# Obesity, public health ethics and the nanny state

Margaret Steele, Mélissa Mialon, S Browne, N Campbell, F Finucane

► To cite this version:

Margaret Steele, Mélissa Mialon, S Browne, N Campbell, F Finucane. Obesity, public health ethics and the nanny state. Ethics, Medicine and Public Health, 2021, 19, 10.1016/j.jemep.2021.100724. hal-05195008

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ORIGINAL ARTICLE

# Obesity, public health ethics and the nanny state

<figure><img src="image_3.png" /></figure>

M. Steele<sup>a,*</sup>, M. Mialon<sup>b</sup>, S. Browne<sup>b</sup>, N. Campbell<sup>b</sup>, F. Finucane<sup>a,c</sup>

Reçu le 7 juillet 2021 ; accepté le 6 septembre 2021

## KEYWORDS

Ethics ;
Harm principle ;
Nanny state ;
Obesity ;
Paternalism

## Summary

**Background.** — Unhealthy dietary patterns are an important contributor to obesity and related non-communicable diseases (NCDs). As with any public health challenge, as well as providing care to affected individuals, whole-population interventions are required to mitigate the environmental determinants of population dietary patterns. The World Health Organisation (WHO) has established recommendations, including a set of low-cost, high-impact 'best buys' for governments seeking to implement these strategies. The Irish government has stated that it wishes to make 'the healthy choice the easy choice.' Yet, in marked contrast to its approach to tobacco- or alcohol-related harms, the Irish government has shown reluctance in implementing those WHO-endorsed strategies or other population-level measures to address unhealthy dietary patterns. Meanwhile, commercial interests work to discredit these measures as ''paternalism'' or more commonly as ''nanny state'' violations of individual liberty.

**Methodology.** — We conducted a narrative review of the philosophical literature on paternalism, particularly the work of the 19th century philosopher John Stuart Mill, who originally formulated what became known as the 'harm principle.'

**Discussion.** — Though an ardent defender of free trade and individual liberty, Mill argued that governments have a responsibility to limit the activities of commercial interests (such as taverns or gambling houses) where they encourage 'excess' that might harm the individual or society.

<footnote><sup>a</sup> Department of Medicine, School of Medicine, CMNHS, NUI Galway, Galway, Ireland</footnote>

<footnote><sup>b</sup> Trinity Business School, Trinity College, Dublin, Ireland</footnote>

<footnote><sup>c</sup> HRB Clinical Research Facility, NUIG and University Hospital Galway, Saolta University Health Care Group, Galway, Ireland</footnote>

<footnote>* Corresponding author. Centre for Endocrinology, Diabetes and Metabolism, Galway University Hospital, Galway, H91 YR71, Ireland.
Adresse e-mail : M.Steele1@nuigalway.ie (M. Steele).</footnote>
*Conclusion.* — The philosophical literature on paternalism gives strong arguments that government measures to limit potential public health harms arising from the consumption of unhealthy diets are not violations of individual liberty. On the contrary, governments are ethically obliged to make such interventions as are necessary to protect the liberty of individuals who are being misinformed and manipulated by industry. Rather than public health measures representing nannying by the state, we argue that they serve to counteract the 'nefarious nannying' by commercial actors, thus enhancing individual liberty rather than diminishing it.

© 2021 L'Auteur(s). Published by Elsevier Masson SAS. This article is published Open Access sous licence CC BY (http://creativecommons.org/licenses/by/4.0/).

Introduction

The global prevalence of obesity continues to rise [1], with concomitant increases in morbidity [2,3] and premature mortality [4]. The evidence that ultra-processed food consumption increases the risks of developing obesity has been confirmed in studies in France [5], the UK [6], Australia [7] and elsewhere [8,9]. For example, the consumption of sugar-sweetened beverages (SSBs) is linked with increased risks for adults [10] and children [11] to have obesity, but also for developing diabetes [12,13], hypertension [14], stroke [15] and cardiovascular diseases [16], and also contributes to early death [17]. The fact that obesity prevalence has affected all sub-groups in similar ways strongly implicates environmental factors in its pathogenesis rather than a collective, population-wide loss of ''personal responsibility'' [18]. The archaic view of obesity as a moral failure [19] has been superseded by evidence that it is a complex neurobehavioral disorder which is highly sensitive to environmental factors [20].

