Cigarette Ban and Government Mandated Exercise: The Implications of Universal Healthcare?

Whoa there, Bucko. What you seem to be arguing for is a vast and terrible abrogation of personal liberty by the State. Did you design this post to raise my hackles and draw me out onto the battlefield? If so…bravo!

Why does universal health care entitle the govt. to mandate that I exercise? According to your argument it’s because they’re giving me “free” health care, and I only deserve that health care if I’ve done nothing to cause my own predicament. There are two glaring problems here.

1) Lots of “healthy” activities willfully engaged in are dangerous. Athletes are sometimes (often?) killed or maimed in the pursuit of their craft. Runners routinely have to have parts replaced. MMA fighters and boxers and hockey players and footballers get beat up as a matter of course. I’d imagine they mostly do these things for fun and profit. If I’m a couch potato then my sports-fun-analog would be something like channel surfing or video game playing. The athlete and I both know that our activities might have health consequences. Why do they “deserve” health care when they are hurt doing something “fun” while I (the couch potato) do not? Are you thinking that there is a difference in the quality of the activities or some virtue possessed by athletes and not by couch potatoes? This is at least not obvious.

2) Your argument against the couch potato deserving health care only works if we assume that the money that the government uses to pay for said health care is not given to the government by the citizens in the form of a tax. If they are getting the money for this from some non-citizen (aka “magical”) source then they may place whatever restrictions on the service they wish. If they’re getting it from my wallet then they had better give me equal access to the services purchased by that money. Perhaps your “opting out” idea is meant to get around this, but it seems to me that the real-life result of a policy like this would be that the health care costs for couch potatoes would be extremely high and the more athletic folk wouldn’t feel to bad for us because we “deserve our condition.” Do we need a new brand of discrimination in the world?

1) This argument just has to be a reductio. Saying that people cannot participate in any actions which might have a potentially negative impact on their future health is just inviting an unacceptable level of government intervention in citizen’s lives. It’s a total abrogation of liberal values, I think. I don’t think I can come up with any activities (or non-activities if you’re a couch potato) that aren’t at least potentially harmful.

2) I think the real solution here is not going to be some kind of government regulation of citizen’s behavior. You’re right that we’re generally not only entitled to the amount of $$ that we put into the system. It seems to me that as long as folks pay into the system as much as they are required to (as determined by whatever system is in place) then they should be given the same benefits as anyone else who also pays in.

The more effective tool in this case is something like peer pressure. If the public generally and vocally disapproves of fat and lazy people then fat and lazy people are more likely to try not to be fat and lazy. Seems to me that this would have the good effects that you’re after here (lower health care costs) without the massive government intrusion that you seem to recommend.

Hey Lil,
So what I’m arguing is that we should expect our fellow citizens to pay out of pocket to treat ailments they knowingly bring upon themselves, but that we should collectively cover ailments thrust upon us through no fault of our own. That seems consistent with fairness, since the naturally healthy didn’t do anything to deserve their fortune, and the naturally unhealthy didn’t do anything to deserve their misfortune. People who actively and willingly deteriorate their health and put themselves at significantly greater risk DO deserve their ailments, insofar as we deserve the fruits of our conscious efforts. (That seems to be what “deserving” is all about.) But when a piano falls on your head and you survive–you certainly don’t deserve that.

Applied to your situation, the weight thing is under your control (unless you have some sort of gland disorder or compulsion… and I think you’re overestimating–no way you need to lose FORTY freaking pounds…), but the c-section wasn’t, your son’s blood thing isn’t, and your husband’s OCD isn’t. Thus, I’m suggesting that if your knees wear out more quickly than they otherwise would, the rest of us would be justified in expecting you to cover the cost of treatment, or at least some percentage based on how much more quickly they grinded away thanks to the extra 10 lbs than they otherwise would. The c-section thing, the blood and the OCD, however, were thrust upon you and your family through no fault of your own. Thus, as members of a democratic polity amongst free equals who owe one another basic respect by virtue of the shared enterprise we call society, the rest of us should willingly and gladly help foot the bill, if not cover it altogether. (Of course, such a society has to be wealthy enough to afford such treatments, but we at least have an obligation to make it a top priority, given how essential stable health is to our quality of life.)

But I think you already understood all of that. Your main point was that there are measures in place to discourage unhealthy behavior and to make the unhealthy (or likely to become unhealthy) pay more than the rest of us. The difference between the existing measures and what I’m proposing is that I’m arguing that citizens should only be penalized for ailments they bring upon themselves, whereas the current system penalizes EVERYBODY who’s sick, whether or not their condition is congenital, the result of an accident, or whatever.

