nuisance and that it detracted from ‘… freedom in the higher sense, from the general power of men to make the best of themselves’ [10, p. 29]. Green believed that excessive drinking posed a threat to the health, finances and capabilities of society and, when the head of the household was a drunkard, it led to the ‘… impoverishment and degradation of all members of the family’ [10, p. 29]. In his view, limiting licensing laws was not enough. Indeed, he believed that public houses should be outlawed. This was not considered an infringement upon the liberty of the individual for he believed that liberties should only be allowed when ‘… the allowance of that liberty is not, as a rule, and on the whole, an impediment to social good’ [10, p. 30]. According to Green, such legislation was necessary as part of a general package of health and education policies.

For supporters of positive liberty, the state is a potential saviour. By creating the social foundations necessary for us to prosper as individuals, state action and intervention is thought to enhance individual freedom. Using this view of freedom, health promotion can be viewed as beneficial and not as a threat to individual freedom. If we hold onto the view that we cannot be free if we are constrained by inner fears and by unhealthy habits, then state action designed to make us healthier in the broadest of senses is good for the freedom of the individual. This line of argument would suggest that negative liberty (the freedom to do as we wish) is a dangerous illusion and that true freedom relies upon us relegating the importance of the immediate satisfaction of our senses and that it consists far more in us making the best of ourselves. There are of course some dangers to this line of argument. In particular, it would seem to provide the state with an open invitation to intervene in the personal lives of the individual and potentially to generalise wildly about the common good and the real good of each component individual. Those who are more fearful of the state are unlikely to allow the state such freedom to monitor and mould the private lives of the citizen.

Health Promotion and Freedom as Empowerment

Not all forms of freedom can be accommodated in the negative and positive camps and it is not necessarily the case that we have to choose between two self-contained and unchanging views of liberty. The advantage of the distinction between negative and positive liberty is that it allows us to view some connections between freedom and the state and to recognise that state activity in itself does not necessarily infringe upon individual freedom. Although advocates of negative liberty might remain unconvinced, there is a considerable body of opinion that would argue that some state intervention in the private lives of the individual could be beneficial for both the individual and for the community. For those who argue in this way, it is still important that we recognise that some limits must be placed upon what the state can do or else we run the risk of swamping the individual with the values held and championed by social and political elites.

For those who want to avoid the cut and dried solutions offered by the supporters of negative and positive liberty, it is possible to view freedom in terms of empowerment. Rather than see freedom as a right to be left alone or to be protected, it could be that freedom has far more to do with the power that we have over ourselves and that it is manifested in our abilities to transform our behaviour and enhance our presence and influence in the community. Radical educationalists have often placed value upon education because it can transform and empower the individual and in so doing help to challenge discrimination and unjust inequalities (see for example [8, 19]). The term is also used frequently by the Blair government in Britain to signify the power that the communities need to combat racism, social exclusion and crime and the power that individuals have to participate in decision making and to transform their fortunes through education and through behaviour that enhances their health [5]. This emphasis upon empowerment affirms the importance of maintaining the sovereignty and integrity of the individual whilst recognising that the state can facilitate individual and community development and support individuals in the choices they make. This would seem to be captured, at least in part, in current British Labour Party plans for health promotion.

Labour policy on health promotion can be found in the lengthy policy document Choosing Health: Making Healthier Choices Easier (2004). John Reid, the architect of this document, claimed in the preface that the debate on health promotion has often focussed on the polar extremes of state responsibility versus individual responsibility. The state could, for example, intervene to limit individual choice by imposing constraints and by banning actions that can harm our health. Alternatively, health could be left to ‘… whatever the hidden hand of the market and freedom of choice produces’ [7, p. 5]. These polar extremes, which correspond to the paternalist and libertarian perspectives identified in the current article, are rejected by the Labour government in favour of a blended or ‘third way’ approach. Reid believed that it is important for the government to intervene in promoting health. He claimed that health promotion should focus upon changing people’s behaviour and that this relies upon gaining the support of people themselves. All the government can do at best is to provide guidance and opportunities and help to ‘create the conditions’ which can help people make healthier choices (Reid, April 2004, p. 2). Reid argues that the government has an obligation to empower individuals to change on their own and to support them in the choices they make (Reid, June 2004). Rather than coerce individuals or simply leave them to fend for themselves, the third way sees the role of the government to support and assist individuals and effectively to empower them to become more independent of state services.