With any public health crisis, a ''two-pronged'' approach is required, whereby those at the greatest risk receive individualised treatment and, simultaneously, population-level risk reduction strategies are deployed [21]. So, we hospitalise the sickest patients with COVID-19 while deploying measures to restrict population-level transmission. We rehabilitate victims of traumatic brain injury while reducing the speed of vehicular traffic. We radiate lung tumours while encouraging people to avoid smoking and we don't treat melanoma with sunblock. Disease is a complex interplay between the environment and the individual. Thus, when there is a flood in the kitchen, we mop up the water, and we also turn down the tap. Recognising the relation between the wet floor (individual treatment) and the tap (population-level treatment) is vital. There is a growing realisation that the causes and treatment for those individuals who are severely affected by overweight and obesity are different from the causes and treatment of the entire population that is at risk of having obesity and overweight [22]. Nutrition front-of-pack labelling, reformulation, restrictions on marketing and advertising (particularly to children), taxation of unhealthy products and restrictions on availability, among other proposed solutions, have been promoted by the World Health Organisation (WHO) as 'best-buys' — that is, highly cost-effective interventions to address population exposure to risk factors including unhealthy diets [23]. Such measures have already met with success in addressing risk factors such as tobacco use, in Ireland [24] and elsewhere.

To take a case in point: given that SSBs comprise a substantial source of free sugars with no nutritional benefits, they are regarded as a reasonable target for public health action [25]. Despite industry lobbyists' insistence that there was a lack of evidence that a ''sugar tax'' would improve dietary patterns [26], the Irish government introduced such a tax in 2018, and consumption declined as it had done with sugar taxes implemented in other countries and jurisdictions [27]. In the UK, the tax has worked as intended [28]: consumption of SSBs has declined, as people have switched to low sugar alternatives, and industry profits have not been adversely affected, nor has employment [29]. However, despite the success of sugar taxes, the introduction of other potentially impactful measures such as mandatory nutrition front-of-pack labelling [30] have been delayed by intensive industry lobbying in different countries [31,32].

In comparison to decisive population-level public health measures to limit tobacco and alcohol harm in Ireland [33], the equivalents of the work-place smoking ban and minimum unit alcohol pricing are yet to materialise in the case of unhealthy diets [34]. Those measures that have been implemented are often centred on voluntary actions from the food industry, an approach which has been less impactful and successful in terms of population health [35,36]. Countries such as the USA and the UK have had more than three decades' worth of policy intended to address obesity, yet the prevalence continues to rise in these countries as it does elsewhere [37]. Reformulation of foods high in sugar and saturated fat — an EU directive to all member states since 2011, but implemented on a voluntary basis across the region — has not led to reduced consumption of those nutrients [38]. Voluntary measures restricting the promotion of unhealthy foods to children, defined in partnership with industry, have been breached repeatedly [39]. Comprehensive analyses of such voluntary measures in the US [40], Australia [41], Canada [42], China [43], New Zealand [44,45] and Spain [46] all point to the same shortcomings in the implementation and outcomes of these measures for protecting the health of children: Voluntary measures have been shown to be self-serving for the food industry, reactive and inadequately enforced, with complaints procedures that lack transparency and accountability, and inconsistency in the responses to complaints. Overall, voluntary measures provide little incentive for restraint by advertisers, and they fail to protect either the rights or the health of children.