So between your and Mike’s thoughts I’m ready to revise my argument a bit, and say that all of the considerations above, rather than supporting MANDATORY exercise, denying coverage to smokers or banning cigarettes outright, supports giving physically active healthy eating nonsmokers discounts or tax rebates, and charging the willfully unhealthy a high percentage of the cost of their care.

That way everyone’s liberties are intact, there’s no state coordinated jumping jacks, but the willfully burdensome pay their fair share into the system, which happens to be more than the consciously healthy.

Hey, I just wanted to address some points Matteson brought up earlier.

First, the statement that athletes are killed in the pursuit of their craft. This statement leads us right into a slippery slope. People who are born necessarily die. People who drive sometimes die. People who walk sometimes die. Dying is a result of living. Sure it can be scary to contemplate and that involves emotions in our argument. However, possibility of death alone doesn’t make an activity unnessesarily unhealthful. The important point is this: Do athletes increase, substantially, and without merit their risk of death? I expect the answer is no.

Second, that runners suffer more injury. I’ve read a few articles (some in runners magazines) that indicate the opposite is true. People are injured while running. However, the consensus I’ve read is that it is by far more healthful than harmful.

Last, the statement “MMA fighters and boxers and hockey players and footballers get beat up as a matter of course”, I expect this statement was meant to imply that being beat-up as a part of their sport makes them more prone to injury, thus more of a burden on the tax payers.

I expect we’ll find this to be false. That is, while they may be injured more, athletes recovery time is often less for the same injury as a couch potato. I understand this is true for football players (compared to sedative individuals). I don’t know why, though (perhaps it has something to do with added muscle or nutrition, or both).

Oh, how I had to chime in on this one. Believe it or not, my comment will probably not be expected. I am a smoker as you well know. I am also diagnosed with OCD and Bi-polar disorder. My opinion, I do not care if the government decides to make me quit BUT I think that as long as the tax payers, who are paying the money out for the current tenncare system should be the ones to make that decision. If that decision was made by the taxpayers then I believe that the government should implement restrictions.
Where the dilemma is with me is that I am currently uninsurable by insurance companies because I have Bi-polar tattooed on my ass. So i have both a preexisting condition and several bad habits to boot. Should I not receive state coverage or free health care because I smoke or receive it because I have a legitimate issue that is by no fault of my own.
Say someone drinks a glass of red wine everyday, said to help your body not harm at this level, if their liver is week anyway ( most over the counter meds, Pain killers that are prescribed for most anything, anti-depressant, mood stabilizers, nerve pills, seizure meds, etc. are processed through the liver) and this person develops cirrhosis of the liver ( usually followed by hep c) should this be covered? I mean after all, it is the federal government paying for most of these medical ” discoveries” so would it not be their fault or the fault of the researchers that say red wine is good for you, to pay. Big tobacco companies have had to pay for peoples pets having cancer due to the second hand smoke of their owners.
and last but not least, there are several ” good” grocery items said to cause cancer or other illnesses. Artificial sweeteners, used by most diabetics, are said to cause depression and anxiety issues and even physical ailments in women? Would this be covered. It is by no fault of their own, yet they are choosing to put it into their bodies.
Hmmm, well i like this post. Thanks.

The whole aspect of “free” healthcare disturbes me in some ways and makes me realize there will be consequences in other ways. When “free” healthcare is instituted there will have to be a major overhaul of the way people think regarding their health and what is expected of them. With Tenncare, many patients come to the ER because it is free to them. I hear from many “I don’t have to pay”, “I can’t get in to see my doctor for this back pain I have had for 2 years,” or “I took an ambulance here because I don’t have the money for gas and I don’t have to pay for this” but yet they will have a cellphone as well as 2 packs of cigs in their purse or pocket. I cannot imagine how the government will mandate or enforce penalties for unhealthy lifestyles when we cannot even control the abuse that goes on in healthcare by all walks of life. Insurance companies already control so much in healthcare it is ridiculous. The insurance company decides how many days you can be in the hospital, what medications you can be prescribed, what tests are necessary, and who can see you if you need a specialists. In the Knoxville News Sentinel Friday May 22nd there was an article regarding increasing the premiums 50.00/month for state employers/school teachers if they have not quit their habit by 2011. This is in regards to how much it costs to take care of smokers on the state health insurance plan. Either way I think it is a hard pill to swallow when you see people abusing their body whether it is alcohol, drugs, or food and knowing it comes out of the taxpayers check each time. How do you control this abuse? How will the government police the mandates? What type of penalty do they need to impose to those that violate the mandate especially if they do not work and live on government funding?

