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
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
People Who Take Health Risks Should Not Pay For The Resulting
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
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
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
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
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.