Ethics

ETHICS Americans despise the thought of paying someone's medical bills when that person's illness directly results from his or her risktaking behaviors. Usually the complaint goes like this: "Now, take Mr. Smith. Here's a guy with diabetes, hypertension, hypercholesterolemia, obesity--the whole nine yards. Not only doesn't he do anything to take care of himself, he smokes, eats all the wrong foods, doesn't take his medicine as prescribed, and misses doctor's appointments. Why should anyone have to pay for his health care costs when he gets really sick and needs expensive care? If he's so irresponsible and doesn't care about his health, why should somebody else have to bear most of the economic burden for his foolishness? His insurer should drop him." Although there's something to be said for that attitude, I'm going to argue that it may frequently turn out to be unfair. I'll discuss some reservations I have about a rush to judgment and repudiation of whatever responsibility we might have for the Mr. Smiths. I'm hoping that a more-tempered attitude might replace the deep-seated animosity that Mr. Smith frequently elicits from us, even though I hardly anticipate convincing everyone.

Health And Personal Responsibility In a recent article on this very subject, Haavi Morreim rightly notes that morality depends on personal responsibility. The conceptual basis for claiming that someone behaved in a morally appropriate or inappropriate manner requires the idea that the person could have done otherwise--that he or she had the free will to choose and do either the right thing or the wrong thing. People bear responsibility for their action because we believe they can exercise free will. For this reason ethicists sometimes point out that zombies or robots are not "moral agents" because they have no self-control or ability to act in any way other than the way they are programmed. This accounts for our impatience with Mr. Smith. We believe he can control his weight, glucose levels, smoking, and the like, if he really wanted to. But he doesn't. He can, but he won't. So we believe he should be the one

32TGM ~ MARCH/APRIL 1996

to suffer the economic consequences of his poor lifestyle habits.

"The conceptual basis for claiming that someone behaved in a morally appropriate or inappropriate manner requires the idea that the person could have done otherwise-that he or she had the free will to choose and do either the right thing or the wrong thing." I must say I'm not convinced either way about this argument. Questions about freedom of the will have baffled philosophers, theologians, and psychologists for millennia. We are all aware of spectacular acts of self-control and willpower; and most of us feel that, usually, people are in control of what they do. On the other hand, we are also acquainted with situations where the person(s) involved--and maybe they are us--seemed to be entirely without willpower; try as they might, they simply could not summon enough inner strength to do the "right" thing (e.g., leave a bad marriage, tell the truth, stop smoking or eating chocolates). Because I don't believe there's a definitive answer to this age-old dilemma-or at least one that I could argue for in this short article--I'll take a different tack. That tack concentrates on fairness. For starters, let's consider that Mr. Smith's critics are condemning his risk behaviors because they believe those behaviors will eventuate in serious illness. In other words, they make a probability estimate that, over time, his behaviors will bring about something nasty (renal failure, stroke, heart attack, etc.). Of course, in many cases their predictions will

be right. But in a tot of cases, they're not. Plenty of people have lived, not mildly, but extraordinarily risk-laden lives--like Winston Churchill, who ate, drank, and smoked excessively and liked to observe that you really know you're alive when you realize someone is shooting bullets at you--who've lived to a ripe old age. There are people who have smoked two packs of cigarettes a day and lived long; there are others who died of smoking-related illnesses early in life. Morreim notes that some people may have "genetic triggers" for lung cancer, whereas others are remarkably resistant to disease despite their poor health habits. Suppose two people abruptly die at age 70, except that one lived unhealthily (yet without serious illness) while the other was the paragon of healthy behaviors. Is there a moral difference between the two such that we should have revoked one's health benefits but not the other's? So one thing we might consider from the outset is how much certainty we should have in a given case about our prediction of risk materialization [i.e., that what we fear happening will happen). And notice that if we're contemplating something drastic, such as rescinding a person's health coverage because we don't like what he or she is doing, we should be fairly certain that we are making an accurate prediction.

Unreasonable Risk This brings up a related issue. At what point does a person begin to take "unreasonable" risks? Say I have diabetes, but I like to smoke. Maybe I concede that I shouldn't smoke at all. But if the issue among the critics of risk-taking behavior is cutting off my health benefits, then at what point should I let go? Might I be allowed to smoke one or two cigarettes a day, five a day, ten a day, or how many before my benefits are revoked? Don't say, "If you have diabetes and you smoke one cigarette a day, we'll stop your benefits" because, according to that way of thinking, you might as well revoke everybody's coverage. The reason is that everyone takes risks. Smoking and eating are obvious targets; but what about people who miss too many meals or don't eat enough nutritious foods, drive too

ETHICScont. fast, drink too much alcohol, don't buckle their seat belts, consume too much caffeine, shoulder too much stress, keep loaded firearms within easy reach, or work so many hours that the psychologic health of their family is endmrgered. The list of risks Americans commonly assume can be long, yet a basic assumption of our personal freedoms and liberties is that people be allowed to take risks. If the government were to regulate red meat consumption on an individual basis-for example, by requiring that each red meat purchaser submit to a cholesterol check before buying steak at his or her grocery store-Americans would scream bloody murder (and probably hire people with low cholesterol levels to purchase their meat). "But we're not talking about otherwise healthy people," the critics might say; "We're only talking about the people who are already disposed to serious illness, such as people with diabetes, emphysema, morbid hypertension, and the like."

