Three Critiques of a Duty to Be Healthy

3appleadayplan.jpgI’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.

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