Among the Irish public, there is evidence of support for a more interventionist approach to dealing with overweight and obesity, especially but not exclusively where children
are concerned [47,48]. Yet any intervention proposed is inevitably met with expressions of concern about threats to individual liberty, choice and personal responsibility. For example, in the UK, an analysis of Twitter responses to the introduction of a sugar tax found that those who opposed the tax were most likely to frame the issue as one of personal responsibility [49]. This is consistent with the ongoing strategy of the food industry to present their products as 'choices' which individuals are at perfect liberty to take or leave, conducive and perhaps even necessary to individual freedom [50]. The industry does this, in part, by ''weaponizing'' concerns about the preservation of liberty purely for the purpose of resisting regulatory threats to their commercial bottom line [51] This is done by framing government interventions as the actions of a so-called 'nanny state'.

The term 'nanny state' is a rhetorical device meant to imply that a government is ''treating competent adults as if they were children'' [50]. Industry actors use the concept of the nanny state to their advantage, invoking emotive images of governments stripping adults of their decision-making autonomy and removing 'free choice' from consumers [52]. Concerns about the nanny state are a perennial challenge to the public health agenda and a constant negative point of reference [53]. In its ''worst'' form, the nanny state refers to instances of so-called ''hard'' or coercive paternalism, which forces or coerces competent adults to behave in a way that is deemed to enhance their well-being, irrespective of their individual beliefs, values or moods. Mandatory seatbelt or motorcycle helmet use are examples of hard paternalism, where the state uses the law to compel us to act in a certain way. However, even much ''softer'' paternalism, which nudges the individual rather than forcing them to make a particular choice, comes in for criticism. When the British government revised downwards the recommendations on safe levels of alcohol consumption, there was outrage in the media about ''killjoy'' health advocates, despite the intervention being purely advisory [54].

Notwithstanding legitimate philosophical concerns about public health policies and paternalism, often an ''arbitrary incoherence'' is apparent in arguments from opponents of the so-called nanny state, where they choose to support some measures of health promotion, such as encouraging people to be more active, while criticising others, such as sugar taxes [53]. How is it nannying to limit the exposure of children to junk food advertising on the one hand, but then not nannying on the other to encourage them to take more exercise? Either both are nannying or neither is, and this logical incoherence may in part be driven by the extent to which proposed interventions could impact on the commercial activities of industry actors [55]. Framing government public health interventions as nanny-statism assumes that without government intervention, individuals choose freely, an idea that is deliberately and systematically promoted by the food industry [56]. This assumption puts the burden to justify any intervention on government, while simultaneously relieving industry of the need to justify its own actions.

John Stuart Mill's classic essay ''On Liberty'' is often invoked in debates over public health interventions. It was in this essay that Mill stated what came to be known as the 'harm principle'. This principle states that ''the only

purpose for which power can be rightfully exercised over any member of a civilized community, against [their] will, is to prevent harm to others. [Their] own good, either physical or moral, is not a sufficient warrant'' [57]. The harm principle is often taken to imply that governments violate individual liberty when they undertake measures to protect public health [58]. Indeed, the harm principle was even cited in a Massachusetts court by motorcyclists arguing for their right not to wear helmets [59]. Yet this principle, like any philosophical concept, must be read in context. Certainly, ''On Liberty'' offers arguments in favour of individual freedom and choice. But this does not mean that Mill opposes any and all government interventions aimed at protecting individuals. In fact, he argues that some such interventions are not only permitted but required. As such, we argue that ''On Liberty'' has much more to offer contemporary public health debates than the harm principle alone. Here, we focus on its relevance to measures to tackle unhealthy diet and obesity.

