Elsevier

Public Health

Volume 129, Issue 8, August 2015, Pages 1021-1029
Public Health

Mini-Symposium
Relational conceptions of paternalism: a way to rebut nanny-state accusations and evaluate public health interventions

https://doi.org/10.1016/j.puhe.2015.03.007Get rights and content

Highlights

  • Public health interventions are sometimes criticized as ‘nanny-state’ actions.

  • A ‘nanny-state’ action is a type of (allegedly) paternalistic action.

  • An allegedly paternalistic act is considered wrong because it undermines autonomy.

  • ‘Nanny-state’ accusations rely on a flawed libertarian conception of autonomy.

  • A relational conception of autonomy and paternalism is more useful to public health.

Abstract

Objectives

‘Nanny-state’ accusations can function as powerful rhetorical weapons against interventions intended to promote public health. Public health advocates often lack effective rebuttals to these criticisms. Nanny-state accusations are largely accusations of paternalism. They conjure up emotive concern about undue governmental interference undermining peoples' autonomy. But autonomy can be understood in various ways. We outline three main conceptions of autonomy, argue that these that can underpin three different conceptions of paternalism, and consider implications for responses to nanny-state accusations and the assessment of public health interventions.

Study design and methods

Detailed conceptual analysis.

Results

The conceptions of paternalism implicit in nanny-state accusations generally depend on libertarian conceptions of autonomy. These reflect unrealistic views of personal independence and do not discriminate sufficiently between trivial and important freedoms. Decisional conceptions of paternalism, like their underlying decisional conceptions of autonomy, have limited applicability in public health contexts. Relational conceptions of paternalism incorporate relational conceptions of autonomy, so recognize that personal autonomy depends on socially shaped skills, self-identities and self-evaluations as well as externally structured opportunities. They encourage attention to the various ways that social interactions and relationships, including disrespect, stigmatization and oppression, can undermine potential for autonomy. While nanny-state accusations target any interference with negative freedom, however trivial, relational conceptions direct concerns to those infringements of negative freedom, or absences of positive freedom, serious enough to undermine self-determination, self-governance and/or self-authorization.

Conclusion

Relational conceptions of autonomy and paternalism offer public health policymakers and practitioners a means for rebutting nanny-state accusations, and can support more nuanced and more appropriately demanding appraisals of public health interventions.

Section snippets

Paternalism: the basic concept

The literature on paternalism is dominated by efforts to differentiate descriptively between paternalistic and non-paternalistic acts.13, 14, 15 Two conditions feature in most standard accounts of paternalism:15

  • 1.

    The paternalist in some way undermines, constricts or limits the autonomy, freedom or liberty of the subject; and

  • 2.

    The paternalist justifies this action on the grounds that it promotes what she understands to be the good, welfare or benefit of the subject.

On most accounts, both the first

The welfare-justification condition

The welfare-justification condition will be satisfied when an actor attempts to justify an intervention on the grounds that it will promote some aspect of subjects' welfare, or prevent their welfare from diminishing. Assessment of whether or not the welfare-justification condition has been met is relatively straightforward. There is no requirement that a paternalist is either genuine or single-minded about the pursuit of subjects' welfare. There is also no requirement that the welfare is

The autonomy-undermining condition and paternalistic actions

Some notion of autonomy, liberty or freedom is fundamental to any discussion of paternalism, but these terms are often used in interchangeable or unexplained ways. Accusations of paternalism will be more serious the greater the moral significance of the aspects of autonomy, liberty or freedom that are undermined. A case can be made that richer notions of autonomy, not just narrow conceptions of liberty or choice, are most significant.19

We now draw on and extend the work of Catriona Mackenzie,

Discussion

We noted at the outset that paternalism is a paradoxical concept, entailing a wrong (undermining autonomy) ostensibly justified by a good (increasing welfare). A well-founded accusation of paternalism must be based on an appropriate conception of autonomy. We have summarised the key features of libertarian, decisional and relational conceptions of autonomy (as elucidated by Mackenzie), and delineated three associated conceptions of paternalism: nanny-state, decisional and relational paternalism.

Acknowledgements

An early version of this work was presented at a workshop on paternalism held on Friday 8 November 2013 at the Centre for Agency, Values and Ethics at Macquarie University. We thank participants in that workshop for their helpful comments. Thanks also to Prof Catriona Mackenzie for her helpful comments on an earlier draft of this manuscript and to Prof Paul Benson for providing us with an early version of his work on stereotype threat.

Ethical approval

Because this is conceptual rather than empirical research,

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