Markkula Center of Applied Ethics

Voluntary Health Risks:
Who Should Pay?

By Claire Andre, Manuel Velasquez, and Tim Mazur

Alcohol abuse cost the U.S. health care system $85.8 billion in 1988. The tab for cigarette smoking totals over $65 billion annually. Costs related to obesity now surpass $27 billion per year.

As the government scrambles to reduce the staggering explosion in health care costs, the American Medical Association recently revealed that at least 25 cents of every health care dollar is spent on the treatment of diseases or disabilities that result from potentially changeable behaviors. Whether the cause is smoking, alcohol abuse, poor diet, lack of exercise, failure to use seat-belts, or overexposure to the sun, preventable health care costs are the first concern of many U.S. health care critics.

What motivates their criticism is overwhelming evidence that individuals with unhealthy habits pay only a fraction of the costs associated with their behaviors; most of the expense is borne by the rest of society in the form of higher insurance premiums, government expenditures for health care, and disability benefits. Lawmakers, insurers, and employers are pressing for policies that would redistribute expenses resulting from voluntary health risks to those who choose to take such risks. Proposals under discussion range from charging "health offenders" higher insurance premiums to President Clinton's Health Security Act of 1993, which included a 99-cent per pack "sin tax" on cigarettes, over four times the current rate of 24 cents.

Clear as this reasoning seems, penalizing individuals for unhealthy behaviors could result in great injustice and social harm. While 18 percent of U.S. citizens with incomes above the poverty line smoke, for example, the figure almost doubles to 33 percent for those with incomes below the poverty line. A one-dollar cigarette tax would have a strongly regressive effect on the low incomes these individuals receive. Consider the added problem of tobacco addiction and the probable result of a tax is not less smoking or lower health care costs, but fewer dollars spent on nutritional food and other essentials - conceivably leading to more illness and higher health care costs.

During this period of health care reform, citizens, politicians, and ethicists seek to answer the question: Should persons who engage in unhealthy behaviors bear the burden of the resulting costs?

People Who Take Health Risks Should Not Pay For The Resulting Cost
Those who oppose policies that would penalize people for unhealthy behaviors invoke principles of justice to support their position. Retributive justice asserts that an individual should be held responsible for the foreseeable consequences of his or her actions, except when the person is uninformed or the action is involuntary. These exceptions are important in considering voluntary health risks.

Numerous studies have shown, for example, that genetics plays an important role in determining whether a person abuses alcohol. Compulsive overeating is sometimes the direct result of psychological factors. Manipulative advertising and peer pressure often lead adolescents, whose ability to make informed choices is limited, to begin smoking; once addicted, a person's capacity to choose not to smoke is further diminished by the physiological, neurological, and psychological nature of cigarette addiction. Recent research showing a higher incidence of risky behaviors among low-income groups suggests that socioeconomic factors, such as inadequate income or lack of education, influence lifestyle behavior - people may drink or smoke because they feel hopeless or need to manage the stress of being poor. Given the powerful influence of such factors on behavior, penalizing individuals who engage in high-risk actions "blames the victims" and ignores the true cause of their behavior.

Similarly, it is unjust to hold people responsible for the costs of diseases or disabilities they could not have prevented. It is impossible to predict accurately the role a person's behavior will play in his or her health problems. Most evidence linking lifestyle and disease is based on aggregate statistical methods and is correlational rather than causal. Most smokers do not develop lung cancer, nor are all persons who develop lung cancer smokers. Lung cancer can be the result of a variety of factors, such as heredity or exposure to hazardous substances in the home or work place. To impose penalties on persons who engage in unhealthy behaviors when the links between behavior and disease are unclear is unjust.

Others who oppose penalizing risk-takers cite the principle of distributive justice, which states that benefits and burdens in a society should be allocated fairly among its members. Policies penalizing risky behaviors would impose greater economic burdens on the poor than on the rest of society. A 1990 Congressional Budget Office report shows that increasing cigarette taxes would hit low-income families more than twelve times harder than high-income families because the poor pay a disproportionate percentage of their income in excise taxes. Such policies, then, would unfairly result in more serious economic harm to persons who are already burdened.

