_________________________________________________________________________
"GIVE
ME LIBERTY OR GIVE ME HEALTH"
An email exchange between Ira Glasser
& Alex Wodak
_________________________________________________________________________
The following exchange began with a Reuters News story reporting that officials
in the Netherlands were close to banning smoking in the nation's 800 cannabis
cafes in order to protect the health of the coffee shop employees.
I sent this story to some friends who know each other including Ira Glasser (a
prominent civil libertarian from New York City) and Alex Wodak (a prominent
physician and public health activist from Sydney, Australia). To my surprise, Glasser
and Wodak rapidly developed a thoughtful, sharply-worded email correspondence about
situations like this when liberty and health appear to conflict.
Ira and Alex are long time opponents of
punitive drug policies and advocates of drug policy reforms, but they approach
the issue from different national, political, and professional perspectives and
priorities. Although they both personally cherish liberty and health, it
quickly becomes apparent that Glasser is most concerned with civil liberties
and Wodak with public health.
As Ira explained to me, the exchange was less about convincing each other than
about clarifying their respective positions and the differences between them.
The exchange ended a week later with both of them leaving for holiday trips.
The correspondents were naturally reluctant to go public with a spontaneous
unguarded private discussion. By employing the ancient arts of trickery and
guilt tripping, I was able to persuade them to let me stitch together their
back-and-forth replies into a single document and pass it along as a service to
others.
It is probably worth adding that, among many other activities and achievements,
Dr. Wodak ran a medically supervised injection room for 20 years, one of the
first such in the world, and Mr. Glasser wrote a prescient and lonely 40 page
critique of the Rockefeller Drug Laws in the early 1970s before they
were passed. Both Glasser and Wodak share a powerful concern with social,
economic and political justice, opposed the U.S. war in Iraq, are very
physically fit, and really like their children.
HGL
#1
From: Harry G. Levine
May 30, 2003
Subject: The end of the Dutch coffee shops?
The following, it seems to me, is BIG news and not good news. This second hand smoke stuff is really
getting out of hand.
-Harry
________________
Reuters:
"Bad Trip Ahead for Dutch Joint Joints"
May 29, 2003
AMSTERDAM (Reuters) - Dutch "coffee shops" famous for selling
cannabis are about to see business go up in smoke.
Officials have just put the finishing touches to a measure banning smoking in
cannabis-selling cafes. Due to get government approval soon, the law aims to
protect employees of all companies from passive smoking.
"Any coffee shop that has employees will be affected too," said Trudy
Prins, director of Dutch anti-smoking group Stivoro.
Although cannabis is formally illegal in the Netherlands, its use and sale are
tolerated under strict government conditions. Coffee shops, where customers can
buy a small amount of cannabis without fear of arrest, are a major tourist
draw.
Coffee shop owners were aghast. "The whole point of going to a coffee shop
is to smoke," said Arjan Roskam, chairman of the Union for Cannabis
Retailers.
The Netherlands boasts around 800 cannabis cafes. Smoking a joint in an
Amsterdam coffee shop vies with canal boat tours and trips to the flower market
for a place on tourists' itineraries.
[note: to help readers distinguish the contributions,
Ira Glasser's comments are in greenish font
Alex Wodak's comments are in reddish font]
#2.
Sender: Ira Glasser
Sat, 31 May 2003
Subject: The end of the Dutch coffee shops?
Actually, I don't understand, and have never understood, why the rights of non-smokers
aren't fully protected by a general ban in restaurants except for those
where people go to smoke.
A broader ban, including the latter, is prohibitionist, patronizing and exactly
what we should be resisting.
--Ira
#3.
June 1, 2003
From: Alex Wodak <awodak@stvincents.com.au>
Subject: The end of the Dutch Coffee Shops
Dear Ira,
The common denial of the rights of non-smokers to breathe clean air in
restaurants is purely and simply a reflection of the power of the tobacco
industry. There is no other explanation.
Re: the rights of non-smokers to breathe clean air in coffee shops:
1. This is partly an occupational health issue. If you happen to have a job
working in a coffee shop, then you are exposed to smoke whether you like it or
not. Get another job? Sure. But for some people, that option is unfortunately
not available.
2. Having some coffee shops smoke free and others not is a possibility in big
cities, but the smaller your town or village, the harder it is to make sure
that some are smoke free and others aren't. For me, the right of some to
breathe clean air has a higher priority that the right of others to pollute the
air.
Alex
#4.
From: Ira Glasser
June 1, 2003
Dear Alex,
I think your analysis is too simplistic. Of course, if it is impossible to
isolate smoke environments in a way that permits smokers to gather without
impinging on the rights of non-smokers to breathe smoke-free air (such as in
elevators and airplanes), the rights of the non-smokers to smoke-free air should
prevail. But that is not the situation in restaurants and cafes explicitly
designated for smokers; non-smokers do not choose to go there, end of story.
As to employees, that's a different story, of course, but since most cafes and
restaurants will be smoke free, hardly a major jobs issue. People who work in
auto repair shops and gas stations might as well claim that carbon monoxide and
gasoline fumes should be banned, which would of course also ban their jobs. And
that's what would happen if the Dutch coffee shops closed: a safe working
environment for employees would be secured by eliminating their jobs -- Vietnam
logic.
