The stewardship model: striking the balance
Tuesday 3 June 2008
'The difference between the stewardship model and the nanny state is that the nanny will always go straight to the top of the ladder'
Tom Baldwin,
University of York
The thinking behind the Nuffield Council on Bioethics report Public health: ethical issues was that previous public health reports had not gone into enough detail about the state's responsibilities, Professor of Philosophy at the University of York and member of the report's working group, Tom Baldwin, told delegates in the Ethical issues in obesity and alcohol policy session.
‘If we think about the state's role in general, the opposing positions are the libertarian – to let people get on with their own lives, and the collectivist – to express the will of the community and promote general welfare.' The liberal position is about finding a balance between the two, he said, and public health could almost be seen to be a paradigm case about finding that balance.
Stewardship model
The report's response had been to come up with the ‘stewardship model', which sees the state as the steward of the health of the nation. 'The implication is that the state has responsibilities it can't abdicate by saying "if people have bad habits it's their own fault"'. In applying this model the state needs to be active in promoting public health and opportunities for communities, he said. ‘It can't walk away from self-inflicted health problems, but the difficulty is how to provide interventions that aren't coercive.'
Intervention ladder
The model also provides an ‘intervention ladder', with ‘do nothing' at the bottom and 'eliminate choice' at the top. The state works through schools, hospitals and employers, he said, but there are also significant third-party players such as the food, drink, tobacco and pharmaceutical industries. 'If you can get what you want by involving them on a voluntary basis, then fine,' he said. 'But if you're not getting what you want that way, then the constraints are fewer than with private individuals. Businesses are not private individuals with aspirations and hopes and fears – they are there to make money, so there is not the same need for holding back.'
The model allows for the effectiveness of interventions to be reviewed at all times, he said, and whether there is a case for moving up to the next rung. 'The difference between the stewardship model and the nanny state is that the nanny will always go straight to the top of the ladder,' he said. 'The steward's role is one of not abdicating from responsibility but still wanting to keep as far down the ladder as possible.'