Political Notes 191, An End to Paternalism in Healthcare (2004), by Professor David Marsland

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An End to Paternalism in Healthcare
avid Marsland

Political Notes No. 191

ISSN 0267 7059                   ISBN: 85637 710 5

An occasional publication of the Libertarian Alliance,
Suite 35, 2 Lansdowne Row, Mayfair, London W1J 6HL.

© 2004: Libertarian Alliance; David Marsland,

Professor David Marsland has most recently been appointed Professor of Sociology at the University of Buckingham. His many publications include Seeds of Bankruptcy (Claridge Press, 1988) and Welfare or Welfare State? (Macmillan, 1996) as well as numerous articles and pamphlets. In 1991 he received the first Thatcher Award for contributions to the analysis of freedom and in November 2003 received the Libertarian Alliance’s Liberty in Theory award. Frequently appearing on radio and television, his best known appearance to date—according to his students—has been on the Ali G Show. This essay is based on a talk delivered at the King’s Fund seminar ‘From Nanny State to Personal Responsibility’ on the 26th May 2004. Professor Marsland’s fellow speakers were the Rt. Hon. Tessa Jowell MP, Secretary of State for Culture, Media, and Sport, and Mr Will Hutton, journalist, author, and Chief Executive of The Work Foundation. It first appeared in its present form in the November 2004 issue of The Individual, the journal of the Society for Individual Freedom (www.individualist.org.uk).

The views expressed in this publication are those of its author, and
not necessarily those of the Libertarian Alliance, its Committee,
Advisory Council or subscribers.



We thought it was best for him.”  Character in the horror film Beast in the Cellar (1970), explaining why her brother has been bricked up for thirty years and turned into a sub-human monster.

It is not difficult to argue—from a libertarian perspective—that the modern liberal democratic state is intolerably intrusive and authoritarian.  Its tendencies towards political correction and oppressive nannying, not least in the sphere of health, are manifest.  Nor is it, however, much more difficult to argue—from a socialist perspective—that the state is nervously timorous in the use of its legitimate power to address fundamental health needs and urgent healthcare problems.  The anxious paralysis of the British Government—in healthcare and across the board—in the face of perceived pressures by big business, the media and the electorate is evident.

It is easiest of all to argue—from the pragmatic perspective of the Establishment—that the state is, after all, doing the best that can be managed in difficult circumstances with its complex, arbitrarily shifting balancing-act in the face of contradictory and cross-cutting pressures: between liberty and efficiency, localism and centralism, consumers and producers, long-term and short term, realism and dreaming.  Do let’s be practical, as it were.

Against these libertarian, socialist and pragmatic positions, I commend—in relation to health and healthcare—a distinct and more radical perspective.  This highlights gross and counter-productive over-reliance on state power in some spheres, and its negligent under-utilisation in others.  Both these errors derive from a single source—misconstrual of the state’s proper and limited role in a genuinely liberal society.  A democratic state should be modest in scope—but confident and vigorous in its action within its appropriate—and definitively minimal—domain.

The root of the problem is socialised medicine—the National Health Service itself and its utopian founding principles.  No other healthcare system anywhere in the world or at any other time in history has combined state monopoly ownership, control and delivery with free as-of-right supply for the whole population, from bishops, through bar-tenders to beggars and from tinkers, through teachers to tycoons (Marsland, 1996a).

Not surprisingly, though we have been slow to acknowledge the truth, the consequences of this ultra-bureaucratic, super-paternalistic system are gravely negative: extravagant costs, gross waste, arbitrary inequity, stifled innovation, squalid standards and hopeless inefficiency (Bosanquet, 2001 & 2004).  On these grounds in and of themselves the NHS should be urgently de-nationalised.

The state should be excluded entirely from ownership, delivery and control.  All this should be restored to the more efficient and more humane hands of voluntary, charitable and independent agencies (Green, 1985).  The state’s influence should be restricted to common-sensical regulation.  Subsidised supply should be limited to the small minority of people on genuinely low incomes, and even in these cases it should be strictly conditional.

However, the healthcare Behemoth has even worse effects than sustained inefficiency—effects which lead on directly to the sub-fascistic phenomena of state nannying and political correction.  It turns us all into irresponsible serfs lacking entirely in personal and family responsibility for our own health.  It destroys our capacity for autonomous attention to the conditions of our health and to the destructive effects upon it of our own freely chosen foolish—or worse—behaviour (Marsland, 1996b).