Private health insurance is a socialist program that is the root of many ills. Don’t get me wrong, I don’t support government health care except as a safety net for LEGAL immigrants (illegal being ALIENS not immigrants!!!!) But the reason we have a health care crisis is that so many have created a private socialist enterprise of insurance companies running our health lives. I argue do away with ALL health insurance, let free market work and health care will become MUCH more affordable for all. Allow for catastrophic coverage & medical savings accounts with $5million cap.

If my healthy children born today could have funds set aside for their health care needs, by adulthood they could have a sizable health care nest egg. If my unhealthy child (brought on by infant vaccine adverse event) could have some sort of catastrophic coverage, her needs would be somewhat cared for. Insurance to date has not cared for them as-is.

Additionally, we the consumer being put in control of our own health spending would no longer accept the outrageous cost of medical equipment, prescriptions, etc. No longer could pharmaceutical companies charge $ 500 for a blood pressure prescription when I could likely choose a comparable $4 prescription and would be far more likely to if I didn’t perceive the magic insurance fairy as taking care of the increased cost.

I know this because my attitude changed when our insurance went from $20 copays here & there to $5,000/yr deductibles. Suddenly I cared and began bargaining health care costs. It’s the free market system at its best.

Hi, Peter. Thanks for dropping by.

That’s of course an excellent point. I was being a little flippant in that line–surprised you’re the first to point it out. I smoked for several years myself, and understand how difficult it is to quit. I used to go back and forth between cigarettes and chewing tobacco (gross, I know!), til I finally quit both with LOTS of chewing gum and coffee.

I guess the underlying point is that adults are responsible for their decisions. People often get hooked on tobacco at a young age, before their rational capacities have matured (if they ever mature), and thus it’s more difficult to blame a person who developed the smoking habit in their teens than a 30-something. However, everyone knows cigarettes are incredibly unhealthy, quitting–though difficult–isn’t impossible, and so I think it follows pretty quickly that anyone who continues to knowingly degrade their health shouldn’t expect the rest of us to pay the inevitable health costs. Folks who come down with ailments through no fault of their own are another story–suffering from bad luck, and thus worthy of our collective support. It’s similarly just a matter of GOOD luck that I wasn’t born with a congenital debilitating defect, and thus it’s unfair to force those who are sick through no fault of their own to shoulder the entire financial burden. But those who refuse to exercise, eat incredibly unhealthily and indulge in other body degrading habits exercise much control over their condition, and thus should be held financially responsible.

Thanks again for posting–feel free to do so on other topics (or submit a rejoinder here).

Your smoking stat was so compelling, Peter, I had to set it aside for a while and reflect. And I read all sorts of overlapping agreement in your post–excellent job. But first, just a quick comment on this:

“I don’t care if they deserve it. I want to people to get health care. Period. Appeals to philosophy and tradition are worthless when you’re dead.”

That’s where we diverge. I’m interested in discovering what justice demands–what’s ethically required–not simply pushing a particular favored point of view. Indeed, we are all part of a society, and we are indeed obligated to look out for one another. But we also have an obligation to respect one another–to not take more than we deserve–to respect the lives, goals and resources of others, just as we expect others to respect us. Harming ourselves often harms others, and when it comes to incredibly expensive healthcare, consciously damaging my body and expecting finite collective resources to pay for its repair seems just as selfish as cheating the tax collector. You’re of course free to begin with a conclusion and instrumentally erect whatever argument suits it. But I hope that you’ll come to appreciate the truth, whatever it turns out to be. (Don’t mean to sound self-righteous, buddy. I appreciate your candor. I just wanted to clarify the philosoher’s mission.)

Now on to your smoking stat.

If the vast majority of nicotine addicts get hooked before they’re fully rational, we can’t hold them fully accountable for the harm smoking does their body. Once a person reaches the age of accountability, however, I think it’s OK to hold them to a higher standard–to expect them to buck up and cast aside habits knowingly damaging their health. So while smokers can’t be fully blamed for their situation, and their addiction is excusable, theydon’t get a free pass. Quilting’s incredibly hard, but it’s not impossible.