As to your use of the term "clean air," that is often a misnomer too.
The second-hand smoke mania has resulted, for example, in smokers being forced
to go outside their offices and restaurants, where they gather at the entrances
in far greater concentrations, so that those of us who do not smoke (I among
them) must run a gauntlet of second-hand smoke far more intense than anything
that would result from occasional smoking that is decentralized, or isolated in
special restaurants. This phenomenon is now beginning to spawn demands for
banning smokers from congregating outside. Where this must end is in
prohibition.
As to clean air: what clean air? There are a few automobiles in NY, for
example, and trucks and buses, and what they do to the air I breathe is far
worse than what a smoker might do if I ran into one. Especially if smokers were
isolated in cafes I did not choose to go to. Permitting such isolation is the
correct balance between the rights of people to do what they will with their
own bodies and my right not to have their choices forced on me.
--Ira
#5
June 2, 2003
From: Alex Wodak
Dear Ira,
Let's get back to objectives. Surely we agree that tobacco smoking is a major
public health problem in most countries?
Can we also agree that communities enjoy immense health, social and economic
benefits from reduced smoking levels?
Can we agree that many western countries have reduced smoking levels using a
wide variety of measures (raising prices, reducing availability, restricting
advertising, increasing quit smoking cessation rates, increasing the rights of
non- smokers to breath cleaner air compared to smokers rights to pollute air)?
None of these measures are intrinsically offensive but each of them can get
implemented excessively so that they do upset people like yourself. That does
not make the measure offensive. Excessive implementation is what upsets people.
But worldwide 5 million people are estimated to die from cigarette smoking each
year. That's total and permanent loss of life, liberty and the pursuit of
happiness.
And the all powerful tobacco industry fights every effective measure to reduce
smoking. It's wrong to label these measures as prohibition. There have been
examples of flagrant and total tobacco prohibition. They have not been
sustainable. No self respecting public health nazi - myself included - wants
tobacco prohibition. Simply because it will not work. Prohibitions can work
against drugs hardly anyone wants. That's not tobacco.
Banning people from congregating outside buildings won't end in prohibition. It
will end in undermining the laws which try to keep buildings smoke free.
Anti tobacco measures here have very strong popular support. Daily smoking is
now down to under 20%. Most smokers support these measures too.
Alex
#6.
From: Ira Glasser
June 3, 2003
Dear Alex,
1. We do not agree that tobacco smoking is a major public health problem,
only that it is a major health problem. If we attempted to define public
health, the disagreement would become manifest.
To me, public health involves providing research and information to citizens so
that they know what they're doing, and requiring producers to keep their
products clean and uninfected and their packages clearly labeled with
ingredients and warnings, and policies like that. Public health does not mean
placing legal limits short of prohibition, but analytically indistinguishable
from prohibition, on the poor health choices citizens make.
McDonalds promotes obesity, diabetes and cardiovascular disease, and targets
children, whose early eating habits are a predictive predicate for major health
problems as adults. And McDonalds is not alone. What about Krispy Kreme donuts?
And all those packaged foods that contain the killer transfats? What do you
propose to do about all that except try to educate people, and put
informational consumer pressure on producers and require ingredient listing and
warnings? Do you wish to make it difficult for bad eaters to eat badly by
outlawing certain foods in public places?
Children can be said to be second-hand consumers of unhealthy foods because
they are inevitably influenced by what their parents eat and buy. Shall we have
public health workers intervene, and remove those children from their dangerous
parental environment, as some tobacco fascists have proposed doing with
children whose parents smoke?
It is one thing to require car manufacturers to install seat belts, and quite
another to use the police power of the state to punish people who don't use
them. The first is public health. The second isn't and violates John Stuart
Mills' basic libertarian dictum.
2. How many people die from the consequences of excessive, prolonged
tobacco smoking is not an argument for banning smoking in smoke shops, anymore
than the number of people who die in traffic accidents is an argument for
banning cars on highways.
Permanent loss of life results from consuming too many sugars, fats and
carbs, probably more loss of life than excessive smoking of tobacco. What
follows from that, Alex?
The tobacco company fights every measure to reduce smoking. Yes, and McDonalds
would fight similar measures if they were introduced (like heavy taxes,
restrictions on advertising, reducing legal availability, etc.) to reduce
eating fatty hamburgers with carboloaded buns, french fries (fat and carbs) and
a giant, sugar-laden Coke. What follows from that, Alex? A justification for
laws that restrict people from eating at McDonalds?
The only thing that could possibly justify banning smoking in smoke shops where
people who choose to smoke go to smoke is the smoke unwillingly breathed by
workers. But in your most recent email you haven't responded to my objections
to that rationale. Instead, you abandon that justification, and move to a
broader justification, which is much more alarming, and is in fact precisely
what the prohibitionists, especially the treatment prohibitionists, always say:
drugs are unhealthy and we are guardians of the public health; therefore we
must intervene to prevent people who wish to use from using (for their own
good), or burden their use so that they stop using.
And when those burdens prove insufficient, we escalate the burdens until, at
last, prohibition emerges as the final solution. And since we have accepted the
public health intervention argument for the lesser burdens, we have no
principled basis on which to resist that argument when it emerges as the
rationale for prohibition. Indeed, your objection to prohibition is not
principled but pragmatic. You say you do not want tobacco prohibition
"Simply because it will not work."
