Monday, December 12

"The State has no business in the kitchens of the nation"

This article from the Times of London is disturbing for more reasons than I can articulate in a single post. The salient passages are:

One of Britain’s leading surgeons has called on the government to introduce curbs on the sale of alcohol, limiting the amount that customers can consume per visit to a pub or bar. John Smith, president of the Royal College of Surgeons of Edinburgh, believes that such restrictions would be the logical next step to improving the nation’s health following the ban on smoking in public buildings.

. . .

If, as a nation, we are serious about trying to prevent illnesses associated with social habits, then this is something that must be considered seriously.

. . .

Last week the National Institute for Clinical Excellence (Nice), which advises on the cost effectiveness of providing treatment on the National Health Service, said patients who endangered their health by smoking, gross overeating or heavy drinking should be denied medical treatment.

These passages are a good illustration of some questions I posed to the then Conservative Party Shadow Health Minister, Dr. Liam Fox, at a question and answer event. Unfortunately, I was detained at work and was unable to attend the actual event, so I have no idea if Dr. Fox responded to my pre-submitted questions. I am going to use this opportunity to pose the questions again to the general (and generally nonexistent on this site) reading public. If anyone has any comments, I would be very interested to hear them.

Without further ado, the questions:

"To what extant does nationalised health care insurance (1) create a moral hazard, and (2) give the government an excuse to interfere in the otherwise private choices of citizens to engage in risky activities?

"To expand the first part of the question, to what extent does the knowledge that they will not have to pay directly for medical procedures affect the choices that individuals (especially those in lower tax brackets or who are exempt from paying taxes) make when it comes to engaging in, or failing to abandon, behaviour that will seriously affect their health in the future, such as smoking, poor diet, and lack of regular exercise?

"To expand the second part of the question, to what extent does the fact that the financial costs of health risks are spread across the entire population and are not borne disproportionately by those who engage in high-risk activities (such as smoking, using drugs, cycling without a helmet, eating fatty foods) give the government an excuse to legislate against the otherwise private choices of individuals who enjoy these activities? In other words, does a nationalised health care system result in a significant increase in governmental regulation of other, tangentially related spheres of activity? If so, is there any way to avoid this while retaining an NHS-style system? Well, those were the questions as posed two years ago (with a few British-to-American spelling changes)."

The Times article certainly illustrates some of the concerns underlying my questions. I find the proposal from NICE (now doesn't that provoke a nice Orwellian chill) particularly galling. It is certainly another example of who the transformation of medicine from a treatment-oriented profession to a public health-oriented profession has profound implications for individual liberty and personal responsibility. One hears of physicians sometimes developing a "god complex," but in this case an entire profession seems to ooze ambitions worthy of a divine pretender. Without even probing the political, social, or moral quagmire that is the public health debate, the practical objections to NICE's policy are legion. Off the top of my head, I can think of at least five questions that I'd like to hear NICE answer:

1. Who would have the authority to withhold treatment? An individual physician? A hospital? The entire NHS?

2. Would there by any appeal process? And, if so, wouldn't that create an administrative nightmare and entail the further expansion of an already bloated NHS bureaucracy to create a quasi-legal system?

3. Would there by a requirement that a decision to withhold treatment be based on solid, proven evidence? How would a physician ever know this? How would he know if an alcoholic patient has been drinking, assuming the patient showed up sober for appointments? Smoking and overeating would be even more difficult to prove. And there is the question of causation--how does a doctor know that a patient's lung cancer is due to four decades of smoking rather than four decades of inhaling solvents at his factory job?

4. Why single out smoking, drinking, and overeating? Why treat people who don't wear seatbelts? Or speed? Or play dangerous sports? Or engage in high-risk sexual practices? Why provide abortions to women who had consensual sex? Each of these activities involves the same sort of choice that as smoking, drinking, and overeating, and involves a likelihood or certainty that taxpayers will have to cover the costs of resulting medical treatment. I think it is a fair question to ask why the NHS should deny treatment to an alcoholic suffering from liver disease but continue to provide expensive drugs to a man who contracted AIDS through unprotected sex? (I mean, of course, "[i]f, as a nation, we are serious about trying to prevent illnesses associated with social habits.")

5. Are they serious? Would they really stand by as an obese man collapsed and died of a heart attack in an emergency room? Of course not. This is all self-indulgent moral preening.

At least someone in Jolly Olde seems to have retained an ounce (or its EU-mandated metric equivalent) of common sense. The article ends with the following observation:

Paul Waterson, chief executive of the Scottish Licensed Trade Association, said such a ban would be unworkable. “One thing I found during the smoking debate was that some of the medical profession lack common sense when it comes to dealing with real issues in the real world,” he said. “The idea of restricting the number of drinks is unworkable, impractical and would erode personal freedoms.”

Pretty much sums it up.


Anonymous Anonymous said...

H - it sure is good to have you back. The years 2002-2005 have seemed much darker in your absence. Although I must say that after three years away I expected more from a first posting than a fairly superficial analysis of why Tookie must die. I was hoping for some sort of intelligent view from the right about the current state of American foreign policy (perhaps the sort of thing Christopher Hitchens might write if he ever sobered up) or the state of things in Israel, where even your pal Sharon seems to have abandoned the dead-end Likudnik dream.

As to this posting, as an initial matter I note that the New Yorker had an interesting article analyzing the question of moral hazard in the context of national health insurance. It might be tough to pull yourself away from high-brow reading like the New York Sun (if that rag even still exists), but I'd recommend the New Yorker piece on this question.

You are obviously right that the position espoused by NICE in the Times article is laughable and morally indefensible. But with respect to the greater question of moral hazard, I find it hard to believe that you're seriously raising the question of whether a national health system encourages people to engage in risky behaviour that they'd otherwise avoid if forced to deal with their own medical expenses. For the love of God, man, you live in the United States - how can you even ask whether being faced with his or her own medical expenses will affect one's actions in terms of, for example, diet and regularity of exercise. Yes, clearly the lack of national health insurance has made Americans, and in particular the poor and uninsured, paragons of a healthy lifestyle, eschewing fast food at all costs and exercising regularly. The question you raise fails the laugh test.

The simple fact is that the specious linking of hazardous lifestyles to effective national health insurance is a typical conservative red herring, unsupported by facts (and by any reasonable view of the world around us), but sufficiently compelling as a sound-bite to gain some currency in the world of Fox News (and, probably, the New York Sun).

12:09 PM  

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