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Other Acknowledgements

4 Philosophical Theories

4.2 Liberalism and Public Health

4.2.1 What does liberty mean and why is it important?

Liberal thinkers have usually defined freedom either as the lack of constraints or as the ability of individuals to decide for themselves what happens in their lives.36 Within the most classical forms of liberalism, to say that people are free means primarily that they are not legally or otherwise coercively prevented from acting according to their desires and plans. In practice this would mean, for instance that no one should be legally denied access to houses with sanitation or medical services on offer. This definition is, however, problematic since individuals are not always free, at least not according to everyday thinking, even if they are

not hindered from doing what they desire, or want to do. If my poverty forces me to live without sanitation or lack of medication kills me and my family, it might be misleading to praise my freedom.

On the other hand, the non-restriction of options and the capacity to make autonomous decisions have been seen as valuable in the liberal tradition. Some theorists have thought that the value of freedom is intrinsic and intuitively detectable to anybody. They think that it is symbolically important to individuals to know that there are more books in the nearby library than they are ever going to read, and more restaurants than they are ever going to visit.37 These theorists may also believe that the freedom of choice exemplified by the books and dishes is somehow self-evidently valuable, and should in no way be restricted. There are, however, difficulties with this argument for freedom and its symbolic value. A wide range of choices can, of course, be symbolically exhilarating and personally satisfying but if this liberty seriously interferes with othersÕ liberties, not to mention their welfare interests, egalitarian liberalists should be ready to consider restrictions of freedom. They should accept that some of the money meant for library books is spent, if politically so decided, in elderly care.

In a liberal welfare state, one of the major challenges is the constant bargaining about resources between different sectors of public services like education, health, social security, public works and within these particular sectors. This means that there may be major differences in views about the proportional importance of various preventive measures in matters concerning peopleÕs health. This constant battle for scarce resources has accentuated the need for efficiency in public services. Although efficiency is a necessary instrumental value in the provision of these services, it may easily become an all-encompassing value for the most market-oriented politicians. If this happens, concern for equality and individual autonomy quickly vanishes into thin air.

Other champions of liberty have argued that the value of freedom is instrumental rather than intrinsic. A society, they say, which does not unduly interfere with the choices of its members encourages their creativity, genius and industriousness.38 These qualities are seen as valuable because they lay the foundation for material wellbeing and cultural flourishing in a society, and bring happiness to the nation as a whole. The flaw of this defence is that it cannot be supported by empirical proof. A better way to defend the value of freedom can, I think, be found. First, the value of freedom of action and choice is instrumental, and it is based on the fact that the non-restriction of a personÕs options is, to some degree at least, a necessary condition for autonomous decision-making. Second, autonomy and self- determination are valuable in themselves, since they belong to the primary elements of a good and happy human life. Material well-being is, no doubt, possible without liberty and autonomy, but whether or not such welfare is worth pursuing is another matter. The happiness and wellbeing that most ethical theories see as the highest goal of human life conceptually presupposes that individuals are free to decide what the direction of their life and their actions is.

According to the basic principles of Millean liberalism competent individuals are fully entitled to make choices which they themselves or others regard as irrational. Rationality and irrationality can be defined in many ways, but no morally neutral description can in and by itself legitimise the use of coercion on others. Besides, most forms of rationality are such that individuals cannot even in theory be forced to assume them. The consistency and realism of peopleÕs beliefs, which is sometimes seen as a hallmark of rationality, can be increased by

education but it can seldom be furthered by legal sanctions Ð Prohibition laws in the U.S. and in Finland in early 20th century pretty much prove the point.

Some moralists have challenged this strictly liberal view by arguing that irrational decisions are never autonomous: individuals who continuously make them should be likened to the mentally ill and the emotionally disturbed. The proponents of more moderate doctrines have suggested, accordingly, that choices which are not rational should be restricted on the grounds that they are not sufficiently self-determined. But seen from the Millean viewpoint this argument is skewed. When competent human beings make informed decisions without the coercive influence of others, the ensuing actions are autonomous in the relevant technical sense even when they can be depicted as self-destructive or silly.