There has been a good deal of discussion about obesity recently, since the Royal College of Surgeons criticized access to weight loss operations in the UK as a ‘postcode lottery’: http://www.guardian.co.uk/commentisfree/2010/jan/21/morbid-obesity-gastric-bands-nhs-costs
One common response – for example by Catherine Bennett in The Observer ( http://www.guardian.co.uk/commentisfree/2010/jan/24/homeopathy-obesity-gastric-bands ) has been that the question of unfairness shouldn’t be permitted to arise in the first place. Obesity, since it is self-inflicted, should not be treated by the NHS at all. Rather, the money should be spent on treatments for involuntary ailments, such as cataract operations or hip replacements.
Against this, it could be argued that interventions to cause weight loss, such as gastric bands, are in fact a highly effective use of NHS resources, since (a) they tend to work pretty well and (b) they save the costs of further treatment down the line for conditions which would otherwise have been caused by the obesity. This argument, however, fails to deal with the original deflection of responsibility for obesity onto the sufferers themselves. If they bring obesity on themselves, which then gives rise to further medical problems, then plausibly they have brought those problems on themselves as well. The NHS should refrain from treatment throughout.
The attribution of responsibility, however, is a far from straightforward matter. On one view, libertarianism, we have genuine freedom of the will, which somehow enables us to act in a way that is neither determined by the laws of nature, nor random. But making sense of free will in this way is not easy. The philosopher Roderick Chisholm, for example, suggests that free action constitutes a ‘little miracle’ each time it happens.
On another view — compatibilism — freedom and responsibility are consistent with our actions being the result of deterministic processes over which we have no control. Unfree actions are those, for example, caused by physical coercion. I am free if, had I chosen otherwise, then I could have acted otherwise. But how free am I, really, if I wasn’t actually free to choose otherwise?
Some determinists are incompatibilists, and believe that we should give up on talk of responsibility entirely. That view, of course, is itself highly counterintuitive. But given that we are nowhere near consensus on this issue, it might be said to be fairer to give the obese the benefit of the doubt.
Even if we do have free will, however, it’s not anyway clear that we’d want to hold the obese responsible for their condition. First, much obesity begins at a young age, well before the ‘age of responsibility’. Second, most if not all of us are subjected (again, from a young age) to a vast amount of so-called ‘persuasive’ advertising, peer pressure, and other influences in favour of over-consumption of unhealthy foods. Finally, if we refuse to treat obesity, it isn’t clear why we shouldn’t also refuse to treat many other conditions which could be said to be self-inflicted: sports injuries, skin cancers caused by over-exposure to the sun, injuries resulting from travel, and so on. An NHS which continues to treat patients independently of issues of voluntariness, by providing some degree of background health cover for all of us, sustains a liberal culture in which individuals can engage in a wide range of jobs and social and leisure activities without constantly having to check whether their decision will be taken by the state to be genuinely free.
Actually, “responsibility” is straightforwardly precluded by the logical fact that a human being cannot be “causa-sui.”
“Finally, if we refuse to treat obesity, it isn’t clear why we shouldn’t also refuse to treat many other conditions which could be said to be self-inflicted: sports injuries, skin cancers caused by over-exposure to the sun, injuries resulting from travel, and so on.”
I don’t think that these examples constitute logical analogies. Sports injuries, travel injuries etc arise from random chance as do most accidents. We have to distinguish between unhealthy lifestyle choices and random injuries or medical conditions. Obesity, smoking, drug taking and excessive alcohol intake all result from concious unhealthy lifestyle choices although one might argue that that some of these choices are related to other problems that help to establish addictions.
Random injuries and medical conditions such as broken limbs or exposure to viruses or contagious diseases are rarely the result of unhealthy lifestyle choices.
Maybe a way to address this issue is to offer support and weaning programs to people who engage in unhealthy lifestyle choices but then apply sanctions to those who either refuse or fail to respond to them. This could be established on the basis that you will be given the lowest priority, and go right to the bottom of the list, to receive NHS treatment for surgery, implants or transplants that become desireable or necessary as a result of maintaining these unhealthy lifestyle choices unless you have an immediate and acute life threatening condition.
Roger. You conclude that “an NHS which continues to treat patients independently of issues of voluntariness, by providing some degree of background health cover for all of us, sustains a liberal culture in which individuals can engage in a wide range of jobs and social and leisure activities without constantly having to check whether their decision will be taken by the state to be genuinely free”. Why would be it a “liberal culture”? Yes, I say that Rawls’ liberalism would approve this principle, but this is because free will and the problem of responsibility in choices is simply disregarded in Rawls’ design of the original position. In Brazil, we have a NHS (it is called “SUS”) that covers treatments for obesity (medical appointments, medications, even surgeries). Actually, the law says that all persons have rights to an “integral assistance to health”, “including pharmaceutical assistance”. Problems of responsibility are completely disregarded. The have a place in private contracts of insurance, but in Brazil even private health plans are regulated by a constitutional and by some special laws and controlled by a governmental agency that prohibits plans that don’t cover all medical situations without restrictions. Individual responsibility has only a place in private contracts of insurance for properties or other “disposable goods”. Recently I’ve read an argument for this. Luigi Ferrajoli, an Italian law philosopher, says that “fundamental rights are rights attributed to all persons” and they are “undisposable”. This means that I cannot waive or be alienated of those rights. The right to health would be a paradigmatic case of fundamental right (a right to a “positive expectation of services” attributed to all human beings, following Ferrajoli’s interpretation of the human rights catalog). My interpretation is that if individual responsibility would have a place in rights to health those right would have be, following Ferrajoli, another character. For Ferrajoli, besides the “fundamental rights” (undisposable and universal by formal restrictions) there are the “property rights”. Property rights are disposable rights, and they are not “universal”, but “singular” (essentially private). Following this approach, in USA (pre-Obama) people don’t have a fundamental right to health, for what they have is a disposable right to health care and assistance. I don’t agree with Ferrajoli that all rights to health MUST BE fundamental (in his sense of universal and undisposable). I don’t think that is what says the 1948 human rights declaration. (Actually, my view of what we mean by a “right” is very different from the simple view that rights are “entitlements to goods”, since I agree with Judith Jarvis Thomsons that rights are essentially “claims against someone else”, the duty bearer). Nevertheless, that is his theory, and here, in Brazil, that view is simply a common sense between law professionals (judges, prosecutors, lawyers, and authorities). That is the view supported also by academics in health schools. But I think it would be sensible to make a threshold, since not all “rights to health” MUST BE “universal rights”. If it would be true, then there are some rights to health that can be disposable, and here there would be a place for individual responsibility. What do you think about? PS: Roger, excuse-me for the excessive length of my comment. Tears. Marco Azevedo.
Thanks for all the comments above. A quick response to Marco. I think the situation in the US is that many people have no de facto right to health care, and those that have it do so only because of independent property or employment rights. De iure is another matter, and I’d be prepared to accept the idea that citizens in modern developed countries have inalienable rights to health care. But even here there might have to be limits in certain cases. So imagine that e.g. kidneys are in short supply for transplantation. The fact that someone has already irreparably damaged three kidneys received through transplantation might be said to count against their receiving a fourth when there are other equally needy recipients. But the justification for this needn’t be based on any assumption of free will or voluntariness. It could be straightforwardly consequentialist.
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