I do not want prohibition even if it does work because of the collateral damage
such interventions cause, and because they fundamentally intrude the police
power of the state into the zone of what Mills called "individual
sovereignty."
3. You conclude by offering a majoritarian justification for your positions:
"Anti-tobacco measures," you say, "have very strong popular
support." Please, Alex. The Patriot Act has very strong popular support.
So did Jim Crow laws, lynching and criminal laws banning abortions and birth
control. Broad popular support produced sodomy laws and discrimination against
gays, and indeed drug prohibition today in the United States enjoys broad
popular support. Broad popular support is never an argument against liberty; it
is a problem for the exercise of liberty. Give this one up.
4. You say that daily smoking is now down to 20%, and you attribute that to the
restrictive measures you cite. But at least in the United States the bulk of
the drop in daily smoking occurred before all these restrictive measures were
passed, and the factors that caused that drop continued to operate after the
restrictive measures were passed. Those factors are mostly educational; most
people who smoked decades ago simply didn't know about the health hazards of
heavy smoking; when they found out, many abandoned smoking, and many more are
still trying. I do not think that evidence exists to show that the restrictive
measures you applaud can be reliably cited as the primary cause of the drop in
daily smoking.
5. In any case, there remains the little matter of liberty with which we began
this discussion. In the case of the Dutch coffee shops, the liberty interests
of the smokers is clearly served by the shops remaining open, and disserved by
the state closing them. The liberty interests of those who work in the shops
and do not wish to breathe second hand marijuana smoke (a smaller class than
the class of all Dutch coffee shop employees, to be sure) would be served by
banning smoking there. But then they would lose their jobs and have to work at
other cafes or restaurants. Which they can do now. There is a liberty interest
there, but not a very weighty one.
By the way, are those coffee shop employees
complaining? Are they behind this new pending Dutch law? Or is someone else in
authority deciding for them what is in their best interests? All this would be
nice to know.
--Ira
#7.
From: Alex Wodak
June 3, 2003
Dear Ira,
There is reasonable agreement about what constitutes public health. It refers
to a health problem which has a major effect at the population level. By that
definition, tobacco is one hell of a public health problem. Less so now in
parts of the developed world and increasingly in the developing world
I know the US smoking data a bit but am much more familiar with the Australian
data. You are quite right that it's very hard to estimate accurately the extent
to which different control measures have contributed to the reduction in
smoking (and subsequent massive reduction in lung cancer, heart disease and
lung disease). But we have a pretty good idea of what works powerfully and
consistently and what works a little some times. Most people would put high
cigarette taxes as one of the most effective measures we have. US cigarette
prices are among the lowest in the western world thanks to the power of the
tobacco industry (which have strongly supported Dubya all along).
One of the differences between us is that you seem to be opposed to prohibition
on principle whereas I am very comfortable being a selective prohibitionist. In
my defense I would say that I only prohibit drugs which almost no-one likes,
which are a pain in the arse to manufacture or smuggle and where the
(inevitable) replacement drug is not even worse. So banning barbiturates makes
sense to me. Nasty drugs. Cause a lot of harm. Difficult to make. And replaced
by benzos which are not innocuous but are not as nasty as barbiturates. And I
am no fan of tobacco prohibition. I do support control measures if they are
effective, inexpensive, and any unintended negative consequences are tolerable.
My approach to the current obesity epidemic is much the same. Try and squeeze
the industry (eg restrict ads) but bans are pointless. Where possible, try and
work with the industry. That's not easy of course.
Australia was the first country in the world to introduce compulsory safety
belts. That decision saved an enormous number of lives. I remember visiting a
hospital after that law had come in and the hospital worked out that this had
saved them (permanently) about 40 beds. It's asking people to give up a little
bit of liberty for a hell of a lot of benefit (health, social and economic). In
the 29 industrialised countries where health is seen as a collective benefit
(ie the entire civilised world), safety belts make a lot of sense. In the one
industrialised country where everything including health is seen in terms of
the individual, and where tens of millions have no health insurance, safety
belts are a minor issue.
What you say about smoking and knowledge of tobacco's health hazards is true
but only to a point. There is a huge (10:1) gradient in smoking from SES 5 to
SES 1. So, yes, the well educated and privileged people like us don't smoke but
50% of the blue collar folks do and they really pay for that.
I don't see why anyone can object to the idea that if someone in the Netherlands
wants to go to a coffee shop to buy some cannabis, sure, go ahead, but if he
wants to light up inside and thereby compel the staff to inhale his smoke, why
can't the staff member say "I'm sorry but you cannot smoke in here. You
are free to smoke outside, or in the park, or in your own home". We both
want to protect people's jobs.
Your arguments against policies supported by the majority in the US are very
powerful. But then its also true that the US is often more extreme in these
things than many other countries (while also venerating other freedoms to a
greater extent than most other countries).
The good news from here is that the age of consent for gay men was just lowered
in my state last week to 16 (same as heteros). So now, as of last week, all
states and territories in Australia have an equal age of consent.
Alex
#8.
From: Ira Glasser
June 5, 2003
Alex--
1. No, no. "A health problem which has a major effect at the population
level" cannot do as a definition of public health if by "public
health" one means policies of government intervention, backed by the
police power of the state, into individuals' sovereignty over their own bodies.