Moral Fairness But that brings up another, very serious issue about moral fairness. Is it morally appropriate to single out a group of people and impose penalties on them (by way of threatening loss of their health care benefits) because they behave in ways that are thoroughly common among other, more healthy people? Suppose Mr. Smith contracted his diabetes as a juvenile, and let's assume that up to that point he was a healthy, happy adolescent. Clearly he was not responsible for the onset of his disease but had the rotten luck to inherit a bad set of genes. Critics of his behavior, though, now want to impose an additional burden on him. Because of a genetic misfortune over which he had no control, Mr. Smith now finds himself threatened with a substantial economic penalty for doing certain things that give him pleasure. But if, as John Rawls suggests in his famous book A Theory of Justice, a moral objective of justice is to correct the undeserved inequalities that exist in a given society, are we doing right by Mr. Smith in insisting he deprive himself of those enjoyments that offset the burdens of his disease? "But how," Mr. Smith's critics might ask, "can these so-called pleasures really be

worthwhile or offset his misery if they predictably dispose him to much greater suffering later on? If we allow Mr. Smith his ill-advised, short-range gratifications, aren't we helping to bring about a long-range disaster, such as blindness, stroke, or kidney failure, whose burdens will be immensely more painful to him and whosecosts we will have to pay?" The answer is "yes." If we only sympathize with Mr. Smith's plight and do nothing to allay his risky behaviors, we clearly are helping to invite an undesirable economic situation for ourselves and a nasty health situation for Mr. Smith. But for now, let's note that there is a sense of double injustice that awaits the Mr. Smiths of America if we revoke their health benefits because they don't maintain healthy lifestyles. That is, they did nothing to merit the initial burdens, inconveniences, and unpleasantness of their disease, but they now find they will be severely penalized for doing a few things that may be the only real pleasures they experience. One thing we might say at this point--and it is an issue that Morreim emphasizes in her article--is that revoking health care benefits when a person becomes ill or is most in need of them seems, on the face of it, remarkably cruel. If we feel any compassion for Mr. Smith at all, we must admit that we will be mildly inconvenienced by the economic burdens of his risky behavior, but he will pay the real costs in terms of experiencing the pain and suffering of a serious disease or disability. A compassionate response might suggest that the suffering he will experience one day is suffering enough without adding the additional misery of extinguishing his health benefits. How would it be if, in the interests of achieving our own economic goals, we said to Mr. Smith, "We've been telling you all along what was going to happen if you persisted with your unhealthy lifestyle. And now it has. Well, you'll get no money from us for your rehabilitation or the rest of your health care needs. You'll have to spend whatever you have, and then you'll probably wind up in a cheap nursing home." Could our conscience really rest easy with this solution? Should it?

And although this next comment will sound bizarre, R is nevertheless pertinent if we are concerned only about the cost savings that accrue if Mr. Smith had desisted from his adverse lifestyle choices--and that is, at least one research paper that Morreim cites implies that risk-taking behavior often results in considerable cost savings to a society. The reason is that when many risk takers have their strokes or heart attacks, they die within a short period of time and often around the time they retire. Consequently, they save Medicare or their pension plans considerable outlays of money that healthier, more medically fortunate people go on to enjoy. Indeed, the Mr. Smiths of the world probably are going to become ill from their disease sooner or later--perhaps sooner if they practice riskladen behaviors, later if they are more careful. Of course, there are many persons with chronic diseases who monitor their health habits scrupulously, only to have disaster strike early in their lives. The point is that someone will have to pay for those serious illness when they eventually transpire. In many cases, then, it may be a thoroughly speculative matter as to how much money is "really" saved by insistence--through the imposition of disincentives like revoking health care benefits--that persons with documented disease comply with healthy lifestyle habits.

