Exercise, Population Health and Paternalism

“Given the overwhelming evidence, it seems obvious that we should all be physically active. It’s essential if you want to live a healthy and fulfilling life into old age”. It is perhaps surprising, therefore, how little is done to ensure people take more exercise. Office for National Statistics data from 2019 showed around a third of adults in England were considered either fairly inactive or inactive. Yet health promotion efforts to increase physical activity rarely reach further than providing encouraging messages on the NHS website and a few attempts at encouragement by opportunistic doctors faced with a physically inactive patient. Compared to other public health interventions – banning smoking in public places, requiring food retailers to display nutritional information on labels, hassling people to attend large scale cancer screening programs, prohibiting multi-buy offers on alcohol sales, imposing minimum unit pricing, and so on – the efforts to encourage physical activity look half-hearted.

What more could be done? Much has been made of the potential for ‘nudges’ to improve public health. These involve changes to the physical and social environment that make it easier (and more likely) that people will make ‘healthy’ choices. Nudges seek to walk the line between intrusive, liberty restrictive interventions that force behaviour change, and efforts at persuasion which have limited impact. In the physical activity context, nudges include stairs featuring motivational messages (or even calorie counts), placing lifts or escalators in a less visible position (though making sure they’re still available for those who need them), or mHealth technology that provides feedback on people’s activity levels (such as step counters). But clearly more could be done if there was greater willingness to enforce coercive legislation in this context. For instance, efforts to encourage active travel, although increasing, have generally been limited in the UK (particularly in comparison with some of our European neighbours). Cars continue to dominate roads and cycling infrastructure, even in cities where cycling is reasonably popular, is minimal and of generally poor quality. In particular there is an apparent unwillingness to commit to making non-active travel inconvenient and less appealing, along the lines of smoking and binge drinking. 
“Step right up! It’s the miracle cure we’ve all been waiting for”
Wilson, James. “Why it’s time to stop worrying about paternalism in health policy.” Public Health Ethics 4.3 (2011): 269-279.

Perhaps one explanation for this is that such interventions would involve intentionally making life less convenient for people. But this is where the bullet must be bitten: if physical activity really is believed to be as good as the NHS suggests when they declare it a “miracle cure” supported by “overwhelming evidence” then it is surely neglectful to continue to allow people to shorten and worsen their lives through failure to be more active? After all, there has been a huge (and successful) effort to reduce smoking rates in the face of robust evidence of serious harm. Few people think that restrictive regulation of tobacco smoking is inappropriate. Of course, if the messaging from the NHS is exaggerated – perhaps as a tool to try to encourage more physical activity via persuasion – then intrusive regulation would not be warranted. But in such a case, neither would such vigorous claims for exercise as a wonder ‘drug’ be justified.
Setting aside any queries about the causal direction of the relationship between exercise and good health, or the precise effect size of the benefits exercise offers, it at least seems that the NHS is convinced that it is a remarkably potent health promotion tool.
The NHS is emphatic in its confidence that exercise is highly beneficial for health. From their page on the “Benefits of exercise” come statements like:
“This is no snake oil. Whatever your age, there’s strong scientific evidence that being physically active can help you lead a healthier and happier life”
Written by Rebecca Brown
Such interventions are, presumably, paternalistic (if motivated by a benevolent attitude to make people healthier). There is a longstanding disdain towards paternalism in medical ethics, but this has largely been articulated in the clinical context. The translation of anti-paternalism to public health contexts is trickier. As James Wilson (2011) points out, two key features of paternalism which are supposed to make it problematic in individual contexts – interference with liberty and lack of informed consent – are endemic to many public health interventions. Paternalism, Wilson argues, should not be offered as a general objection to public health interventions. Instead, we must consider whether the infringements of liberty involved in a (paternalistic) intervention are justified.
There is a general preference to use the ‘least restrictive alternative’ when it comes to public health interventions. A less remarked upon but still relevant consideration is whether we are obligated to use a more restrictive alternative if this is needed to bring about some important benefit. For instance, it might be unethical to fail to have a smoking ban in place if the harms of smoking are sufficiently severe. A very non-restrictive intervention (e.g. the NHS creating a webpage that says exercise is good for health) is of no use if it has no effect on physical activity. The policy options seem to be to either 1. make no attempt to encourage physical activity; 2. use non-restrictive methods to encourage physical activity (e.g. gentle persuasion); or 3. use more restrictive methods to increase physical activity (e.g. hard and soft regulation). Given the failure of the second approach to have much of an impact on physical activity (at least insofar as the UK population is increasingly inactive) and the pronounced enthusiasm of health promoters for exercise as a tool for better health, it is surprising that more intrusive methods for increasing physical activity have not been implemented.