## Paternalism, liberty and choice

The harm principle is a protection against paternalism. Paternalism can be defined as ''the interference by a state or an individual with another person, against their will, and defended or motivated by a claim that the person interfered with will be better off or protected from harm'' [60]. Mill was an early advocate of the 'utilitarian' approach to ethics. This approach to ethics values happiness above all else, and equates happiness with pleasure and the absence of pain [61]. Thus, Mill argues that actions are right insofar as they bring about pleasure to those affected, or wrong if they bring about pain [57]. This concern with happiness informed Mill's politics as well as his ethics: he proposes that the most efficient way to bring about the greatest amount of happiness is to leave individuals free to pursue their own happiness as they see fit. In other words, in a just society, individuals should be allowed to do as they please, as long as they don't harm anyone else. Failure to respect this boundary is paternalism, and this is morally wrong not only because it violates liberty but because, in doing so, it also limits an individual's ability to pursue happiness in the way they think best.

However, Mill's stance on state intervention to protect individuals is much more nuanced than the harm principle alone would suggest, and it can illuminate contemporary debates about obesity-related public health interventions. In particular, Mill is very clear that any individual or group that sells anything is undertaking an activity which affects society as a whole, not just the sellers and buyers: ''Whoever undertakes to sell any description of goods to the public, does what affects the interest of other persons, and of society in general; and thus his conduct, in principle, comes within the jurisdiction of society'' [57]. Thus, despite his undoubted rejection of paternalism and commitment to liberty, Mill would not accept that the relationship between producers, retailers and consumers of food is purely a private matter between the relevant individuals; rather, it is the concern of society as a whole, and thus of government. In fact, Mill says that governments have not just a right but a responsibility to tax harmful products. His argument is that since governments must raise revenue, they have a responsibility to raise it in such a way as to encourage behaviour
that is likely to make people more happy and discourage behaviour that is likely to make people less happy [57].

Mill also argues in favour of what we would now call "warning labels". He says that poisons, for example, should carry warning labels, even though they can be used – and presumably in most cases are used – in ways that increase happiness rather than causing harm [57]. A similar case might be made for nutrition warning labels on unhealthy foods. There is evidence that industry attempts to mislead or confuse the public about the healthiness of its products, for example by attempting to co-opt and direct nutrition research [62,63]. In this context, measures such as warning labels are not contrary to, but rather are necessary for freedom since they ensure individuals have relevant information about the products that might otherwise be difficult to access.

Mill gives particular attention to those who encourage excess: His examples include keepers of gambling-houses and pub owners. He describes their interest in encouraging 'excess' behaviour as "'a real evil'" which "'justifies the State in imposing restrictions and requiring guarantees'" [57]. Again, this seems highly relevant to the contemporary food industry, which claims to be concerned with health, but whose business models all too often rely on individuals eating a lot of unhealthy food. For example, although unhealthy diets are a much greater contributor to obesity than sedentary behaviour, the marketing and political practices of food companies focus on the lack of exercise as the cause of obesity, a phenomenon known as "'lean-washing'" [64]. Lean-washing can be seen as an attempt to encourage excess since it aims to foster a belief that, from a health or weight point of view, it doesn't matter if you consume lots of unhealthy food as long as you exercise sufficiently diligently afterwards.

Since Mill, philosophers have continued to advance the discussion of paternalism, both critiquing and developing his account [60]. Indeed, many philosophers have argued that Mill goes too far in his prohibition on paternalism. Gostin and Gostin argue that Mill's discussion of paternalism assumes a number of "'false dichotomies", for example the assumption that "'state passivity is liberty enhancing and state action is liberty limiting'" [58]. They point out that actions which might be seen as 'nanny-statism' by some could nonetheless be liberty enhancing, and so justified. Even the idea that paternalism is fundamentally unethical has been challenged. For example, Hanna argues that where an intervention could make an individual better off, the onus should be on those opposing the intervention to justify their position [65]. In short, Mill's prohibition on paternalism is regarded as quite extreme by many philosophical commentators. It is surely striking that, despite this strong rejection of paternalism, Mill argues in favour of just the kinds of the restrictions that would nowadays be dismissed as not only paternalistic but 'nanny-statism.'