For example, high blood pressure is a health problem that has a major effect at
the population level. And a widespread problem in this area is that many
individuals do not take the medicine they should, even when prescribed. Would
this justify punitive laws? Civil fines? Coerced treatment? Criminal laws
designed to force people into treatment as a diversion from prison? (Please say
no, Alex.) If you say yes, then we have a very fundamental clash of values,
which we should talk further about. But if you say no, then let's call high
blood pressure at the population level a health problem, and reserve the
definition of public health to those problems that justify the intervention of
the state, backed by the police power. Such intervention, when directed at
producers to insure cleanliness and product safety, or to require candid and
informational listings of ingredients for the protection of consumers, is
generally justifiable. But under what circumstances would such intervention
into the decisional sovereignty of the consumer be justified? If not for
untreated high blood pressure, then for what and why?
2. You seem to concede, in whole or in part, most of the points I make, but
nonetheless and for reasons unstated or not fully stated, continue to cling to
your positions. I would like you to be more rigorous. You made a number of
points, some of them factual assertions (like the implicitly exclusive causal
link between a wide range of restrictive laws and the sharp decline in the
percentage of the population that smokes), some of them normative principles
(like the support of majorities for some of these restrictions) in support of
your position. I rebutted those points. You conceded my rebuttals, at least
partially. Then you restated your original position without modification. This
is not intellectually rigorous.
3. You concede that you are not, in principle, against state prohibition of
sovereign behaviors that do not directly harm or coerce anyone else. You are,
you say, a selective anti-prohibitionist. But if that's the principle, who gets
to make the selection? Not you, Alex. More likely William Bennett or John
Walters. And once you permit selective prohibition, then all we get to argue
about is the selection. And that argument will be won, always, by those in
power. Democratic power, perhaps, but then we're back to the problem with
majorities, which I had hoped I had disabused you of.
It is rather like the problem of free speech. You might say, as you do about
prohibition, "I do not in principle support free speech; I selectively
support it, when it seems to me to accomplish my ends." But then when a government
makes a different selection, which you don't like, you find yourself without
the principle to say: "You may not make that selection, because the
principle of free speech bars the government from making any selection."
Instead, you are reduced to arguing with the government about the propriety of
its particular selection, an argument you can never win, because once the
principle of selective free speech is accepted, then who should make the
selection, if not the government, the more so if the government is
democratically chosen (those majorities, again)?
If Mills' principle of individual sovereignty is not available to assert
against the drug czar, if we accept, in the name of benevolent public health,
the principle of selective prohibition, then why shouldn't the democratically
chosen government official, supported by majoritarian opinion, make the
selection instead of you? What conceit leads you to imagine that your selection
would or should prevail? And doesn't your support for the principle of selective
prohibition therefore lead inevitably to the bad guys, when they gain power,
making their own selection, also in the name of what they believe is good for
people?
4. I would like you to focus on individual sovereignty as a value, and tell me
why I should trust the state, even if you are the state, to protect me in ways
I do not wish to be protected? The collateral damage and outright mischief
caused by such ostensibly benevolent interventions has been immense
historically. We all, including you I suspect, engage in behavior that exposes
us to risk. Who is the best arbiter of that risk, you or a legislature? OK,
seat belts save lives. So require car manufacturers to install them, and
produce information designed to persuade me to use them. But if I choose not
to, for reasons good or bad, should the state be more empowered to force me to
use them than it should be to force me to take blood pressure medication? If
yes, why?
--Ira
#9
June 5, 2003
From: Alex Wodak
Dear Ira,
I would be surprised if you could get any support from academia for your
definition of what constitutes public health. Whether high blood pressure gets
to be called a public health problem or not does not depend on whether
government is involved. It depends on whether it has a major impact on the
community or not. One reason for this is that government is involved in
virtually every health problem, whether we like it or not. Governments
determine whether or not there will be a universal health care system. If there
is no universal health care system, then the guy who cleans the windshield of
your car at the traffic lights is more likely to get, say, TB (and also pass it
on to you).
Coerced treatment for high blood pressure? No, that's nonsense on stilts. But
coerced treatment for some (note emphasis on 'some') forms of schizophrenia or
other mental illness? I support that, but this requires a fine balance between
the patient's autonomy and the threat to the patient and others. When is it
justified? Rarely. People with severe mental health problems who threaten
others. People with infections who are non-compliant with medication and
threaten others (eg the guy with TB who won't take his medication). Someone who
is mentally impaired and can't look after himself. Over here, there are pretty
strict rules for all of this. I can't go locking up people who are too short
for their own good.
Back to blood pressure. Now why this is par excellence a public health
problem is that clinical treatment has little effect on the complications observed
at the population level. Why? Well, half the cases have never been identified.
Of the half who have been identified, half never had their blood pressure
properly controlled. Of the half who have been identified and have had their
blood pressure controlled, half stop taking their tablets. So what is much more
effective than clinical treatment (for say the 5% with the highest blood
pressure) is trying to lower blood pressure just a smidgeon (1 mm) for the
entire population. How's that done? By getting the community to want less salt
and the food industry to use less salt, increasing the amount of exercise
people take etc etc.
