More on the M&M Study

By Scott Burris

Stephanie Morain and Michelle Mello’s recent paper in the March issue of Health Affairs is an extremely important contribution. It reports on a survey of American adults investigating their support for a range of current health interventions, and finds – contrary to the myth being propagated in politics and the media – that people strongly support the public health mission and the interventions that accomplish it. There is no better way to celebrate the end of Public Health Week than by sending a pdf to every one you know.

Having praised the piece, though, I want now to disagree with one part of the authors’ analysis. The table below shows the support for a fruit basket of public health interventions.

From this, M&M conclude “that the greater the restraint a legal intervention imposes on individual liberty, the greater public opposition to the intervention is likely to be. There was much support among our respondents for strategies that enable people to exercise healthful choicesfor example, menu labeling and improving access to nicotine patchesbut little support for more coercive measures, such as insurance premium surcharges.”

I don’t see that in the data.

Some of the measures that get high support are coercive – requiring PE, limiting what you can buy with food stamps. And of course M&M don’t ask about all sorts of coercive interventions – public smoking bans, safety belt laws – that we now appreciate and take for granted. Meanwhile, the lack of support for measures like insurance surcharges for the obese or firing smokers could be attributed to factors other than a dislike of coercion. Many of us would find such targeting unfair or unnecessary. It’s true that M&M’s respondents who felt this way attributed their views to suspicion of government and a love of liberty, but as Jonathan Haidt teaches, these explanations may be the convenient rational explanation for an intuition of unfairness. Surveys that give people a limited number of options to explain their beliefs can be misleading in this way.

The old trope that public health involves a tragic choice between individual liberty and public good rarely captures the real politics and moral challenges of public health. As Evan Anderson and I have shown, behavioral regulations that are backed by good evidence and prevent easily understandable harms are popular with both the public and lawmakers, even if they are coercive. The M&M study supports this view. As I read M&M’s data, the danger for public health doesn’t lie in coercion per se. What the public doesn’t like is coercion that seems to go too far. “Too far” might be seen in using coercion for small marginal gains, or getting into areas where the evidence is thin or complicated enough that it looks like the government is making value judgments people would prefer to make themselves.

As we conclude Public Health Week, we can be happy that the public and policy makers for the most part see policy, including coercive policy, as a necessary and legitimate part of public health work. 

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