Mill's critics also provide insights relevant to contemporary debates. For example, in a critique of Mill's account of paternalism, philosopher Gerald Dworkin discusses a statutory limit on how many hours a worker can work per week, noting that this might seem to interfere with the right of the individual to choose to work more hours [66]. But, Dworkin argues, in the absence of such a law, it would be very difficult for any one employee to refuse to work overtime.

Passing the law makes it possible for more employees to choose to limit their work hours. Dworkin points out that making this choice possible requires collective action and that no individual could make this choice in isolation. As such, the law should not be seen as paternalistic. This could be compared to public health interventions aimed at changing the environment, since this is something that a great many individuals might like to do but could not do on their own. It is all but impossible for an individual shopper to choose unilaterally to avoid sweet displays at the checkouts when grocery shopping, for example, and it is also extremely difficult for an individual retailer to remove them, because of its competitive environment. In this context, regulation of the choice architecture in the retail environment could enable the choice to limit or avoid sweet displays without any incursion on the rights of those who wish to buy sweets.

Discussion of paternalism is, of course, by no means limited to philosophers. Thaler and Sunstein's "'Nudge'" espouses 'libertarian paternalism' [67]. Like Mill's "'On Liberty', "'Nudge'" attempts to resolve the tension between preservation of individual liberty and advancement of the greater good. Like Mill, Thaler and Sunstein argue that an intervention is not a violation of individual liberty if it enables an individual to do what the individual actually wants to do. They use the example of a cafeteria, arguing that the 'choice architecture' of the cafeteria should be such that it nudges people towards healthier rather than towards less healthy choices. This, they argue, is not a limit on liberty, since most people do in fact want to eat (more) healthily. This is similar to Mill's argument that it is ethical to use physical force if necessary to stop a person from walking on to a bridge you know to be unsafe, since you can assume the person does not want to fall into the water [57]. The Irish government acknowledges the importance of what Thaler and Sunstein call choice architecture when it claims that it wants to "'make the healthy choice the easy choice'" [34]. A strong ethical case can be made not only that the government may do this, but that it must.

## Irish obesity policy: 'nanny state' or neglect?

Despite his commitment to individual liberty, Mill was unequivocal that governments have a responsibility to limit the actions of any entity that encourages activities such as drinking or gambling to an extent that is likely to pose a risk to the happiness of the individual consumers of these products [57]. The same arguments can be applied to entities that encourage excessive consumption of harmful foods. There is strong evidence that the food industry does precisely that. For example, in the US, 98% of foods advertised are unhealthy [68]. Food advertising and marketing seek to exploit the "'intrinsically rewarding'" (and thus difficult to resist) nature of these foods, driving children to consume them [68]. Adults, too, are vulnerable to this kind of marketing, with repeated exposure to food advertising leading directly to beliefs and behaviours without active, deliberate processing of the information presented [69]. In this context, it seems naïve to assume that individuals enjoy liberty as long
as governments do not intervene in their choices. Instead, by
failing to intervene, governments may inadvertently be per-
mitting the excessive intervention of commercial producers
of unhealthy foods to limit the liberty of individuals.

As mentioned above, in explaining how intervention and
even coercion can be compatible with liberty, Mill used the
example of a man walking towards a dangerous bridge. He
noted that persuasion and education would always be pre-
ferable to coercion, even in this scenario. If a bystander
had the option simply to tell the man the bridge was dan-
gerous and then allow him to make his own decision on how
to proceed, that would, of course, be the right thing to do,
but direct intervention is justified if it is the only way to
prevent the man from unwittingly putting himself in grave
danger. For Mill's man-on-the-bridge analogy to be relevant
in the context of obesity policy and the individual facing the
risks of developing obesity, we need to imagine that, as he
goes about his day, making choices about the best course of
action, the man is constantly bombarded with claims that
the view from the bridge is breath-taking, that all of the
cool people hang out on the bridge, that the people who
own the bridge are working hard to make it safer, and that
most people get across the bridge just fine, if they are ade-
quately careful and sensible. We would also have to imagine
that there are similar bridges everywhere — in fact, there
are whole neighbourhoods where they are the only way to
get around. For Mill, it is not a violation of the man's liberty
to physically restrain him from walking on to the bridge. In
contemporary discourse about legislation to protect and pro-
mote healthy diets, public health advocates are only asking
that governments flag the undoubtedly dangers posed by the
bridge, prevent the bridge owners from downplaying the
risks associated with traversing it and make it slightly easier
for individuals to choose safer alternative routes. Many of
these measures could be funded simply by a charge for
using the bridge. In short, philosophical and ethical prin-
ciples would endorse such strategies as enhancing rather
than diminishing individual liberties. As it stands, crowds
are thronging to cross the bridge and the bridge-owners
communicate frequently and reassuringly, always emphas-
sing the people's need to cross it and the role of individual
carelessness and fecklessness where the occasional accident
occurs