Wobbling? I am not sure that e-mail is the best way of arguing some of these
propositions. I suspect that what you regard as inconsistency on my part has
probably got something to do with the venue for this debate. Drawing inferences
on what has worked to reduce smoking prevalence is harder than you might think.
Econometric studies of price and consumption are very helpful in explaining
changes in consumption in the short run. Not so good for the longer run.
Availability is harder to study because it has so many components (eg outlet
density, outlet conditions) and some are hard to measure. But the biggest
problem, and this is a very big problem generally in public health, is the
interactive effect. Everything affects everything else. Simon Chapman wrote a
memorable paper on the difficulties of trying to estimate the contribution of
different elements of tobacco control in the British Medical Journal called
'Unravelling gossamer threads with boxing gloves".
"You concede that you are not, in principle, against state prohibition of
sovereign behaviors that do not directly harm or coerce anyone else."
Sorry. You have me mixed up with someone else. I support state prohibition of
unpopular and very harmful drugs that are hard to make or smuggle provided the
replacement drug is not even worse. That's not many drugs.
For example, I am trying (along with many colleagues) to get rid of pethidine
(called meperidine or Demerol in the US). Why? Pethidine is an obsolete drug.
Other drugs are more effective and much safer. So why hang on to pethidine? I
am also trying to get rid of temazepam gel caps which drug users like to inject
here. Problem is that some lose fingers, hands, or feet as a result. But we
would leave temazepam tablets alone because they don't cause the same problems.
So would you go out and campaign for obsolete drugs when there are better
drugs? Advocate that we retain temazepam gel caps when there is no clear
advantage for them and a considerable problem is associated with their use?
Who gets to make the decision here is advisory committees made up of people
with relevant experience. The Minister has the final say. I am not on those
committees but I am in contact with people who are and sometimes help them
collect ammunition. People in the US seem to outsiders to be so much more
fearful of what their governments get up to. Even before the boy from Crawford
stole the US Presidential election, it is easy to understand why Americans fear
their governments more than we do. We have our share of shysters and ganefs
getting into power, but they are pale imitations of your leaders (like RM
Nixon, GW Bush, Cheney, or Rummy).
The system of western pharmacology that has been built up over centuries has
its problems, but it also has brought huge benefits. It allows us to regulate
drugs and we do that pretty well here. (We also have a great system of keeping
drug prices down, which the US is trying to wreck as part of a free trade
agreement that is being negotiated). So overall, I don't feel bad at all about
regulating drugs in my environment. Yes, I can understand why you are so
nervous about it in your environment.
The case for compelling car occupants to buckle up is very strong. And in a
universal health care system, your decision to not be bothered about wearing
safety belts means you have to spend 18 months in a rehabilitation hospital at
my expence. Compliance with safety belts here is about 98%. Make no mistake
about it, this legislation has the consent of the governed here.
I would prefer you to take your blood pressure pills but here we try to
encourage you to take essential medicines by subsidising the price of drugs
that are very effective rather than by arresting you if you don't take them. We
prefer carrots to sticks. I don't have a problem with that. How does that work?
A committee of doctors and economists vet all new drug applications from the
pharmaceutical industry. If you want to sell a new drug here now, you have to
prove that it is more effective, safer and more cost effective than other drugs
already on the market. Now you can see why the US is trying to wreck this
system. I suppose that Rummy, former CEO of GD Searle, can't wait.
Alex
#10
From: Ira Glasser
Jun 6, 2003
Dear Alex,
It will perhaps not surprise you that whether or not my definition of
"public health" gets "support from academia" does not
affect my argument. That "academia" believes something is not itself
an argument, but rather a citation of authority in lieu of an argument. You
keep doing this, first citing "popular support" and now citing
"academic support" as a way of wriggling out of the argument itself.
You concede the problematic nature of "popular support" as a
justification when liberty is at stake, but then default back to it by your
references to the "consent of the governed," which of course begs the
question for those whose liberties are violated and who are outvoted.
I ask you to consider and confront the value of individual sovereignty and how
it is affected by what you say, but you do not. Indeed, you obscure that
question by constantly blurring the lines of the argument. In your comments on
high blood pressure, seat belts and TB, for example, you say "no" to
coercing people to take their blood pressure medicines, and refer instead to
persuading them to eat less salt and do more exercise. OK. But then why not the
same approach to seat belt use, a question I keep asking you, and which you
keep avoiding. You say that if I don't use a seat belt and am as a result
injured, citizens pay, either through higher insurance premiums or through
higher taxes if health is government-provided. But the same thing is true of
people who don't take their blood pressure medicine, and suffer the medical
consequences. Why eschew coercion in one instance and not the other? You never
say.
You also confuse the TB issue with the blood pressure/seat belt issue. An
untreated infectious disease directly injures me in a way that an untreated
non-infectious disease does not. From the point of view of Millsian liberty
principles, the two are fundamentally different, yet you commingle them in the
same paragraph without appearing to be aware of the analytic difference, much
less attempting to resolve it.
If you believe that a citizen's dependence upon government-funded health
services justifies the government's authority, without principled or legal
limits over the individual's sovereignty, then you feed and support the
conservatives' traditional fear that government funded services lead inevitably
to loss of liberty and government tyranny -- Hayek's "Road to
Serfdom." In America, at least, that fear has been a significant factor in
preventing government-funded health services, and liberals who feed that fear
do a disservice to the very programs they say they favor. It behooves those of
us who believe in government-funded health services to confront the value of
maintaining individual sovereignty and construct legal limits over government
power to assure such sovereignty.
