Dr Philip Lee, Conservative MP for Bracknell and a practising GP, today suggested that people whose lifestyle choices lead to medical problems should have to contribute towards their healthcare costs. He apparently highlighted type 2 diabetes – which can be brought on by an unhealthy diet, being overweight, and lack of exercise, although some people are genetically disposed to it – and is quoted in the Huffington Post as saying, ‘If you want to have doughnuts for breakfast, lunch and dinner, fine, but there’s a cost’.
At first glance, the idea that those who lead unhealthy lifestyles should bear the burden of their own resulting health problems seems fair. But there are serious problems with this idea. Let us consider two of them.
First, it seems likely that this sort of policy is not merely about penalising people for unhealthy lifestyle choices. Dr Lee’s comment about doughnuts and diabetes suggests that he is targeting fat, lazy people with a cavalier attitude towards their own health. Discussions of this sort of policy also often highlight (as the Huffington Post article does) the cost of treating the health problems of smokers and heavy drinkers. But it is not only fat people, smokers, and heavy drinkers whose lifestyles end up costing the NHS money. People often suffer health problems as a result of leading lifestyles that we do not normally think of as being unhealthy: sporty people are at an increased risk of suffering joint problems, computer users of eye strain, outdoorsy people of skin cancer, drivers of injuries in car accidents, and so on. If a policy of making people pay for healthcare necessitated by their lifestyle choices is to be fair, we must ensure that we target Olympic gold medallists with knee injuries just as heavily as we target doughnut-guzzling smokers with diabetes. If we do not, such a policy could end up as a surreptitious tax on people with the sort of lifestyles that society frowns upon. This would be a sinister and worrying outcome. We might celebrate those who win Olympic gold medals over those who sit at home with a fag and a doughnut, but financially penalising people for doing the latter amounts to a curtailment of freedom that is unacceptable in a society that aspires to liberal values.
Second, whilst Dr Lee’s suggestion is intended to save the NHS money, it could end up doing the reverse. How is it to be determined to what extent a patient’s lifestyle is responsible for her health problems? Whatever the method, it is likely to involve a significant amount of time and effort – and therefore expense – spent information-gathering, consulting, discussing, and evaluating. Perhaps it might require even more sophisticated and expensive processes: some people, after all, may be genetically disposed to diabetes, lung cancer, or liver disease. It would be unfair to penalise such people for their health problems, even if they are fat, smoking, alcoholics. So it might become necessary to screen people for such genetic predispositions before concluding that their health problems are caused by their lifestyles. This burden on the NHS is likely to grow as medical understanding of various diseases advances: every new factor that is identified as contributing to a disease is another factor that must be taken into account when evaluating the extent to which a patient is responsible for the fact that she suffers from that disease.
The idea that those who cost the NHS the most should be made to contribute the most is intuitively appealing. But a policy that attempts to enforce it risks being unacceptably paternalistic and counter-productive. This does not entail that such a policy could never be made to work. If such a policy was transparent about what it aimed to achieve, perhaps it could be workable, cost-effective, and even an incentive for people to lead healthier lifestyles. For example, the government might introduce a policy that all smokers who suffer respiratory problems will be made to contribute towards the cost of their treatment, regardless of whether or not they are genetically disposed to such problems. It could do so without representing the policy as part of a general campaign against those whose lifestyles cost the NHS money – a campaign which, in fairness, should also target athletes and the like. Such a policy may be controversial, but it is not obviously any more unfair than the taxes already levied on tobacco. Even so, it would perhaps be difficult to avoid such a policy being represented by the media as part of a general ‘make the unhealthy pay’ campaign.
In a moderately sane world isn’t this just a rehashing of the tension between a laissez-faire approach to healthcare and a socialised one? The free riding/moral hazard stuff undermines (potentially) the socialised system. But then the sheer brutality of dumb genetic luck makes libertarian approaches look a bit like double-jeopardy to many of us.
