Three Critiques of a Duty to Be Healthy
posted by Frank Pasquale
I’ve been attending a conference on health care rationing, and the extent of a so-called “duty to be healthy” has been a provocative theme. From a solidaristic perspective favoring universal coverage, Professor Wendy Mariner has suggested that “wellness programs” designed to keep employees healthy may seem good for everyone, but have a darker ideological undertone. They undermine support for social insurance that spreads the costs of illness, and instead inculcate the idea that individuals themselves are responsible for sickness. In another presentation, Leonard Glantz quoted the 2004 book The Cost of Smoking, which suggested that savings arising out of premature deaths might actually save the government more money (on average) than smoking-related illnesses would cost it (on pages 156 and 161). (Kip Viscusi made a similar argument in 1997.)
With a libertarian angle, Jacob Sullum is even more critical of any “duty” to maintain one’s health:
Maximizing health is not the same as maximizing happiness. The public health mission to minimize morbidity and mortality leaves no room for the possibility that someone might accept a shorter life span, or an increased risk of disease or injury, in exchange for more pleasure or less discomfort. . . . But even if certain habits do, on balance, increase taxpayer costs, the problem is not that some people do risky things; it’s that the government forces other people to pay their medical bills. People who don’t want to pay for the consequences of such dangerous behavior shouldn’t support taxpayer-funded health care. (emphasis added).
I disagree; I think that Sullum’s position is tempting mainly because a) we overestimate the degree to which our own behavior influences our health, and b) because those with good habits tend to give themselves a bit too much credit for the inculcation of those habits. As for a), consider this cancer risk assessment tool–not too much is asked about behavior under one’s control. As for b)–I admit that this is an area of fundamental philosophical disagreement on the degree to which one’s will is free to change harmful habits. But given recent books like Gina Kolata’s, I think we’d all be well advised to think “there but for the grace of God go I” when contemplating those we’d blame for poor health. Our healthcare non-system is often stacked against them.
May 31, 2007 at 10:01 pm
Posted in: Health Law
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Responses (2)
Daniel Goldberg - June 1, 2007 at 10:56 am
Fascinating. One of the projects I am currently involved in is tracing the extent to which our theories of disease causality inform public health policy (and I think the effect is quite large, indeed).
If we tend to think that our lifestyles have a greater effect in causing disease, we are very likely to promulgate and support different public health policies than if we, as you suggest, overestimate the extent to which our behavior influences health. I’m curious as to the reasons why you believe this, though. Naturally, one of the chief attractions of the lifestyle theory is that it renders so much of our health a factor of personal responsibility, which is obviously culturally appealing.
Do you think this appeal masks some weaknesses in the lifestyle theory? The individual responsibility ethos has a dark side, of course, most notably seen in the attitudes towards obese persons.
Is Ideology-Free Health Reform Possible : HEALTH REFORM WATCH - June 18, 2009 at 6:35 pm
[...] Yet I found the most compelling talks to be Uwe Reinhardt’s and Maggie Mahar’s. Far from preaching “middle of the road”-ism, both found fault with the incrementalism it usually results in. Mahar noted that the Massachusetts plan does not have a compelling model of controlling costs–and that without cost control it is virtually impossible to accomplish sustainable reform. Reinhardt underscored the degree to which policy elites in other countries consider the risk of bankruptcy due to medical bills in the US “obscene”–a value commitment hard to square with much rhetoric of personal responsibility. [...]
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