Your argument, implied or explicit (that the use of tax-raised funds to provide
essential services to people dependent upon them justifies an infantilization
of the recipients of such services by the government provider) is a dangerous
argument. It threatens not only individual rights, but also the services, which
many people will not accept if it means trading in their autonomy. Your implied
argument (that this may be a valid concern in America, but isn't in Australia)
is weightless. These principles are not temporal or geographic; they go to the
heart of how we structure government in relation to its citizens and how we
provide for essential services and assure individuals' autonomy over their own
minds and bodies, so long as they do not coerce or directly injure other
individuals. That is the task I am asking you to confront.
--Ira
#11
June 6, 2003
From: H. G. Levine
To: Alex Wodak, Ira Glasser
Subject: Your conversation and the meanings of "Public Health"
Dear Alex and Ira,
The more I read over your exchange the better it gets. I know you two didn't
intend to make this public, but you owe it to the world and history to let me
share it. But I don't want to guilt trip you or anything. Not me.
After my umpteenth read through I got curious about what other authorities
would say "public health" is. Guess what? There are substantial
national differences on this.
Below you will find the entry on Public Health from the Columbia
Encyclopedia (U.S.) and the beginning of a very long entry from the famed Britannica.
The U.S. encyclopedia describes "public health" pretty much as
Glasser did, the Britannica pretty much as Wodak did. An amazing coincidence!
As you can see, the British conception is considerably broader than the
American one.
Given the pitiful level of international knowledge about these kinds of
important but taken-for-granted matters, it is not surprising that NONE of us
know this. Further, since people think within the categories of their own local
societies, it is also completely understandable why we all first develop our
thought about political and social issues in terms of the language and
conceptions our own national cultures.
The other side has global drug prohibition, but we are still far away from a
global opposition.
Harry
[note: See the Appendix for the encyclopedia entries]
#12
From: Ira Glasser
June 6, 2003
Dear Alex,
In rereading Harry's compilation of our recent exchanges, I thought it might be
useful to stop the line by line, point by point exegesis of replies and attempt
to summarize the question I think we have been discussing.
I would like to request that you consider the value of liberty -- an
individual's sovereignty over her own mind and body -- as a limit on the value
of public health, and then try to develop a set of bright-line principles,
which could be codified into laws, that would establish the proper boundaries
between the two values. I believe that's what we've been debating.
I would further ask that as you develop those limiting principles -- an
exercise, if you are willing to undertake it, that would bring clarity to our
debate -- you temporarily set aside your own considerable benevolence as well
as the virtue of the public health goals you advocate. Imagine instead that the
person with unlimited legal authority to implement and enforce those public
goals is not you but your worst nightmare, say John Ashcroft or Ed Meese or
William Bennett or John Walters or Pat Robertson, etc., etc.
Ask yourself if the limiting principles you develop, the legal restraints on
the power of such a person, would be sufficient to maintain the proper
boundaries between liberty and public health, so that those who value
individual sovereignty could rely on those legal restraints for protection of
their rights instead of being wholly dependent for the maintenance of their
liberties on the fortuitous hope that only people of your humaneness would ever
be in positions of authority.
Looking at the question from this perspective could help to further illuminate
where we differ and where we do not.
--Ira
#13
June 7, 2003
From: Alex Wodak
Dear Ira,
Of course I agree that civil liberties is one of the considerations that comes
into play when considering public health, especially under the US definition
but even under the broader definition that Harry quoted. And it's obviously not
as simple as just a tradeoff between one and the other.
The emphasis given to civil liberties will depend on the magnitude of the
threat to public health and the magnitude of the threat to civil liberties.
Most public health people would want a fairly severe threat to public health
before considering encroaching seriously on civil liberties. And sometimes it
works so that expanding civil liberties helps protect public health. AIDS is an
excellent example of that. Jonathan Mann was the first to realise just how
important that was.
Other factors come into this as well: effectiveness of the intervention, other
benefits and other side effects of the intervention, cost, cost effectiveness,
feasibility, community support. And there is some degree of interaction between
all of these. I assume that most civil libertarians would accept the need to
restrict, say, vending machine alcohol sales on highways. I hope that civil
libertarians would accept the need for gun control. Yes it is partly about
balancing competing interests, but it is also more complicated than that.
Part of the problem with this discussion is that you (understandably) base your
case on your experience in the US and I base mine (I hope understandably) on my
experience of life where I live. And the US is exceptional in so many ways.
There are a lot of ways that our two countries are similar. But there are also
many ways that Australia is like all the other developed countries and the US
is an out-lier (universal health care, gun laws, death penalty, etc, etc).
We have a very different attitude to authority here. The English journalist
Pringle (who then settled in Australia) was struck by the case of a migrant
with mental illness who got into a fight with a policeman (unarmed of course).
A crowd gathered around and cheered every time the migrant gained the
ascendancy. Australian politicians are often reminded that they are just like
the rest of us. For example, the current Prime Minister, as stiflingly tedious
as he is moralistic, was asked just before an election (live radio) whether
politicians approaching an election, like elite athletes before an important
sporting event, refrained from sex. I cannot imagine that ever happening in the
US.