Finally, Utilitarians argue that the overall harm of policies that penalize people who engage in hazardous behavior would exceed the overall benefit. For example, reformers want to raise excise taxes because they believe higher cigarette and alcohol prices will reduce consumption, thereby decreasing risky behaviors and lowering health care costs. Utilitarians, however, note that, while U.S. cigarette prices rose 40 percent between 1981 and 1988, demand stayed level - proof that raising prices cannot be counted on as a means to change behaviors. Higher taxes on alcohol might induce the occasional drinker to decrease his or her consumption but it is unlikely to affect the behavior of the alcoholic or the adolescent drinker, those persons most vulnerable to health risks.

Even if penalties successfully discouraged unhealthy behaviors, few savings would be realized. A person who dies from a heart attack at age 60 because of obesity is less costly than a person who maintains his or her health into old age when more expensive treatment is probable. Smokers who stop smoking and heavy drinkers who stop drinking may live longer as a result and incur additional medical expenses. And the argument that low-income smokers would most likely forgo food and basic health care to meet the costs of higher taxes or insurance premiums further demonstrates that policies meant to reallocate health care expenses would probably increase, not decrease, overall costs.

People Should Pay For Their Health Risks
Those in favor of policies that redistribute the costs of voluntary health risks base their arguments on a different view of justice. They believe that all people should be held responsible for the foreseeable consequences of their voluntary actions; therefore, people who voluntarily engage in risky behaviors should be held responsible for the resulting health care costs.

It is well-documented that certain behaviors and lifestyles are hazardous to personal health. Consuming foods high in LDL cholesterol, smoking, being overweight, and physical inactivity are the key modifiable risk factors in coronary heart disease, the leading cause of death in the United States. Cigarette smoking is responsible for 87 percent of all lung cancer cases and 82 percent of all deaths from chronic obstructive pulmonary disease. Cirrhosis of the liver, principally caused by alcohol abuse, was the ninth leading cause of death in the United States in 1990.

Disease and disability resulting from unhealthy habits like these impose enormous costs on society. Coronary heart disease, for example, costs the nation approximately $43 billion per year. According to Louis Sullivan, former secretary of health and human services, every person in the United States pays $221 annually for the health expenses of smokers alone. "Cigarette smoking has an adverse impact on every American, whether or not he or she smokes. That $221 cost comes out of the pockets of smokers and nonsmokers alike, largely in the form of increased health care and insurance costs."

Proponents of a redistribution of health care costs argue that individuals who choose to behave in ways that pose risks to their health ought to be held responsible for the consequences of those choices, including the costs of the resulting health care required. It is unjust to burden individuals who have avoided unhealthy habits with the extra health care costs of those who have not.

Others argue that society ought to adopt those policies that bring about the greatest overall social benefits and the least social harm. The number of persons who die each year of smoking-related illnesses is 419,000. Penalizing people for risky behaviors would benefit society by discouraging such behaviors, significantly decreasing health care costs, and saving lives. According to a 1990 Congressional Budget Office report, increasing the price of alcoholic beverages by 18 percent would lead to a 10 percent drop in demand and a corresponding decrease in alcohol-related health care costs. In Canada, cigarette use decreased 61 percent among teens and 38 percent overall when the price of a pack reached U.S. $4.45. When benefits such as reduced costs and saved lives are measured against the relatively minor harms of excise taxes and higher insurance premiums, society has a moral obligation to charge persons for their unhealthy behaviors.

As medical costs soar and alternative means of funding health care in the United States are considered, the question of whether society should subsidize health care associated with unhealthy behaviors is critical. In answering the question, we need to assess carefully the different appeals to justice, the benefits and harms of penalties, and the extent to which we are justified in holding people responsible for the consequences of their behaviors.

Further Reading

Dworkin, Gerald. "Faking Risks, Assessing Responsibility." Hastings Center Report (October 1981): 26-31.

Garland, Susan B. "Health Care Costs: Trying to Cool the Fever." Business Week (May 21, 1990): 46-47.

Knowles, John H. "The Responsibility of the Individual." Daedalus 106 (Winter 1977): 57-80.

Veatch, Robert M. "Voluntary Risks to Health: The Ethical Issues." JAMA: Journal of American Medical Association, 243 (1980): 50-55.

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