Paternalism and Alcohol Policy
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Paternalism and alcohol policy Kari Poikolainen, University of Helsinki, Finland Drugs and Alcohol Today, Publication date: 23 September 2020 https://doi.org/10.1108/DAT-07-2020-0048 Abstract Purpose - To investigate to what degree scientific evidence supports contemporary paternalistic alcohol policy practices targeting fully competent adults. Design/methodology/approach - Paternalism may be acceptable if it is effective, fair and protects the safety of the citizen or a third party from the harms caused by the citizen's autonomic actions. To be justifiable, paternalistic actions should bring about clearly more benefits than harms. Otherwise autonomy should prevail. The evidence related to alcohol control policies is assessed against these principles. Findings - In peaceful civilized societies alcohol control policies (high prices, restrictions on supply and marketing) have no or only insignificant effectiveness. Some policies are unfair and may bring about more harms than benefits. There is strong evidence showing that brief interventions aiming to reduce alcohol intake are inefficient. Wide-scale screening for such interventions is likely to waste health service resources. There is sufficient evidence to refute the claim that the above policies are effective measures to reduce alcohol-related harms. Heavy alcohol use during pregnancy and driving motor vehicles while intoxicated may bring about harm to others than the user. Behavioural interventions to reduce heavy use in pregnancy have been shown to be inefficient. Light alcohol use may have no harmful effect on the developing embryo while heavy use is likely to cause harm. There is moderate evidence for enforcing legal blood alcohol concentration limits to reduce traffic accidents and fatalities. Originality - This is the first review on the acceptability of paternalism in currently recommended alcohol policies. It shows that in only a few cases paternalism is effective and compatible with freedom and fairness. Keywords Alcohol policies, Efficiency, Fairness, Freedom, Paternalism, Autonomy Paper type Research paper Introduction What kinds of paternalism are acceptable in alcohol policy? Has the state the right to interfere with the adult citizen's alcohol use? What types of interference might be fair? Has the state the right to lie in order to protect its citizens? Have health authorities similar rights to the state? These are serious, difficult and often neglected questions. I shall first set up the background and criteria for acceptable paternalism, then review the evidence related to alcohol policies supporting or refuting paternalism and finally discuss the appropriate role of paternalism. The state is parens patrie of its population. Like a good father and mother its duty is to take care of those in need of help. The state keeps order and protects the weak, infirm and handicapped. In the parent-child and caregiver-patient relationships paternalism has an important role to play. However, the extent of paternalism is always debatable and can be criticized, depending on particular historic, cultural and social circumstances in various countries. In spite of this, the prevailing view on alcohol policy focuses on global and universal measures to diminish alcohol- related problems. Good parents also give as much freedom as possible to the adults of the family. Fully competent citizens should have as much autonomy as reasonable and possible. For them, the balance between actions of authority and autonomy of the citizens must be carefully considered (Dworkin, 2020). Focusing on this adult population, paternalism will be appraised. In my view, paternalism may be acceptable if it is effective and fair, if a paternalistic action protects the safety of a third party and if paternalistic actions clearly bring about more benefits than harms (proportionality principle). Otherwise autonomy should prevail. The proportionality principle implies that weighing the pros and cons should take account of the values of the citizens in addition to the aforementioned criteria. Harm to others requires to be clearly established, as for example in the transmission of serious contagious disease. Paternalism is not acceptable if all it does is weaken the citizen's own welfare. Citizens should have the right to live according to their own values. This is the liberalistic view, supported among others by the champions of the Enlightenment, Immanuel Kant, John Stuart Mill, Benjamin Constant and Alexis de Toqueville. In our times, the Ottawa Charter on health promotion has endorsed empowerment of citizens, defending their rights against coercive paternalism (WHO, 1986). Findings Target 1: the whole adult population State alcohol policies aim to protect citizens from harms due to alcohol intake. The paternalistic aim is to improve the welfare or good of the citizen even against his own will. The “nanny state” knows what is best for the citizen: all citizens should drink as little alcohol as possible, preferably none, in order to avoid alcohol-related harms. To this end, it applies the following measures: to reduce any alcohol intake by high alcohol prices (excise tax, minimum price laws), restrictions on the supply (availability) of alcohol (restrictions on hours of on- and off-premise sales, mail order sales, sales to underage persons and intoxicated ones), and marketing (restrictions on advertising, discounts and free samples). All these efforts go under the name population alcohol control policies. We should ask which, if any, of these measures are effective and fair. A common belief in some academic and administrative circles is that the above measures are effective. World Health Organization endorses these ideas stating that “the most cost-effective actions to reduce the harmful use of alcohol include increasing taxes on alcoholic beverages, enforcing restrictions on exposure to alcohol advertising, and restrictions on the physical availability of retailed alcohol” (WHO, 2010, 2020). The above view was put together originally from three types of findings: 1) the distribution of alcohol consumption was found to be roughly lognormal in surveys of various population samples, 2) higher price and restricted availability of alcohol decreased alcohol consumption in some populations and 3) alcoholics had higher mortality than the general population after treatment. The conclusion was: if the consumption is decreased in a population then alcohol-related harms will decrease (Bruun et al., 1975). In this argument, there are several errors and weaknesses. The effects of population alcohol control policies on per capita alcohol consumption. In Italy, France and Spain, decrease in alcohol consumption started years before the first control policy measures were implemented (Allamani et al., 2014). Some effect on alcohol consumption has been observed in some studies but others have not found any effect (Wagenaar et al., 2009, Dumont et al., 2017). The effect or lack of effect varies between studies and depends on what selected population groups have been studied and how alcohol consumption has been measured (Nelson and McNall, 2017). It is noteworthy that heavy drinkers and alcoholics are influenced less than the rest (Ayyagari et al., 2009, Wagenaar et al., 2009). The effects of population alcohol control policies on various types of harm. To find out the effects of changes in price and restrictions and other control policy measures, before-and-after studies, including time-series studies, are commonly carried out. No consistent picture emerges when these studies are reviewed; the types of harms under study vary; there are studies on liver disease, composites of alcohol-specific diseases and injuries, hospitalizations and deaths from the aforementioned outcomes, crimes and other harms. For all the studies that have found some positive association of control policies there is at least an equal number of studies that have found no association or negative one (Nelson and McNall, 2016). This is understandable since most studies have several deficiencies (Poikolainen, 2020). One probable reason is that drinking habits and patterns (not usually measured) are more important than the average alcohol consumption in determining the harmful consequences. Another is that cultures change slowly, driven by inputs and processes nobody really understands (chaos theory, emergence). Inputs that have much impact at certain point in time may have no impact at all in different situations. The evidence for positive effects of comes largely from before-after comparisons in populations suffering from some undesirable circumstances. These include repression by totalitarian regimes, catastrophes, war, economic crisis and famine.