So, What Should We Do? But that suggestion seems to point us in a direction where no one wants to go, namely, that we should be indifferent to the Mr. Smiths of the world and prepare to pay up when their irresponsibilities materialize as serious illness. Also, I have to admit that I've stacked the deck in my favor by describing Mr. Smith as having juvenile diabetes. What if he worked himself into becoming a health care disaster by doing everything he could to live unhealthily? This would really make us angry because now he'd look totally responsible for his plight. So, what should we do? First of all, no duty exists in our society to be charitable. If Mr. Smith's insurer could terminate his coverage without legal repercussions, he very well might. And that possibility needs to be acknowledged if not respected. If the objectives of the insurance industry are

MARCH/APRIL 1996 ,, TCM 33

ETHICScont. economically driven, Mr. Smith probably presents a poor financial risk that any thirdparty payor would prefer to be without. I would try to strike a moral medium, however, between the extremes of bleeding-heart sympathy for Mr. Smith's medical problems and a knee-jerk revocation of his health benefits. I would argue that Mr. Smith's risk-taking behavior should merit his having to pay a higher insurance premium for his lifestyle choices. Conversely, to the extent that he would stop smoking, lose weight, and bring down his cholesterol levels, his premiums might be considerably lowered. We also might require that as part of his insurance continuation, he enroll in a stop-smoking class or, if he receives his insurance through his employer, that he visit a professional in employee health every so often. I would want these opportunities to be available to him during work hours, not afterward when they might seem like penalties. Furthermore, I would make clear that none of these activities would be required of him--that is, his coverage would not be discontinued if he refused to engage in any of them. I'd be careful about revoking Mr. Smith's health benefits outright though, because doing so might backfire on others who are more responsible. That is, if we allow someone's health coverage to be revoked because he presents a high probability of an expensive illness, then what difference does it make if he came by that probability through genetic inheritance or through dangerous lifestyle choices? If I am at serious risk for heart disease because of a genetic disposition even though I've lived a heart-healthy life, wouldn't an insurer want to be rid of me just as he'd want to be rid of Mr. Smith? Would you sell fire insurance to someone whose house is burning down? Wouldn't Smith and I be smoldering houses, and why should it matter how we became incendiary? Like Morreim, I believe that strategies that penalize unhealthy behavior but don't ultimately revoke benefits represent a best strategy. We need to accept the fact that disease and disability will occur in all our lives and that people who make poor lifestyle

34TQM

9 MARCH/APRIL 1996

choices are not necessarily evil, nor might they have the same wherewithal to change their behaviors as other, healthier persons do? And to the extent that some of these folk did nothing to bring on their illnesses in the first place, they might deserve some special consideration. And if they utterly refuse to change their behaviors, then they are the ones who are likely to experience the greatest burden. We may have to pay more for our health insurance premiums because of their foolishness, but they will suffer most. Finally, before we revoke someone's health care benefits, we should be sure that "innocent" folks will not get caught up in our self-righteousness. Everyone takes risks. Some survive in high style; others experience disaster; and the rest muddle through. If we can't adequately predict who those folks might be, we might do better at changing lifestyle choices with gentle persuasion and some modest penalties before taking the drastic route of disenfranchising people from receiving health care because we don't approve their lifestyle choices. To do so is to risk finding ourselves or someone we love cast into the darkness of the have-nots.

Bibliography Manning WG, Emmett BK, Newhouse JP. The taxes of sin: do smokers and drinkers pay their way? JAMA 1989;261:1604-9.

C .SE READERSERVICES TM

SUBSCRIPTION SERVICES To subscribe to The Case Manager, change the name or address on your current subscription, or ask questions regarding your subscription contact: Subscription Services, Mosby-Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146; (800) 453-4351; Fax: (314) 432-

1158; E-mail: [email protected] Individuals Institutions

U.S.A. Canada* Int'l** $40.00 $62.06 $58.00 $42.00 $64.20 $60.00

9 Includes Canadian GST. 99Exclusive of Japan and India. Contact Publisher for rate and agent information

EDITORIALCONTRIBUTIONS The Case Manager encourages article queries and submissions. Copies of the Writer's Guidelines are available through the ICMA FaxBoard service. Call (501) 2279488 and request document #2280 by

selecting #8 from the menu. Address queries or submit manuscripts to: Nathania Sawyer, Managing Editor, The Case Manager, 10801 Executive Center Drive, Suite 509, Little Rock, AR 72211.

(501) 223-5165; fax (501) 223-0519.

BACKISSUES Limited back issues are available for $9.00 each by contacting Subscription Services at (800) 453-4351.

REPRINTS AND PERMISSION Morreim EH. Lifestyles of the risky and infamous. Hastings Center Rep 1995;25:5-12.[]

John D. Banja, PhD, is an associate professor of rehabilitation medicine and a medical ethicist specializing in disability issues at Emory University School of Medicine in Atlanta, Ga.

Direct all inquiries regarding copyrighted material from this publication to Associate Publisher, Journal Permissions at the St. Louis address above or call (314) 579-2808; fax (314) 432-1380. All rights reserved. No part of this publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the publisher. Document delivery of single articles from The Case Manager is available by calling Mosby Document Express | at (800) 55-

Reprint orders: Mosby- Year Book, Inc., 11830 Westline Industrial Drive, St. Louis, MO 63146-3318; phone (314) 453-4350; reprint no. 68/1/72231

MOSBY. For information on bulk quantity reprints, call (314) 453-4350.