We sleep too little, exercise hardly at all, drink and take drugs to excess, eat sloppily, celebrate promiscuity and perversion, and make of mere hedonistic ‘fun’ an almost sacred mission.  It is national suicide (Marsland, 2004).

Little wonder if the state finds itself compelled to trick and bully us instead into life-styles we might have chosen freely if we had been left free to face the consequences of their irresponsibly-chosen alternatives (O’Keeffe, 1999).  Save for the clinically self-destructive few, most would learn and act wisely were it not for the state healthcare cocoon.

Cigarette smoking would have reduced anyway, and would continue to decrease, without hypocritically increased prices, without censorship of advertising, without the imposition of tyrannical controls on restaurants and public houses, and without generalised witch-finder vilification.  Clear, honest information would suffice, with the addition only of effective parental control of children.

Again, obesity would be less widespread and dangerous if socialists had not outlawed competitive sport in schools; if normal neighbourhood control by ridicule of ‘fatty’ and of ‘skinny’ alike had not been politically corrected; if ultra-feminism and inadequate education had not robbed the population of its domestic cooking skills; and if parental control of children had not been sabotaged by decades of systematic subversion of the family (Segalman, 1998).

And drinking and drugs would not be flying out of control if, instead of wasting money and power on healthcare, the state had protected the police and the courts from political correction and enhanced their traditional effective control of punks and juvenile delinquents (Judicial Studies Board, 2004); if local communities and local people had not been inhibited by bullying state edicts in dealing toughly with wild-west estates, infamous streets, and known gangsters; if children and young people had not been released into moral free-fall by state sabotage of the family (Morgan, 1999).

Unless the state lets go of its adamantine grip on healthcare, autonomous self-control by individuals, families and local communities will continue to decay.  Health problems—from obesity, through drug abuse, heart disease and cancer to the current epidemic of sexually transmitted diseases—will continue to escalate.  The temptation for further illegitimate, authoritarian and counter-productive state interference in the lives of individuals and in the functioning of families, communities and organisations—benevolent but not, alas, beneficent—will increase still further.

Indeed, once the process of well-intentioned nannying for the sake of health has got under way, and achieved—with the support of habit, state-controlled science, and a compliant media—a specious legitimacy, there is no evident stopping place.  Since everything affects health for good or ill to some degree, the domain of state health intervention is potentially infinite in scope.  It is also—as both National Socialists and Communists long ago demonstrated—an open door to comprehensive political oppression.

Current modest beginnings on the path of political correction and state nannying may be, even in a deeply free and genuinely democratic society such as ours, the long-run pre-cursors of incipient fascism.  One can imagine already that guidelines on the allowable weight of brief cases carried to and from work might be introduced to control back injuries.  Entry to night-clubs might be restricted not just by age but also by occupation—to prevent so-called ‘key-workers’ exposing the public to undue risk the next day.  Cafes serving anything officially classified as ‘junk food’ to under-eighteens might be subject to prosecution.  Selling salt without a prescription might be outlawed, lest home-cooked food should escape the bland tastelessness of the state-regimented processed alternatives.  Newsreaders may be required to make explicit their currently implicit assumption that ‘additive’ means ‘poison’ and ‘chemical’ means ‘deadly pollutant’.

In point of fact, the British Government has so far proved—to the annoyance of health-fascists everywhere—quite sensible, resisting fashionable pressures to ban this, require that, and change the other.  It remains at present reasonably well aware of the damage which surrender to the pressure groups might do to individual freedom, to trust in science, to employment levels, and to business success (Marsland, 2000). 