While I get the logic of the state sending signals about lifestyle choices via the tax system, I also find it potentially illiberal (and administratively burdensome, of course, and problematic for Anders-ish reasons to do with surveillance). I don’t like the idea that “the state” passes judgements on our lifestyles, item-by-item (even if it could do so non-invasively). Who are these people, anyway? Answer: busybodies, mainly. NGOs and other self-appointed champions of the good and the righteous. They bother me far more than corporations. If I don’t like a company, I don’t buy their products. Dooers of good are harder to evade in this way, since their favoured instrument is the law of the land (hence evasion comes at high cost). [Personally I think we’re entering into a New Victorian age full of ethical prescription and moral seriousness, hideous though the prospect seems to me.]
How about just taxing the doughnuts, cigarettes, and booze (even more)? The collected taxes can even go to the NHS.
I completely agree with you both! Thanks for the comments.
Why shift responsibility to the person who has the unhealthy lifestyle?
It is a fact that advertising alters our behaviour, so it is a fact that advertising is getting us to adopt an unhealthy lifestyle.
We should have the right to have advertising that is targeted to our needs, to only offer fatty bad foods to people who have a life style that can “afford” these things in moderation.
If we are overweight then these adverts should be suppressed.
Why not move the burden from the state to the entities that are profiting from the sales of the unhealthy lifestyle.
It is unrealistic and untrue to say we have a free choice, we do not, we are constantly being manipulated and it is time the manipulation was brought under control.
I strongly disagree with this point about advertising. If this truly worked then surely the governments advertising for ‘healthy living’ would have equally the same results. I am surrounded by adverts for alcohol yet they don’t make me forget the implications of drinking to excess every night. It’s to do with education. I know that if I eat a million donuts everyday and do not exercise, then I will become fat and be unhealthy. It’s pretty much common sense, we’re not brainwashed into thinking fatty foods are actually good for us, it is a personal choice that cannot be blamed on anyone else but ourselves.
Bruce, I wouldn’t go as far as to claim that people who are influenced by advertising are not responsible for the choices they make. But I agree that there is a wider cultural issue here. The government (or at least previous governments) agrees with you: cigarette advertising and sponsorship has been banned because of concerns about the effects of smoking on health. If similar concerns apply to fattening food, there is a case for banning adverts for that, too. Other actions by the government haven’t exactly helped here though: school sports fields have been sold off, and (at least until a few years ago) meals offered by at least some schools were shockingly unhealthy (as revealed by Jamie Oliver’s TV series). So it shouldn’t be surprising that obesity is now a problem, and it probably shouldn’t be considered exclusively the fault of the obese.
I appreciate Bruce’s effort to identify factors — other than “laziness” and “eating a million donuts” — that might be contributing to the obesity epidemic.
Further reading along these lines: “Exploring links between working conditions and obesity in low wage workers”.
But even if obesity were the result of private decisions, it seems to me that taxes on certain foods would still be problematic. Whose values would such taxes embody? Answer: Guardian-readers, like always, since these are the people with the moral certainty and organisational skills to coordinate such lists, and the only people with the OCDness and time on their hands to run around monitoring everyone against an itemized ethical spreadsheet. eg: how’s your carbon footprint? Who grew your coffee? And your chocolate? Who sewed your t-shirt? What are you drinking? Which charities do you give to? Is this efficient? That isn’t cigarette smoke I smell, is it? etc.
For those of us who either (a) do not possess/do not admire this sort of temperament; and/or (b) think this an arbitrary list which differs only in its details from other sorts of busybodyness (that of theocratic regimes or Victorian England, for instance), this whole approach comes across as completely unjustified, illiberal, and very uptight.
Personally, I don’t think my (or your) freedom to do stuff ought generally to be constrained, line by line, action by action, purchase by purchase, by the sort of self-appointed, unelected worrywarts who lobby for taxes or prohibitions on everything of which they disapprove. That, to me, is completely illiberal, since it’s actually a very intolerant way to live. (Since the essence of tolerance is putting up with things you don’t like.) And this actually *is* a big deal, since I think it’s the core of why a lot of people vote *against* the left. It’s not necessarily that they’re drawn to the policies and arguments of the centre-right; it’s that they genuinely loathe being nagged/told how to live.
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