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Medical advice, unsweetened — is medical paternalism a problem?

In a now much-shared clip from a recent Daily Politics broadcast, two school girls were seen to take the veteran reporter Andrew Neil to task about the sugar tax budget announcement, whilst he fought for the public right to ‘break the rules’.  The girls eloquently fielded success statistics regarding the implementation of seat belts in the 80s — an unpopular act at the time — to put their combatant in his place, concluding that ‘if it’s saving lives, and it’s helping the NHS, perhaps we should be told what to do’.

As it did with seat belts and does now with sugary drinks, the foundations of this quandary are built on choice.  And by extension, as Neil made implicit from his position as professional devil’s advocate, whether that choice is an educated one or not is immaterial.  The point is, whether it was safer or not, a person had a right to make the decision not to wear a seatbelt.  In the same vein, before last week, one might have argued that a person has the right to choose to pay a little bit less for a very-sugary beverage than they would for a not-so-sugary beverage because, well, who are the government to tell me what to do with my blood glucose levels?

I recently brought up the debate over tea (no sugar) with my grandmother — a source of opinion reliable in her steadfastness — who is of Andrew Neil’s generation.  I was amused to hear her suggest that the tax simply wasn’t enough: why not just stop selling sugary drinks altogether — sugar was rationed once, and we did just fine without it?  Why not remove the choice, then, because therein lies the rub.  It reminded me of my communications sessions at medical school, where we are being instructed to remove almost all no-nonsense paternalism from our approach to giving advice, and are instead encouraged to disseminate what are called ‘shared decisions’.  ‘You should quit smoking yesterday’ has mutated into a stumbling beast: ‘have you thought about quitting smoking…?  How do you feel about me asking you to quit smoking…?  It might be a good idea for you to quit smoking — there are notable benefits to quitting smoking’.

I do believe that there is method in my grandmother’s madness.  It may be method filtered by admittedly rose-tinted spectacles, but it is method all the same.  Many quote the fact that levels of obesity and cardiovascular disease were lower at the time when food was rationed.  Yet, anyone willing to apply a scientific lens to the situation will recognise soon enough that this is an associative link not a causative one, much like saying heavy drinkers are more likely to have lung cancer (because they are more likely to smoke).  So, just as heavy drinking doesn’t necessarily cause lung cancer sugar doesn’t necessarily cause obesity in children, but the evidence certainly points to the fact that both it and the environment in which it is consumed are something to bear in mind when writing policy.

At which point, then, do we tell people what they can and cannot drink?  Do we, as per the budget, simply make the ‘unhealthy’ luxuries unaffordable for those historically more likely to be affected by over-consumption of such products?  And does this budget contain the dying embers of medical paternalism?  Or, do we adopt Mr Neil’s approach, and presume that if we tell people what to do, they’ll only go and break the rules anyway — it’s their choice.  Is it going to save lives and the NHS as Neil’s young adversary suggested?  Only time will tell.

Matthew Betts
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