I am writing this on an early train to Manchester. Not a bad time to see what people enjoy for breakfast. The woman opposite is eating one of those lovely looking pastry ropes wound full of chocolate chips and dusted with icing sugar. Although it is not a doughnut, inevitably I am reminded of the comments by Philip Lee, Tory MP for Bracknell, to the effect that if people eat deep-fried dough for breakfast they should pay for the health consequences. Given that we now know the years of austerity are going to drag on just that little bit longer why not shift some of the financial burden of healthcare to those who have a hand in their ill health?
Dr Lee’s comments are unlikely to endear him to a large swathe of the electorate, but there is no harm in identifying a few obvious truths in his comments. Taking responsibility for our health is straightforwardly a good thing. Decisions about what to eat and how much exercise we do are ours and ours alone and if we make good choices our health is likely to flourish. Dr Lee is also concerned about moral hazard: if the costs of our choices are borne by others, we are less likely to behave virtuously. Hand people back the costs of their choices and people are more likely to take responsibility for them. It feels like there is some truth here too.
There are though some obvious challenges for Dr Lee. The work of Michael Marmot and others has identified beyond doubt the social gradient in health. Yes we are all responsible for our choices, but stepping back a little, how do we make sense of the other truth that, viewed in the aggregate, our social position constrains our choices? The idea that the less well off are not responsible for their lifestyle choices is patronising twaddle. (The gyms of South London where I live are full of people not obviously born with silver spoons in their mouths and whose health I can only envy.) But it is also true that environments act as a drag on choices. Those who swim against a stronger tide generally don’t get as far. It seems we have to try and hold truths together that sit uncomfortably with each other: that we are free to make choices but our choices can be powerfully constrained.
Moral hazard also has its problems. It looks like a nice truth but how do we account for the poor health, the obesity, and the diabetes among poor Americans who do not enjoy our universal health coverage? Moral hazard emerged from economic theory, but it is not clear that people behave as rational actors in these things. Handing people the costs of their actions in constrained environments does not obviously make them virtuous: it seems further to compound the vicious interplay of poverty and ill health. Given that it is economic theory we are talking about, a more compelling example of moral hazard emerged during the credit crunch: recall the impotent rage of taxpayers forced to carry the can for financial risk-taking by banks. The innovators took the rewards and our public services are still being eviscerated by the costs.
When we are talking about the allocation of health goods we are obviously in the realm of distributive justice. And when it comes to justice the concept of desert, of people getting what they deserve, is usually somewhere in play. As everyday moral agents we are compelled by it: we feel that the guilty deserve punishment, that effort should be rewarded. Step away from the morally fraught question of the diseases of lifestyle and we all know that health is a lottery: genetics, calamitous accidents, infectious disease; we are not obviously responsible for these things. And here lies the moral genius of the NHS: the NHS is a risk pool mitigating against naturally occurring misfortune, insuring us against illness that we do not deserve and which could otherwise shatter our life-chances.
In the fading dichotomy of British politics, those on the right, like Dr Lee, have tended to concentrate on personal responsibility. Those on the left, more concerned with equality, have looked towards the social determinants of our actions. It seems to me that both these truths are partial. Honestly confronting the major public health challenges arising from the diseases of lifestyle must start with grasping the difficult truth that we are both free and determined in our choices.
Talking about these things to doctor friends also brings up the practical side of all this. Doctors are trained to diagnose illness and to treat or refer accordingly. Confronted with extremely ill patients are they now going to have to look into their souls and decide whether they also deserve the treatment? Is Solomonic wisdom going to be added to the long list of excellences required of a good doctor?
Julian Sheather is ethics manager, BMA. The views he expresses in his blog posts are entirely his own.