But there are already signs of a dangerous momentum.  For example:

  • ·      In relation to smoking in public, the Chief Medical Officer told a public health conference in March this year that he didn’t think “we should give up on the goal of a national ban just like that”.  On the other hand, demonstrating a remarkable talent for highly spun propaganda, he warned that “the word ‘ban’ should not be part of the language of discourse” (Public Health News, 29th March 2004, p. 6).
  • ·     The modest, realistic and practical enterprise which was Health Education has been transformed over the past ten years into the undisciplined, utopian project of Health Promotion.  Genuine, objective health education is just what we desperately need in our schools and colleges.  Health Promotion, by contrast, is too often an excuse for bullying condescension, manipulative propaganda and fraudulent campaigning.  Moreover, Health Promotion now appears to be in the process of stitching itself seamlessly into Public Health, thus gaining for itself entirely illegitimately an authority which its largely anti-medical and pseudo-scientific condition in no way merits.
  • ·     Vegetarian, animal-welfare and environmental fanatics are being given regular air-time in the context of every latest suspect piece of research on Variant CJD.  More generally, the market for health scare-stories, especially on television, and the more ludicrous the better, gets more dynamic month by month (Gaffikin, 2001).  Reporting of health statistics is generally amateur, ignorant, biased and easily manipulated by fashionable lobbyists.
  • ·     The leader of the Liberal Democratic Party is reported in the press to have “slunk off to the lavatories” rather than risk criticism for smoking perfectly legitimately at a public event.  Yet another squalid victory for arrogant bullying.
  • ·     Commenting on the new governmental alcohol strategy and its proposals for voluntary reform of the drinks industry, the campaigning charity Alcohol Concern, has urged the government to “make clear its willingness to make the scheme compulsory”.  The editor of the influential journal, Public Health News, appears to take the same view, claiming that “Perhaps the next time round, the government will have to get a little tougher”.

Unless the trend indicated in these examples is resisted and reversed, our freedom will be much diminished for little return.  It is unlikely that this can be achieved without first radically reforming the Health Service, and restoring to the people responsibility for their own health (Green, 1993 & 1999).  Socialism is the source of state nannying and political correction.  It can only make them worse (Ellis, 2004).  Libertarianism is too shy of using police, community and educational power to deal with them.  Pragmatism cannot, by its constitutive nature, stop the ratchet effect.  We need a radical analysis and a radical strategy if we are to rescue our health and our freedom.  Yet the inexorable drift towards political control of health related behaviour is gaining pace.  It is characteristic, for example, that in reporting the debate at which a draft of this paper was presented, Public Health News (31st May 2004) recorded the speech of the Secretary of State fully, presented the fellow-travelling messages of the second main speaker and of the head of the King’s Fund positively—and made no mention whatsoever of the critical and sceptical analysis presented here.  As far as the healthcare establishment is concerned, the earth is apparently still flat.


Nick BOSANQUET, 2001, ‘A Fair Innings for Efficiency in Health Services’, Journal of Medical Ethics, Vol. 27, No. 4, pp. 228-233.

Nick BOSANQUET, 2004, ‘The Long-term Economic Gain from New models of Healthcare Provision’, Paper presented to the Institute of Economic Affairs’ Political Economy Conference, 19th May 2004.

Frank ELLIS, 2004, Political Correctness and the Theoretical Struggle, Auckland, Maxim Institute.

Josephine GAFFIKIN, 2001, Health Wars: The Phantom Menace - An Audit of Health Scares, London, FOREST.

David GREEN, 1985, Working Class Patients and the Medical Establishment, Aldershot, Temple Smith.

David GREEN, 1993, Reinventing Civil Society: The Rediscovery of Welfare Without Politics, London, Institute of Economic Affairs.

David GREEN, 1999, An End to Welfare Rights: The Rediscovery of Independence, London, Institute of Economic Affairs.

JUDICIAL STUDIES BOARD, 2004, Equal Treatment Bench Book, London, Judicial Studies Board.

David MARSLAND, 1996a, ‘Not Cancelled - Postponed: A Revolution in Healthcare’, Health Business Summary, Vol. 13, No. 1, pp. 4-9.

David MARSLAND, 1996b, Welfare or Welfare State?, Basingstoke, Macmillan.

David MARSLAND, 2000, ‘Progressing health and healthcare’, (Chapter 5, pp. 79-100), in Ernest KRAUSZ & Gitta TULEA (eds.), Starting the Twenty-First Century, Transaction Publishers.

David MARSLAND, 2004, ‘Caliban or Taliban?’, Society, Vol. 41, No. 4, pp. 52-55.

Patricia MORGAN, 1999, Farewell to the Family, London, Institute of Economic Affairs, Health and Welfare Unit.

Dennis O’KEEFFE, 1999, Political Correctness and Public Finance, London, Institute of Economic Affairs.

Ralph SEGALMAN, 1998, Reclaiming the Family, St. Paul, Minnesota, Paragon House Press.