Just as it is often said that basing law on exceptional cases produces bad
laws, I think it is a terrible principle to base laws on the possibility that
psychopaths like John Ashcroft or Ed Meese or William Bennett or John Walters
or Pat Robertson might one day be in charge. If you lived in Germany in 1938,
and then extrapolated from that and tried to design laws that were Nazi proof,
it would be hard think that any law was safe.
I am not sure that I have answered your request. I hope I have. Have a great
time in Italy.
Alex
#14
From: Ira Glasser
June 7, 2003
The example of Nazi Germany is an old one, but irrelevant. Our entire
discussion presumes a devotion to the rule of law and a structural democracy.
Once murderers take over, as they did in Germany back then, the only rational
response is to flee and/or shoot back. (Gun control? Hmmm)
However, it is not fanciful to assume that people like Ashcroft and the others
I mentioned might one day be in power when drafting rules that establish
constitutional boundaries between liberty and power, including democratic
power. I didn't invent those names and every one of them were enemies of
individual sovereignty, often for what they believed to be benevolent reasons.
Every one of them attained considerable governmental power (and I could name
scores of others), and every one of them did considerable damage to individual
rights and would have done more but for the restraints available in the Bill Of
Rights.
The Bill of Rights was explicitly and consciously designed in anticipation that
people like that would come to power, and that it was insufficient in any
political culture to depend on always having good people respectful of rights
in power at all times. You will recall that the people who thought this were
English and had no experience at that time with what you call the peculiar
American culture. But they did understand English and European history. And the
Bill of Rights resulted from exactly the kind of exercise I have requested you
to undertake, and was explicitly understood at the time as a set of rules
establishing legal boundaries between the zone of individual sovereignty and
the legitimate exercise of democratic power.
Your argument that all this is unnecessary except in the United States is
profoundly unhistorical and naively complacent. The Future of Freedom, a
new book by Fareed Zakaria, describes how the practice of democracy in
developing countries without legal limits to insure individual rights produces
tyranny, indeed a tyranny far worse in some respects and far harder to resist
precisely because it enjoys the consent of the governed, i.e., the consent of
the majority.
Imagine exporting democracy -- but without liberty, without a Bill of Rights --
to Iraq, for example, where Shiite majorities would then proceed to create a
democratic tyranny of the majority. This is a universal problem we are
discussing, and you are avoiding it by pretending that the United States is
unique. And no, you have not answered my request; you have explained why you
don't think you need to. Try, please.
Now I am really off to Italy, literally out the door!!
--Ira
[Note from HGL: In response to encouragement from me, Dr. Wodak submitted a
final statement.]
#15
From: Alex Wodak
June 9, 2003
This exchange of views grew out of a difference of opinion over the rights and
wrongs of banning smoking in taverns to protect the rights and occupational
health and safety of staff, but also to protect non-smoking patrons from the
risks of second hand smoke. Research has shown fairly consistently that solid
majorities of smokers support most smoking restrictions. This makes it hard to
claim that this issue is a choice between the rights of smokers to pollute the
air that non-smokers have to then breathe or the protection of public health.
The ban is a win for both.
The request to devise measures to protect the community from abuse of smoking
restrictions sounds attractive but is not feasible. Unscrupulous and malevolent
leaders who acquire power even by democratic means have shown time and again
that they are always able to subvert seemingly innocuous legislation for their
own purposes. It is much more difficult to argue this approach inside the US
where there have been many more unscrupulous and malevolent leaders than in
most other countries.
Alex
.
. .
THE END... FOR NOW.....
Ira Glasser has discussed some of these issues in Doing Good: The Limits of
Benevolence, and in Visions of Liberty: The Bill of Rights for All
Americans. Alex Wodak has discussed some of these issues in Modernising
Australia's Drug Policy and in Drug Prohibition: The Call for Change.
I also recommend Jacob Sullum's smart new book: Saying Yes: In Defense of
Drug Use. All five books are available from Amazon.com.
APPENDIX 1: SMOKE AND THE DUTCH COFFEE HOUSES
I wrote to Dr. Frederick Polak, a psychiatrist and drug policy reformer in
Amsterdam, sent him the original Reuters News story, and asked what he knew
about all this. His reply follows.
From: "F Polak" <fpolak@knmg.nl>
Re: Second hand smoke and the Dutch coffee shops?
June, 1, 2003
Harry,
The push against smoking has been going on here for some time already, but this
complication was new for me too.
In the psychiatric institutes the situation has become very difficult because,
for the people who have to live there, for years smoking cigarettes was often
the only habit that still was allowed.
This ban on smoking is based on an enormous exaggeration of the damage that
passive smoking can do to the non-smoking persons present in the cafe or coffee
shop. And in the coffee shops, as a well known coffee shop owner explained on
TV, the clients come to his place with the purpose of smoking, and every member
of his personnel is a regular pot smoker, so the whole ban makes no sense.
But remember, it is OK to smoke if there is a smoke-free zone and a designated
smoking area, and I think that the coffee shop owners can afford to put aside a
little money to make that arrangement. Some coffee shops however are too small
to allow for this solution and I don't know whether the government will accept
that.
F. Polak
APPENDIX 2: U.S. AND U.K. ENCYCLOPEDIA ENTRIES FOR "PUBLIC
HEALTH":
From: Columbia Encyclopedia (U.S.)
