Norm asks two questions:
People on the wrong end of social and economic inequalities don’t just experience health disadvantages from smoking, but disadvantages across the board – in every area of health, in life expectancy, in the pattern of life chances in general. Shall we impose compulsory legal norms about diet, about exercise, about whatever else, on the grounds of wanting to protect the worse-off from the effects of inequality?
Sometimes we should and we do—if the inequality is gross enough, if evidence of the effectiveness of a policy is solid enough, if the consequences of not implementing it severe enough, and if the compulsion we impose is modest enough. In fact, if a health problem is sufficiently serious, we already do far worse: we break normal medical confidentiality and isolate individuals. In the UK, the poor are disproportionately affected by infectious disease, just as they are disproportionately affected by smoking. The link between cigarette addiction and premature death is stronger than that between smallpox infection and premature death. In both cases, we use the law to protect those around the victims as well as the victims themselves.
Inequality itself closes down – or impinges otherwise negatively on – the freedoms and the choices of those with fewest resources. (It does it already.) For this we should deprive them of the freedom to have a smoke in a pub, somewhere?
Many people who smoke die horrible deaths. Far fewer people who give up smoking do. The legislation against smoking in public places has resulted in a massive fall in the number of smokers in this country and changed the public perception of smoking in general—much as changes in legislation changed the perception of drink-driving; when I write this I am not drawing any moral equivalence between these practices, though they both used to boost pub takings and kill poor people.
I have no doubt that if such a smoking ban had been qualified or partial it would have had a limited effect on the consumption of cigarettes by the general public, rather like the limited effect that “partially” giving up smoking has on a smoker’s habits. When the Institute of Cancer Research and its clinical partner the Royal Marsden hospital only enforced a ban on smoking within their buildings, rather than their entire sites, you could see patients (and their relatives and friends) lined up outside for a desperate gasp at the tobacco that helped to put them there. They were occasionally accompanied by some of the medical equipment that was helping to keep them here. This is the horrifying nature of the disease. Even (especially?) when the Grim Reaper is sitting in a visitor’s chair on the palliative care ward asking for the TV remote control so he can put Bargain Hunt on, some of its other occupants won’t stop stuffing death sticks into their own rotting mouths. Some—God help them—even ask others to do so for them because they can no longer do it themselves.
Unlike, say, injecting heroin, smoking cigarettes in itself kills. (Passive smoking kills too.) Half of all smokers eventually die of cancer or a smoking-related disease. Smoking tortures and destroys its victims in a variety of ugly ways. If they are lucky, they only suffer bronchitis or heart attacks or lose limbs; if they are unlucky, they die as uncontrollably growing blossoms of their own flesh foul their bodies. Lung cancers caused by smoking are among the commonest and deadliest forms of cancer in humans.
Where they have been enforced, public smoking bans have improved the health of smokers and those who have to work around them. They save lives. Like vaccination programmes, these effects are seen amongst the rich and the poor. Weighed against the appalling toll of smoking on humanity as a whole, even weighed against the inevitable suffering of a few thousand of those who would otherwise have not given up had it not been for public prohibition in England and elsewhere, talk of “depriving” smokers of a “freedom” is morally obtuse.
When it comes to protecting the disadvantaged from the effects of inequality, superficially “illiberal” evidence-based public health programmes are the anti-Marxism. Marxism seemed a good way to reduce inequality in theory—to those with a dangerously incomplete understanding of history, science, logic, and human nature. The lack of evidence to support its utopian revelations didn’t shake the confidence of many Marxists in their anti-human, pseudoscientific cult. Sadly, they didn’t stop at being wrong in print, but urged their prescriptions upon their fellows and continued to do so as the corpses piled up. In practice, Communism resulted in the murder and enslavement of more human beings than any other ideology in the history of mankind. A relatively small sub-pile of Communism’s dead were the victims of “biologists” who elevated political theory over scientific fact, to the point when thousands starved. (As cultists often do, they also persecuted those of their professional peers who continued to pursue open enquiry into nature.)
In contrast, real scientists and doctors predicted that even thoroughly tested public health programmes would result in the forced extinction of species, the inflicting of pain on innocent children (sometimes against their parents’ wishes), restrictions upon individuals’ freedom of movement and association, and the deliberate administration of substances that would almost certainly poison and/or kill a proportion of recipients. It was up to governments to consider these consequences and choose whether or not to accept them in pursuit of predicted improvements in general well-being. Despite these awful side effects, such programmes have—even nett of those that have failed or done actual harm—saved many millions of lives and freed millions more from pain, disability, and disfigurement.
Evidence-based public health policy is about counting the corpses before devising ways to reduce their numbers, rather than devising a supposedly practical political philosophy and then later trying to divert the blame for, or simply hide, the slaughter that results when people attempt to use it to change the World “for the better”. No form of state intervention in the lives of individuals has done more to reduce inequality than evidence-based public medicine, but, exactly unlike Communism, most of the time that hasn’t even been its purpose. I know which I prefer, in theory and in practice, for rich and poor.
Norm accuses Libby Brooks of a “narrowness of focus” because when she writes in support of the ban she points out that smoking damages the health of the poor more than that of the rich. Narrowness of focus, the judicious application of reductionism, is one of the great strengths of science. If more political theorists adopted a similar philosophical humility in the face of complex problems then they might, one day, construct a theory worthy of the name. Such narrowness often works in practice. Even now, when we should have long ago learned the bloody lessons of the 20th century, we have to listen to commentators complaining about a lack of a “vision” or an ideology on the part of some politician of whom they disapprove, as though that were a bad thing. The bodies of those sacrificed to big ideas are stacked high enough already.
In the past, coercive public health measures far more illiberal than banning smoking in public places have spared the poor suffering and death, even absent relative improvement in their material circumstances. Indeed, before the development of antibiotic treatment, the best hope of impoverished victims of tuberculosis was the forced imposition “of norms about diet, about exercise, about whatever else, on the grounds of wanting to protect the worse-off from the effects of inequality”—the rich could already afford their own sanatoria and knew the value of their regimens.
If preventing thousands of miserable deaths today means that some people are merely “deprived” of the “freedom[!] to have a smoke in a pub, somewhere”, then that’s just tough. British citizens are still free to kill themselves and their families slowly in private. I can think of worse things in this world than being made to go outside for a public smoke. I’ve seen too many of those things. There’s more than one good reason why the first patients you meet at medical school are dead.