Newsletter | Do We Have Freedom of Choice?

Among the iconic phrases that best evoke the spirit of America - “Just Do It," “I’m Luvin’ It” - “Freedom of Choice” is surely up there.

In just three words, Freedom of Choice expresses the ideals of American liberty, where individuals are empowered to forge their own path. 

The idea dates back to the early years of the republic, when Alexis de Touqueville noted that American individualism was a new and powerful force that might rival the common good of democracy. But the phrase really took off in the consumer age, in the bountiful days after World War II. All at once, there was a surfeit of choices for the average American (provided one had the means or the credit). Soon, there was little light between being a good citizen and being a robust consumer. Indeed, we now commonly call people “consumers” rather than “citizens," their identity as buyers more essential than their role as voters or community members.

Unfortunately, “freedom of choice” is often at odds with that other very American idea of the common good, that quaint notion that we share basic rights, freedoms, and services like public safety and public health (Habits of the Heart is essential reading here). For better or worse, these days those shared ideals are often dismissed as “soft”, while getting yours is seen as “smart.” 

What’s more, freedom of choice has led to some unfortunate consequences, insofar as all that choosing - all that buying - has resulted in a glut of things we don’t need, from 85-inch TVs to Garlic Cheddar McFlavor Fries. What we buy, what we eat, how much exercise we get, how much sleep we get: These things are often framed as choices, which is great for those doing the selling. But it’s also led to a bounty of chronic disease, where our freedom to indulge can lead directly to lifestyles and environments that are just plain unhealthy. 

As Devo sang: “Sink, swim, go down with the ship. But use your freedom of choice.”

We’d been mulling on this tension between individualism and the common good for months, for obvious reasons. The idea of a common anything seems under duress these days, and those hard-won structures of shared values are being defunded and dismantled - public health first among them. 

Which is why we were glad to see a new essay from the Berkeley Media Studies Group on the same theme. It’s a must-read, and contains some real gems:

“Individualism insists that people are masters of their destiny and that with enough hard work, discipline, and self-determination, they can overcome almost any obstacle. These beliefs extend to perceptions about health. Most folks’ gut-level assumption is that people can control their own health outcomes if they make the right choices. But choices are always made in a context. People manifest the false promise of individualism when they encourage families to eat more fruits and vegetables without recognizing the need for all neighborhoods to have healthy, affordable food nearby, or when they tell parents to make sure their children get enough exercise but don’t ensure neighborhoods have safe places for children to play. Conditions matter.”

Obesity is a prime example. For decades, obesity had been treated as a lifestyle issue - a matter of personal willpower. A matter of diet and exercise. That framing propelled decades of the diet industry, with programs like Weight Watchers and Nutrisystem and Jenny Craig taking off in the 1980s and 90s. These companies sold their services (and their products) as the secret to successful individual action. 

A bit of irony here: Heinz Foods bought Weight Watchers in 1978 for $71 million, and owned it for 20 years. And in 2006, Jenny Craig was acquired by Nestle for $600 million. Food companies had created a problem, and then commoditized the solution. There was clearly a lot of money to be made on obesity, even though actually losing weight was just so hard for so many people. But it was still on them.

Only in recent years has that framing of individual agency been challenged, in part with the recognition that obesity is a bonafide medical condition, worthy of medical treatment. In part that was driven by the pharma industry, as it took the arrival of effective drugs to finally begin shifting the perception of obesity. Lilly and Novo Nordisk - makers of Zepbound and Mounjaro respectively - have put billions of dollars in marketing muscle towards shifting the perception of obesity away from personal responsibility and towards one of treatment.

The argument here certainly won’t prevail over the ascendant libertarian dogma. In a City Journal essay entitled “Make America Responsible Again”, the author condemns any attempt to avoid personal responsibility when it comes to health status. “By medicalizing behavioral issues, the elites transfer power from the individual to themselves, the dispensers of technocratic responses to social problems.” 

There's some some truth to that, insofar as public health has relied too much on authority and too little on authenticity to make our case. So how can we flip the script back in favor of the common good and public health?

One popular attempt has been the mantra: “Make the healthy choice the easy choice.” This idea came into vogue amid the Obama optimism of Let’s Move!and it sounds elegant and winning, invoking behavioral economics and nudge-theory to win the battle over people’s health. And it suggests a path to public health through the prism of freedom of choice (we’ve invoked the mantra here at Building H more than once.) Win-win!

But: Many people don’t have much of a choice between what they might eat or how they might behave. And “health” might not be their primary objective when it comes to various options or indulgences. Other triggers and incentives are often at play when we’re talking about reward centers in the brain. As we say, it’s not a fair fight.

So is there another rhetorical approach that can square the circle between individualism and the common good, such that we can make the case for public health?

One argument might be that we need public health in order to give us choices. Public health gives us safe water and safe food. It gives us a variety of foods. It gives us opportunities to socialize and recreate as part of our everyday routines. Only once these basic needs are met can people actually start to take agency and take action. If the basics aren’t there, then people may not really have choices.

There may be something winning to this, but it needs some work. One caveat: It’s worth reading this recent study in the Journal of Health Communication. The project sought to test 20 messages on the value of public health with focus groups, with the goal of developing winning arguments for public health that resonate with the public at large.

Alas, despite a thoughtful design and measurement, the project got waylaid by a misunderstanding of what public health is, in the first place. “Most participants demonstrated a lack of or incomplete understanding of the public health field,” the study reported, noting that many confused “public health” with health insurance such as Medicaid. “Participants conveyed a surprisingly limited or inaccurate understanding of what public health is, what public health professionals do, and how public health affects everyday lives.”

In the end, the project failed to come up with any promising messaging at all.

Which is why we’ve begun noodling on the idea of making a case for public health not as a one massive entity, but rather as a discrete inventory of things that citizens (not consumers) need and expect in order to live their lives and make their choices. Maybe the best case to make for public health is to break it down into specific deliverables, into the things that we all can agree we expect of society (and sometimes of government). 

In some sense, it’s close to (but not exactly) E pluribus unum - “out of many, one” - which is, after all, the very motto of the US. It’s closer to ex uno pluria - "out of the one, many" - which is to say, only after we’ve taken care of the needs of the many, might we start to enjoy the freedoms of the individual.

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