Choosing Health grew out of extensive consultation conducted between April and June 2004 with community groups, the general public, key health care providers and health agencies along with the business community who were asked to express their views on a range of public health issues. People were asked to consider what they want and expect the government to do in terms of promoting health and what could or should be expected from individuals [7, p. 12]. In many ways, the Labour government was deliberately looking for an alternative to excessive state intervention and to the sort of freedom allowed within the libertarian framework. This can be illustrated by taking note of the declared expectations of the individual and the government respectively and of the empowerment strategies outlined in Choosing Health.

It is argued that although individuals need to assume responsibility for their own health, the government can help by providing opportunities and information to help people to choose to live healthier lifestyles. It is clear from the survey conducted, that people accept that they have responsibilities for their own health and that an overwhelming 88% of respondents said that they were opposed to the government telling them how they must live. It was deduced from this that people want to be free to make choices about how they live and that they did not want decisions made for them. The government could assist not by dictating how somebody must live but by providing reliable information and support to people once they have decided to change their behaviour [7, pp. 3–12]. This does not mean, however, that health professionals need to be passive in their dealings with patients. For example, health professionals were asked to consider the long-term benefits of health promotion ‘even when advice on giving up smoking, exercising or changing diet is unwelcome and may initially make relationships difficult’ [7, p. 128]. It was argued in Choosing Health that the government cannot leave it to individuals to reform themselves and that it needs to cooperate with others to ‘provide collective support to help to create an environment which promotes health’ [7, p. 6]. It was found that many people expect the government to help to create the right environment in which they can make healthy choices and that they expect the NHS to take an active role in health promotion and to provide suitable support for individuals who want to change their behaviour [7, p. 13 & pp. 119–121]. It is clear that for the public the government must limit its intervention so as to pay due respect to the sovereignty and personal identity of the individual.

State activity was clearly justified on the grounds that it can help to prevent individuals from harming others. Seemingly owing a great deal to John Stuart Mill, it was argued that one of the key functions of a properly constituted government was to prevent individuals harming others through their actions. It was argued that the choices we make can sometimes have a negative impact upon others and that it was important to strike a balance between ‘allowing people to decide their own actions, while not allowing those actions to unduly inconvenience or damage the health of others’ [7, p. 6]. Choosing Health states that there is widespread support for the government to intervene where the choices made by some can have a detrimental effect upon the health of others and that the government needs to find ways to ‘prevent people from doing things that put the health of others at risk’ [7, p. 15]. The Labour government is therefore looking for ways to place limits upon smoking in enclosed public spaces for example on the grounds that the actions of smokers pose a threat to the health of others who share their space.

To those who would argue that this constitutes a dangerous extension of state power and jurisdiction, the Labour government justifies its policies on the grounds that it is seeking to empower people. Partly in order to avoid the accusation that central government is interfering too much in the life of the individual, the Labour government emphasises that local community groups should have a key role in health promotion. Instead of relying too much upon central government agencies, Labour policy calls upon the voluntary and community sectors to play an active role. It is felt indeed that these decentralised groups are closer to the patient and are capable of facilitating and coordinating collective effort [7, pp. 79–95]. It is important moreover to recognise that the Department of Health envisage patients developing their own personal health plans with some guidance from on-line resources and from personal health trainers drawn from and working within the patient’s own community. This is regarded as a movement away from ‘advice from on high to support from next door’ [7, p. 103] and it is believed that such measures can help individuals attain more control over their own health and thus enable people to transform themselves according to their own interests and on their own terms rather than because they are being forced to change in some prescribed way [7, pp. 106–115]. This, at least according to the current Labour government, shows how state activity can nourish and strengthen individuals rather than subjugate them to remote structures of authority.