Thinking about that objection though led me to also consider environmental influences on character, and how they inevitably shape citizens’ lifestyles. Children lacking health-wise parents, adequate health education, saturated in an unhealthy culture and bombarded with unhealthy temptations are bound to cultivate unhealthy characters. Capable of second-order reflection, we rational animals possess the ability to mold ourselves–to choose the sorts of persons we want to become, complete with fresh desires, habits and perspectives. But to the extent that our rational capacities have been stunted and our our character formed, we’re stuck. So while humans are the freest of creatures, we’re still largely slaves to our environment, and especially to our upbringing. Thus, the sorts of policies I’m recommending would have to be coupled with increased health, diet and critical thinking education, and couldn’t be fairly imposed on most in the existing population.

Of course, to the extend we excuse citizens from accountability on grounds that they lack rationality and true freedom, they lose their status as free equals. But for the sake of argument, we’ll assume that truncated abilities here doesn’t bleed over into bedrock citizenship status.

Further, and this is a criticism that arose in conversation with a professor, my suggestion would unfairly punish the poor. It would grant public healthcare to the health conscious, and deny or minimize it for the willfully unhealthy, and that much seems fair. But those with money would be able to afford care regardless of their habits, which in effect unfairly punishes the poor.

One could reply by arguing that the rich deserve their wealth, and the poor their poverty. And in some cases–where a person ascends via hard work or crashes and burns due to sloth–that is largely true. But very, very often, people are rich or poor not due to ambitiousness or the lack thereof, but to inborn talents or disabilities, the families they’re born into, or good or bad fortune in the market. Since we can say that very, very few (if any) fully deserve their wealth or the lack thereof, if their ability to access healthcare without government assistance turned on their income, the poor would unfairly suffer while the rich enjoyed an unfair advantage.

Thus, we’re presented with at least three options: 1) leave the system as is, where people largely pay for their own healthcare, which absolves them from a responsibility to the rest of us to make healthy decisions, 2) adopt my original argument, base access to healthcare on citizens’ conscious health decisions, and additionally prohibit private medicine–closing the loophole for the luckily rich, or 3) provide care for everyone despite their income or poor health decisions.

All three have their drawbacks. The first unfairly leaves people at the mercy of the genetic lottery and market, the second constrains liberty by denying those with means to purchase private care the legal ability to do so, and last makes us all pay for citizens’ bad decisions.

But maybe a fourth, mixed option would be the best overall–one that provided universal basic emergency and primary care, and even advanced care, but charged those who’ve consciously brought ailments upon themselves higher premiums, to the extent that they can be reasonably held accountable for their choices. It aint perfect, but maybe it’s the most just thing we can do.

Tenaya,

Thanks so much for your very thoughtful post. I’m very sorry about your daughter. I visited your website, and she was a cutie indeed. As a father of a 2-year-old, I can’t imagine how awful that must have been (and still is). May you find peace.

Ok, so you close by stating the following:

“Everyone deserves healthcare whether they did it to themselves or not. And if they did it to themselves they need to be educated on how to break the habit or addiction. And all it takes is people putting the seemingly spare money they waste daily on frivolous items (rich and poor alike – we all do it) aside to make sure that much needed care is given to all who need it.”

I agree that preventative care is preferable to emergency care because a) it avoids the misery of illness, and b) it’s cheaper. But as far as I could tell, your post doesn’t provide any reasons for us to accept your first two sentences — that all deserve healthcare, regardless of whether they brought their ailments upon themselves or not.

In my original article I argued that since we’re committed to holding people accountable for the outcomes of their decisions, and insulating them from factors over which they have no control, we should either deny care to people who choose to place themselves at high risk for disease, or ban unhealthy options, or some mix thereof. However, after reading Chris’s points about how many of our choices are themselves functions of our unchosen circumstances (adult diet diet choices shaped by rearing before age of accountability, hooked on cigarettes before age of reason, etc), I conceded that a more fine grained policy was in order — one that could account for these contingencies, and if they couldn’t be accounted for, well then maybe universal care was the way to go after all.

But I rejected then and reject now the position that it is irrelevant why we become ill. In both your and your daughter’s cases, your ailments were the result of very bad luck — not the result of bad choices — and so even based on my original article, I think your treatments should have been covered by the rest of us, many of whom are naturally healthy as the result of fully undeserved good luck. So I’m not sure why you would conclude as you did. In any case, thanks so much for visiting, reading and writing — it’s been a pleasure.