Ethical and practical implications for
policy-makers

It is important that governments seek to avoid the sup-
pression of freedom. There are genuine tensions between
population-level measures to protect public health, on
one hand, and individual liberty, on the other [70]. In
the Irish context, however, these tensions did not prevent
government from intervening in changing the smoking envi-
ronment, for example [71]. Successive Irish governments
have acknowledged the risks associated with obesity. Since
1992, Ireland has created strategies to counter the shift in
weight of the entire population. Over these 30 years there
have been five programmes for government with obesity
as a key challenge, four obesity taskforces, four national
frameworks, two ten-year national action plans, thirteen

reports on recommendations and progress, four national
nutrition surveys, five sets of guidelines, three policies, and
four healthy eating strategies. Yet, the great majority of
the actions have been educational, promotional and non-
interventionist. In the same window of time, the prevalence
of overweight and obesity in the country has increased ins-
tead of decreasing. Measures that rely on individual agency
are an important part of the solution, but they can only be
effective under certain conditions. Two particularly relevant
conditions, recently described by Coggon and Adams, are ‘‘a
social and commercial environment that meaningfully pro-
vides healthy choices’’ and ‘‘actual deliberation’’ [72]. As
for the first condition, it is by no means obvious that the
social and commercial environment in Ireland can be said
to meaningfully provide healthy choices. For example, Ire-
land currently lacks effective measures to protect children
from marketing of unhealthy foods [73]. This means that,
by the time they reach adulthood, a great many Irish indi-
viduals’ beliefs, preferences and health have already been
profoundly affected by industry actors. Marketing forms part
of the social and commercial environment in which they
must then exercise individual agency. Actual deliberation
refers to conscious, thoughtful decision-making, in contrast
to what is technically known as ‘mindless’ action [72]. As
noted above, repeated exposure to advertising of unheal-
thy food is conducive to just this kind of mindless behaviour
[69]. Ethical and effective public health policy requires more
than just the formal possibility of choice, but the reasonable
expectation that individuals will in fact make conscious
choices [72]. Without this, education and personal respon-
sibility become irrelevant. Mill’s arguments for government
limitations on entities that encourage excess are effectively
arguments for just these conditions. By insisting on measures
such as labelling of dangerous products and limitations on
the sale of harmful products, Mill argues for an environment
in which individuals have multiple, meaningful choices and
are capable of real deliberation between them.