It would be wrong to assume this apparent compromise between libertarian and paternalist values is confined to Britain. The need to devise policies to balance the freedom of the individual with the general welfare of the community informs policy developments in health care and health promotion across the globe. In other parts of the European Union and in Australia, initiatives have been launched to provide people with reliable information on diet and nutrition and to improve the health of children in particular [4, 13, 25]. There are widespread attempts to place limits upon smoking in public places without banning such activity completely. In Sweden, for example, policy makers are seemingly concerned with striking a reasonable balance between individual freedom and the health of the community [30]. In the United States also, where government intervention is often viewed with suspicion, public health campaigns have called upon individuals to reassess their attitudes and health behaviour whilst providing some limited government support to assist individuals in changing their lifestyles and habits [28]. It would seem, indeed, that those who champion health promotion are likely to encounter resistance and that this resistance stems in many cases from the need to recognise, respect and defend the freedoms we feel we have as individuals. Policies designed to empower the individual are unlikely to do so if they are imposed in an authoritarian manner.

Conclusion

We should always remember that there are many types of health promotion and that while some types of health promotion might be intrusive other types would be seen by many people as helpful at best and harmless at the very least. A poster campaign encouraging us to eat more fruit and vegetables is unlikely to offend even the most stubborn and committed of carnivores. Although many types of health education could be regarded as benevolent, attempts to place restrictions upon the behaviour of the individual may well offend and encounter resistance from a sceptical public. Health messages can be viewed as attempts by the governing class to impose their tastes on other sections of society. If this is the case, the government and its Department of Health could be viewed as petty tyrants and as potential threats to individual freedom and respect for diverse lifestyles.

We have attempted to show in this article that at least some forms of health promotion undermine negative liberty by increasing the powers of the state, government agencies and the medical profession over the lives of us all. Libertarians will often point out the importance of maintaining control over our own minds and bodies and that we should be vigilant in defending our personal space and lifestyle choices against an intrusive, unrepresentative and potentially malevolent state. Apart from anything else, those forms of health promotion that seem to target and monitor individuals could be viewed as yet another method of surveillance and control that is used by the state at the expense of the individual. Those who view life in these terms will undoubtedly be critical of health promotion and want to limit as far as possible the intrusions of the state into our private lives.

Health promotion could however be viewed as something that can enhance our freedom. Whereas libertarians are apt to believe that we are all capable of making rational choices about our own lives and our own health behaviour, paternalists will look to the state to guide people to a better understanding of their own best interests. It could be argued that the state has an important role in helping us to overcome the numerous barriers to real freedom and that we lose the plot if we concentrate too much upon the powers held by the state and ignore the beneficial ways in which these powers can be used. From a paternalist point of view, the state can help individuals strive for and in some cases reach their potential by improving the general levels of health, education and security of the community. In accordance with this view, the state should be used to provide what is best for people rather than confine it to the minimal functions allowed (sometimes grudgingly) by libertarians.

Some of the examples used in this article show that there is a third way. We have seen that libertarians tend to believe that the preservation of individual freedom relies upon placing firm restrictions on the power and influence of the state and that paternalists are more likely to believe that the state can be used to promote freedom by providing people with what they need. For the third way, the state is called upon to empower people to rely less upon the state. Rather than make a commitment to leave people alone on the one hand or look after people on the other, the third way approach casts the state in the role of facilitator and reminds individuals that they have certain responsibilities in society that include taking more control over their own lives, health and welfare. This approach asks people to be realistic about their needs and to make use the support mechanisms of the state to rise above any circumstances that keep them down. This approach recognises that health promotion can be used to empower individuals, enhance their freedom and, in the long run, make them less dependant upon the health service and upon services provided by the state. Rather than see health promotion as an intrusion, it is thus possible to see the benefits it can have for both the individual and the community.