The author, who died in June 1994, was a doctor who for years had been critical of the pretensions of the medical profession. His book is divided into three parts. The first is a criticism of "healthism", which is the situation that obtains when health is not just a personal yearning but is part of state ideology. The second is a critique of "lifestylism", which is a doctrine promoted by the medical profession, according to which most diseases are caused by unhealthy behaviour. The third part is critical of "coercive medicine", which is what results from the combination of healthism and lifestylism. Coercive medicine is what, to a greater or lesser extent, we have now: the coercive apparatus of the state is used to try to make people conform to approved lifestyles in the name of "the health of the nation". Coercive medicine is a perversion of the ideals of "humane medicine", ie. the use of medical knowledge and skills to alleviate the suffering of fellow men.

Dr Skrabanek gives many examples to illustrate the contention that the medical profession has always been infested with quacks who make unfounded claims to knowledge in order to promote their own economic or political interests and/or to persuade or coerce people to adopt a particular, usually puritanical, lifestyle. However, the biggest quacks of them all are the modern health promotionists, the apostles of "anticipatory" health care, whose stock-in-trade is the identification of "risk factors", regular health checks to evaluate them, and lifestyle prescriptions to reduce them.

The troubles with these quacks are manifold. The scope for effective medical action is quite limited. The great improvement in public health in developed countries over the last 200 years has been due, not to medical interventions, but to social and environmental factors, eg. nutrition, hygiene, housing, smaller families, clean water (though, because of diminishing returns, any further environmental improvements are likely to yield negligible benefits). The "risk factors" of anticipatory medicine are just a piece of statistical trickery: they do not identify causes. Health checks are fallible, and the consequences of a false-positive result are harmful and may even be tragic (as in the case of unnecessary surgery). For this reason, even where the health tests are based on sound theory, the harms caused by mass screening may well outweigh the benefits to a lucky few. However, the health tests are often not based on sound theory at all, but are instead the offspring of spurious science which assesses evidence according to its conformity with a foregone conclusion. That foregone conclusion is usually that the "sins of the flesh" (drinking, smoking, sex, gormandising, etc.) are damaging to health. As a consequence, the lifestyle prescriptions are not only unlikely to do any good, there is also the real possibility that they will cause harm.

In the course of his discussion, Dr Skrabanek offers his opinion on a wide range of issues, from the rights of pregnant women to the war on drugs, from the role of doctors in carrying out the death penalty to the fashion for blaming victims for disease (and refusing to treat them) while investigating medical treatments for the perpetrators of criminal acts; and, of course, there is a lot to take issue with in all of this (eg. he regards the "commercialisation" of medicine as a bad thing). His ridicule of the health promotionists is often very funny. As a result, this is a provocative and entertaining book. Some of the issues do not receive the kind of detailed discussion that they deserve; but then, it is not that kind of book.

The question I would like to ask and answer is: what are the issues here for libertarians? After all, in a free market any quack would be at liberty to market his/her nostrums to all and sundry, and the gullible amongst us (or better, each of us on our occasions of gullibility) would be taken in by some quack or other. We would expect that a free market would have its share of health promotionists peddling their quack schemes to their stupid customers who willingly pay for them. So why is the current tide of health promotion nonsense an issue for libertarians?

I think there are at least three reasons. First, the health promotionists receive funds from the government. I would imagine that most of the population treat the messages of the health promotionists with the contempt that they deserve and would not willingly part with a penny for this advice. In a free market, people would have the option (and most of them would take it) of turning down the quack schemes of health promotionists; but in our current state of affairs people are compelled by government to pay for this nonsense through taxes.

It is almost inevitable that this should be so where the powers of the state are not tightly circumscribed. For while a politician may recognise that proposed health promotion schemes will yield no benefits (and so would not pay a penny of his/her own money for them), nevertheless, because health has the aura of a good cause, the politician can derive vote-winning benefits from sponsoring such schemes at no personal cost (since the price is paid by the taxpayer). Recall the spectacle of Kenneth Clarke, when health minister, pictured with a fat cigar in one hand, a large brandy in the other, and a shirt-splitting paunch hanging over the top of his trousers. Clearly, in a personal capacity he would not have given the health promotionists the time of day; but at the very same time he was responsible for spending millions of pounds of taxpayers' money on this garbage.

Secondly, the taxpayer is not just forced to pay for daft advice (which he/she would, in principle, be at liberty to ignore), but is also forced to endure (and pay for) curtailment of his/her civil liberties. Thus we not only have to suffer "health" propaganda produced by dozens of state-funded agencies and by the government itself, but we are also subjected to suppression of free speech (as in advertising bans), punitive taxation of disapproved goods and services, criminalisation of victimless activities (eg. taking drugs, boozing "after hours"), and discrimination in state-funded services against people who engage in activities which are legal but disapproved of (eg. refusing NHS treatment to smokers).

Thirdly, even without all this state interference, the health promotion fad would be an issue for libertarians. For the health promotionists do not only target the state, they also market their services to the private sector. Thus, many companies have introduced smoking bans, some test employees for traces of alcohol or drugs, some are laying down restrictions on what legal leisure pursuits their employees may engage in, and some are using tests for "risk factors" in their recruitment selection process. While a good deal of this must be attributable to government sponsorship of health promotion claptrap, such developments on a smaller scale would still be expected in a free market. For the owners of a company are perfectly entitled to introduce whatever restrictions or procedures they like for their own employees (who can look for work elsewhere if they don't like it). However, such "restrictive practices" (to misuse a term), if they cannot be justified in terms of the demands of the job, would be stifling if they became widespread. Free development of the human spirit requires recognition and toleration of people's differences, the accommodation of diversity. So even in a free market there would be a need for libertarians to defend and promote attitudes and practices of toleration. It sounds awfully political, but it is just part of the human condition that freedom requires eternal vigilance.

Danny Frederick