Despite – or perhaps, because of – the complex reality of
choice, industry actors have worked hard to frame debates
about choice, liberty, paternalism and nanny-statism in
ways that best suit their interests. By promoting fear of
government regulation, food industry actors could be said
to be guilty of nefarious nannying themselves, insofar as
they insist on 'protecting' individuals from policies that
are not only of benefit to individuals but, in many cases,
align with the individuals' preferences and values. In fact,
policy makers might do well to reframe the very concept of
'nannying', away from the sense of loss of freedom when
the individual is 'nannied' by the state, to one where the
state seeks to more effectively nanny the industry actors
whose products ultimately do so much harm [55]. Simi-
larly, a social marketing campaign aimed at reframing the
concept of choice could effectively counter the constant
insistence of industry that a seemingly endless choice of
products constitutes individual liberty. Indeed, sometimes
an overabundance of such 'choices' (including unhealthy
ones) can serve to paralyse liberty [74]. As things stand,
individuals often cannot be said to be freely choosing what
and how to eat, since, from early childhood on, they are
constantly being urged, tempted and even manipulated
towards unhealthy foods and eating behaviours. By fai-
ling to act as a counterweight to industry in this regard,
government is failing in its responsibility to enable and
defend the liberty of citizens. In order to develop robust
and effective policy to 'make the healthy choice the easy
choice', policy makers must consider the complexity of
choice, taking account of insights from philosophy, psycho-
logy and behavioural economics such as those mentioned
above. In the case of smoking and, increasingly, alcohol,
policy makers have come to recognise the need for radical
interventions to enable individuals to make healthy choices.
The same approach is desperately needed when it comes to
obesity and unhealthy diets.

In the context of sophisticated and effective food indus-
try opposition, as well as government reluctance to regulate
effectively for the protection and promotion of healthy
diets, some have argued for a strengthening of accoun-
tability both for policy makers and for industry actors,
in order to enhance the effectiveness of obesity pre-
vention and control strategies [75]. This could include
"quasi-regulatory" approaches, with government-specified
and government-monitored progress, enhanced transpa-
rency and more direct measures to address and manage
industry undue influence and conflicts of interest [76]. In our
previous analyses of the relative ineffectiveness of industry-
led reformulation strategies, we have argued that, rather
than a partnership approach, a parallel approach needs to be
taken where success is defined by government, not industry
[38]. Strengthened accountability would enhance govern-
ment leadership and stewardship and would ultimately
diminish the influence of industry actors on the develop-
ment of public health policies [75]. There are also measures
that could mitigate undue influence of corporations and
conflicts of interest [76]. These include enhanced trans-
parency, careful management of interactions with industry
and of conflicts of interest, identification, monitoring and
education about corporate practices, as well as ultimately
prohibiting interactions with industry. It is notable that, with
COVID-19, those countries that imposed the greatest short-
term restrictions on civil liberties have tended to be the ones
least badly affected in terms of morbidity and mortality, but
also in terms of economic and civil liberties outcomes [77].
It may similarly be the case that government interventions
that might seem to limit individuals' food choices are in fact
justified and necessary in order to improve health outcomes,
reduce disease risk and ultimately to enhance liberty.

In defending their libertarian paternalism model, Thaler
and Sunstein point out that choice architecture is already
in place. They are thus arguing not for the introduction
of choice architecture, but only that the choice architec-
ture already in place should be managed for the benefit of
individuals and society as a whole [67]. This line of argu-
ment is similar to Mill's claim that, since governments must
raise taxes in any case, they should do so in the way that is
most conducive to the 'greatest happiness of the greatest
number' [57]. In each case, the point is that individuals are
already subject to the relevant intervention; the question
is only who decides how the intervention should be applied
and to what end. Similarly, in calling for an interventionist
approach to obesity and unhealthy diets, we are not calling
for new constraints on individual liberty and free choice;
rather, we are trying to ensure that existing, unavoidable
constraints are managed with a view to public good rather
than private profit.

Acknowledgements

FMF is funded by a Saolta Group Clinical Research Career
Development Award. MM is funded by the Irish Health
Research Board [Grant Number ARPP-2020-002].

Disclosure of interest

M.S., M.M., S.B. and N.C. declare that they have no com-
peting interest. FMF has in the past (until 2017) received
honoraria, research support, travel grants and has served
on advisory boards for Novo Nordisk, Eli Lilly, Ethicon, Pfizer
Inc., Sanofi-Aventis, Astra Zeneca, Merck-Serono, Boehrin-
ger Ingelheim, Janssen, and Novartis.

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