PUBLIC HEALTH: field of medicine and hygiene dealing with the prevention of
disease and the promotion of health by government agencies. In the United
States, public health authorities are engaged in many activities, including
inspection of persons and goods entering the country to determine that they are
free of contagious disease. They are empowered to isolate persons with certain
diseases and to quarantine such individuals, if necessary, for the public good.
Public health officials are responsible for supervising the purity of the
water, milk, and food supply as well as the persons who handle these items and
the public eating places that dispense them. They are responsible for the good
health of animals that supply food and for the extermination of wildlife,
rodents, and insects that contribute to disease. Public health authorities are
also concerned with the pollution levels in air and water, and must assure the
safety of water used for drinking, for swimming, and as a source of sea food.
In addition, they collect vital statistics on death rates, birth rates,
communicable and chronic diseases, and other indicators of the state of public
health.
The duties of carrying out the many services required to keep the population
healthy and to prevent serious outbreaks of disease are divided among local,
state, and federal government agencies. They provide health officers and nurses
for the schools and visiting nurses for the home. They oversee the water
supply, the disposal of sewage, the production and distribution of milk, and
the proper handling of food in restaurants. Public health agencies impose
standards of public health on local communities when needed; they give
financial and technical assistance to local communities in time of crisis, such
as that caused by epidemics, hurricanes, and floods.
The principal federal health agency in the U.S. today is the Public Health
Services division of the Department of Health and Human Services. It consists
of five agencies including the National Institutes of Health, its research arm,
which conducts extensive research into neurology, blindness, AIDS, immunology,
and heart disease. The Centers for Disease Control and Prevention, another
agency under the Public Health Service, maintains statistical data on all
diseases; it was instrumental in showing the relationship between tampons and
toxic shock syndrome, as well as pinpointing the source of Legionnaire’s
disease to a new water-borne organism. The Food and Drug Administration is the
arm charged with assuring the effectiveness and purity of food, drugs, and
cosmetics. The Alcohol, Drug Abuse and Mental Health Administration was
established by Congress more recently to address substance abuse and mental
health problems. To carry out all these activities the public health services
employ large numbers of physicians, dentists, veterinarians, laboratory
technicians, nurses, sanitary engineers, health educators, psychologists, and
social workers (see also Surgeon General, United States).
Because of the frequent and rapid transportation of people and disease vectors
by air there has been a growing need for the monitoring of public health on a
global level. This is done by the UN’s World Health Organization.
------------------------------------------------------------------------------
From: Encyclopedia Britannica (U.K.)
PUBLIC HEALTH: the art and science of preventing disease, prolonging life, and
promoting physical and mental health, sanitation, personal hygiene, control of
infection, and organization of health services. From the normal human
interactions involved in dealing with the many problems of social life, there
has emerged a recognition of the importance of community action in the
promotion of health and the prevention and treatment of disease; this is
expressed in the concept of public health.
Comparable terms for public health medicine are social medicine and community
medicine; the latter has been widely adopted in the United Kingdom, and the
practitioners are called community physicians. The practice of public health
draws heavily on medical science and philosophy and concentrates especially on
manipulating and controlling the environment for the benefit of the public. It
is concerned therefore with housing, water supplies, and food. Noxious agents
can be introduced into these through farming, fertilizers, inadequate sewage disposal
and drainage, construction, defective heating and ventilating systems,
machinery, and toxic chemicals. Public health medicine is part of the greater
enterprise of preserving and improving the public health. Community physicians
cooperate with such diverse groups as architects, builders, sanitary and
heating and ventilating engineers, factory and food inspectors, psychologists
and sociologists, chemists, physicists, and toxicologists. Occupational
medicine is concerned with the health, safety, and welfare of persons in the
workplace. It may be viewed as a specialized part of public health medicine
since its aim is to reduce the risks in the environment in which persons work.
The venture of preserving, maintaining, and actively promoting public health
requires special methods of information-gathering (epidemiology) and corporate
arrangements to act upon significant findings and put them into practice.
Statistics collected by epidemiologists attempt to describe and explain the
occurrence of disease in a population by correlating factors such as diet,
environment, radiation, or cigarette smoking with the incidence and prevalence
of disease. The government, through laws and regulations, creates agencies to
oversee and formally inspect such things as water supplies, food processing,
sewage treatment, drains, air contamination, and pollution. Governments also
are concerned with the control of epidemic infections by means of enforced
quarantine and isolation—for example, the health control that takes place at seaports
and airports in an attempt to assure that infectious diseases are not brought
into a country.
This section traces the historical development of public health, beginning in
ancient times and emphasizing how various public health concepts have evolved.
It outlines the organizational and administrative methods of handling these
problems in the developed and the developing countries of the world. Special
attention is given to the developing countries and to how the health problems,
limitations of resources, education of health personnel, and other factors must
be taken into account in designing health service systems. Finally, there are
descriptions of the most recent developments in public health, together with
some indications of the problems still to be solved.
[This is the beginning of a long entry in the Britannica.]
If anyone would like to comment on this exchange or the questions it raises,
you can send messages to me at hglevine@hereinstead.com. I can't guarantee that I will post them, but
I might.
Click here to return to http://www.hereinstead.com/
HGL
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