“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.

“Approximately 90 percent of all smokers start before age 18; the average age for a new smoker is 13.”

This would suggest that people who smoke almost never make conscious rational decisions to do so. 13 year olds simply do not have the ability to make rational choices, and once you are addicted, conscious rational choice goes out the window.

People know that smoking is bad. People know that eating fast food is bad. People know that riding motorcycles without helmets, or not wearing seatbelts, or any number of things entails risk. Ad yet they do it anyway.

If the possibility of dying from lung cancer isn’t enough to stop people from smoking, I don’t think that an insurance rate increase will do much either. When it comes to people health, the moral hazard arguments are much different from those in the realm of, say, finance.

There are two main issues that health care reform must deal with, and they are related to a degree.

The first is universal coverage. There is absolutely no doubt that our country can afford it. Every other western, industrialized country has done so, and it works. It may or may not be deficit neutral, but that is beside the point. For the people who think that America is based on some sort of rugged individualism that precludes us from doing that, no matter how much we’d like to, my answer is that if you think that, then you should change your mind. Because real people are dying out there, every day, because of our insistence in clinging to some ideal where no one gets health care they don’t deserve.

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.

The second issue is how to make such a system more efficient. And here there is room to debate. We should be actively looking around the world to see what works. We should not be reflexively ruling out methods of delivery because they are government-run, or because they are socialist, or because the French do it. I won’t get into the details of what I think should be done, but I will say that a large number of people in this country automatically rule out certain methods of delivery on purely ideological grounds, and that is unfortunate. They never bother to look at options objectively.

To get back to the point of the article, I agree with your general conclusion. A society should look out for its members. It should provide for their health care, if it can. If it can find ways to convince them not to kill themselves through unhealthy consumption, it should. It should do this in ways that will not restrict peoples’ rights, but it should take into account the externalities imposed on society by their behavior.

Like it or not, we are all part of society. You don’t get to “opt out”. That’s just not how humans are made. We should keep this in mind when we talk about the supremacy of individual rights. Let’s work together on this to help those who need it, and to do it in a way that won’t bankrupt us. Let’s confront reality, and not fight demons that don’t exist. Let’s be human.

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).

Seriously? Have you ever actually met a smoker?

I’m a smoker. I hate everything about my habit. If it was “not that difficult” to quit I would have done it long ago.

I realize in your post you assume that educated adults make rational decisions about smoker. Do you really believe that? Do you actually think people wait until they’re 21, get out their Consumer Reports article on smoking, and make an informed decision about whether to start?

This myth of the rational consumer, or the rational economic creature in general has been demolished. You should get your blog up to speed on that.

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.