Negative Freedom and Death in the United States

Abstract

Personal freedoms have been characterized as “positive” (freedom to pursue opportunities) and “negative” (freedom from external constraints on decision making). An ecological analysis of US data revealed a strong positive association (r = 0.41; P = .003) between state-level negative personal freedom (defined in terms of regulation of personal behavior) and state-level age-adjusted rates of unintentional injury. A conceptual emphasis on positive freedom construed as freedom to pursue a life without risk of unintentional injury could help motivate a conversation to improve public health.

In the United States, state governments influence people's lives largely through the nature and extent of freedoms that they offer to their residents. For decades, there have been 2 major competing political definitions of freedom: “positive” and “negative.”^1,2 Negative freedom is characterized by the absence of external constraints on personal decision making, and positive freedom is portrayed as the exposure to conditions necessary to pursue desired opportunities. In terms of the current health care financing debate, a system in which the government removes itself completely from the provision of health care so that individuals are permitted to do whatever they deem to be important for themselves without interference would exemplify negative freedom; providing a public option to ensure that all individuals receive a minimum standard of health care is an example of a government enabling positive freedom.

There has been far greater emphasis on the negative view of freedom than on the positive view. A recent report measuring states across different aspects of freedom primarily based its measurements on the extent of existing negative freedoms, with states having the fewest and least intrusive regulations considered to be the freest.³ The report defines “personal freedom” as the absence of state policies proscribing individual behaviors, exemplifying the concept of negative freedom, and it characterizes personal freedom as an inherently good quality that is the opposite of “paternalism.” Although paternalism carries the connotation of an authority that dictates overbearing rules, it also suggests a philosophy of protection that could give individuals the security necessary to pursue important goals—an example of positive freedom. We conducted this study to assess the relation between negative personal freedom and death from unintentional injury in the United States.

METHODS

We performed an ecological analysis comparing state scores of personal freedom with state-specific age-adjusted unintentional injury fatalities for 2006, the most recent year for which these data were available. The index of personal freedom measured the absence of state-level policies, regulations, and laws governing injury-related behaviors, including the following: use of alcohol, tobacco, and marijuana; wearing helmets while riding bicycles and motorcycles; use of fireworks; use of seat belts and cell phones while driving automobiles; and use of firearms.³ Each policy item within the index was standardized by calculating the number of standard deviations each state scored higher (more free) than the mean. Each policy item was weighted according to the number of people the policy affected, the intensity of opinions related to the issue, and the magnitude of state policy variation.

State-specific age-adjusted rates of unintentional injury mortality included all deaths consistent with codes V01-X59 and Y85-Y86 in the International Classification of Diseases-10.⁴ Unintentional injury mortalities included such mechanisms of death as firearms, motor vehicle crashes, poisonings (including poisoning deaths that were drug- and alcohol-induced), burns, and falls.⁵ We used SAS version 9.1 (SAS Institute, Cary, NC) to calculate Pearson correlation coefficients and to create a linear regression model of the association between state personal freedom index scores and state age-adjusted rates of unintentional injury mortality.

RESULTS

The personal freedom index was standardized with a mean of 0 and ranged from a low score of −0.294 for Maryland to a high score of 0.272 for Alaska. The mean state age-adjusted unintentional injury mortality rate was 43.6 per 100 000, with a low rate of 25.9 per 100 000 for New York and a high rate of 67.1 per 100 000 for New Mexico. There was a strong positive relationship (r = 0.41; P = .003) between state personal freedom index score and state unintentional injury mortality rate (Figure 1). An increase of 1 standard deviation (SD = 0.109) in state personal freedom was associated with an increase in the state age-adjusted unintentional injury mortality rate of 4.2 per 100 000 (95% confidence interval = 1.6, 6.9).

FIGURE 1.

Correlation of state-level personal freedom index scores with state-level age-adjusted unintentional injury mortality rates per 100 000: United States, 2006.

DISCUSSION

Although the concept of personal freedom is appealing on an intuitive level, from a health perspective a negative framing of personal freedom may have an adverse impact. Health-related policies that require specific behaviors are necessarily seen as curtailing negative freedom, despite the fact that these policies have often been associated with lower rates of unintentional injuries.⁶ Alternatively, these policies could be seen as increasing positive freedom—the ability to pursue desired opportunities. For example, when laws mandate the use of motorcycle helmets or prohibit text messaging while driving in a state, this creates a social environment in which riding without a helmet or texting while driving are seen as unacceptable behaviors. A person is relieved of the burden of deciding the proper course of action and is liberated from any risk or feeling of risk associated with these unsafe behaviors.

The results of this study must be interpreted in light of the caveats implied by this ecological cross-sectional analysis. Further studies on this topic should investigate individual health outcomes and account for potential confounding factors at the individual and contextual levels. Nonetheless, this study suggests that conceptualizing freedoms mainly in negative terms can limit improvements in the health of the nation's citizens. Alternatively, conceptualizing freedom in positive terms, such as the freedom from experiencing a fatal unintentional injury, shifts the focus considerably to beneficial outcomes that freedoms can make possible.