Do public health measures really make us happier?

Many of us accept public health policies relating to things deemed harmful, like alcohol, vapes, fatty or sugary food or cigarettes, without question.

However a new book by Martin Wilkinson, a professor of politics and international relations and former chair of the New Zealand Bioethics Council, concludes that many public health interventions probably make people worse off, infringe on their autonomy and don’t have compensating benefits for others.

Free to access, The Ethics of Public Health Paternalism (Oxford University Press, 2025) examines the various ways of making people healthier, according to whether they make it harder to be unhealthy, easier to be healthy, influence beliefs, or ‘nudge’ people towards certain choices.

The book covers measures like taxes, label warnings, age limits and bans on sales and marketing, as well as health promotions like ‘five plus a day’, subsidies to gyms, enticements to stop unhealthy behaviour, product placement in stores and the provision of walking and cycling infrastructure.

It features examples like the prohibition of alcohol in the US (from 1920 to 1933) and the Danish fat tax, a tax on saturated fat in food products, introduced in 2011, repealed in 2012, and the first of its kind in the world.

It also defines the concept of ‘paternalism’ in relation to health policies. A main reason often given for the state to intervene in citizens’ health is because people would, if left to their own devices, make unhealthy choices that are bad for them, says Wilkinson.

“But trying to stop people harming themselves sounds paternalistic, and paternalism in public health raises two main questions: Why do we think that getting people to make healthier choices would make them better off? And should people not be free to choose for themselves?”
 

He specifies that adults, rather than children, are the focus of the book and that smoking is the one area where he believes the sheer weight of evidence supports efforts to discourage it.

Otherwise, he is on a collision course with the majority of public health advocates, he admits.

“I’m doubtful about the merits of many of the interventions they want. I argue that adults ought to be free to run their own lives, and that some, but not all, public health interventions would infringe on their autonomy.”

He says the book engages with ideas that writers and public health advocates have offered, found not only in books and academic articles but also in blogs, pamphlets, interviews, and health promotion campaigns.

He believes public health advocates who want to steer people into healthier behaviour have not been good at giving convincing reasons for doing so.

“They generally assume that to be healthier is to be better off, but this assumption is often wrong, because health is neither the only value nor the supreme value.

"To decide when people would benefit from being healthier, we must consider the value of health in their lives, how their unhealthy behaviour might be mistaken, and the evidence about whether it is or not.”

While the book is obviously critical of public health, Wilkinson says he’s not taking a free market or libertarian position.

“I take no view about the size of the government, its role in the economy, or its duties to redistribute or to support a welfare state. Nor do I believe that paternalism towards adults is always wrong, only that it is questionable.”

He believes in fact that perhaps paternalistic influences on people’s choices would make them better off, perhaps they wouldn’t infringe upon people’s autonomy after all, or perhaps the infringement is justified.

“Finally, however, I remain unconvinced,” he says. “A persistent theme of the book is that we often don’t have very good, or in fact competing, evidence on these issues. Because the absence of evidence is not evidence of absence, I don’t conclude that public health interventions are unjustifiable, only that they have not been justified.”

The Ethics of Public Health Paternalism (Oxford University Press, 2025) by T M Wilkinson is open access and published online from 20 January 2025 and in print from 6 February 2025.