Sunday, May 29, 2011

Has preventative health care become code for paternalism?

‘The Taskforce says that prevention is everyone’s business – and we call on the state, territory and local governments, on non-government and peak organisations, health professionals and practitioners, communities, families and on individuals to contribute towards making Australia the healthiest country by 2020.’ (Extract from ‘Taking Preventative Action’, the federal government’s response to the Report of the National Preventative Health Taskforce).

I find the sentiments in the quoted passage objectionable for two reasons. First, preventative health care is not ‘everyone’s business’. Individual adults have primary responsibility for their own preventative health care because no-one is better able to exercise that responsibility than they are. Individuals who are persuaded that preventative health care is a collective responsibility could be expected to look increasingly to the various levels of government, non-government organisations, health professionals and practitioners, communities and families – everyone except themselves - to accept responsibility for what they eat, drink and inhale.

Second, the goal of making Australia the healthiest country by 2020 is being put forward as though it is self-evidently desirable collective good that should be pursued by any and every means available to everyone. The goal is not self-evidently desirable. Individual health is not a collective good. And the end does not justify the means that are being proposed to pursue it.

If you delve behind the spin about making Australia the healthiest country my 2020, the underlying goal seems to be to raise average life expectancy in Australia to the highest level in the world by reducing the incidence of chronic disease. What does this entail? It would be hard to object to the goal of enabling individual Australians to reduce their risk of chronic disease. The problem is that the government’s strategy is more about achieving national goals than providing better opportunities for individuals - more about behaviour modification than about ‘enabling’ individuals to reduce their health risks.

The government claims that analysis of ‘the drivers of preventable chronic disease demonstrates that a small number of modifiable risk factors are responsible for the greatest share of the burden’. The behavioural risk factors led by obesity, tobacco and alcohol apparently account for nearly one-third of Australia’s total burden of disease and injury. The chronic conditions for which some of these factors are implicated include heart disease, stroke, kidney disease, arthritis, osteoporosis, lung cancer, colorectal cancer, depression and oral health problems.

Since these risk factors stem from individual lifestyles it is obviously desirable for individuals to be aware of them. There may be a role for governments in provision of this information. Perhaps governments should also be involved in helping people in various ways to live more healthy lifestyles. It is questionable how far governments should go down this path, but it is difficult to object to modest efforts by governments to improve opportunities for people to live healthier lifestyles.

However, rather than helping people to help themselves the federal government has chosen the path of Skinnerian behaviour modification. It has chosen to drive changes in behaviour through what it describes as the ‘world’s strongest tobacco crackdown’. (This is one instance when I hope the government doesn’t actually mean what it says – some people in Bhutan have apparently been jailed recently for possession of more than small amounts of tobacco products.) The government’s strategy also involves ‘changing the culture of binge drinking’ and ‘tackling obesity’, but in this post I will focus on smoking.

Some of the tactics being used in the tobacco crackdown involve information and persuasion but there is also an element of punishment involved. The tobacco excise has been increased to over $10 for a packet of 30 cigarettes and legislation is proposed to require cigarettes to be sold in plain packaging. It seems to me that this amounts to persecution of smokers and their families. It will reduce the amount of household budgets available to be spent on other products and encourage some to avoid excise by obtaining tobacco from illegal sources.

As a former smoker, I am probably more strongly against smoking than most people who have never smoked. I encourage other people to quit smoking and discourage young people from taking up the habit. But having given up smoking several times, I know how hard this can be. Governments have no basis on which to judge that people are not in their right mind if they consider that the pleasures they might obtain from additional years of life are not worth the pain of giving up smoking.

In my view this question of whether smokers are capable of judging what is in their own best interests is at the crux of the matter. The politicians and bureaucrats who seek to modify the behaviour of smokers may see themselves as enhancing the capability of these people to have lives that they ‘have reason to value’, in accordance with well-being criteria proposed by Amartya Sen. If so, their attitudes highlight a major problem with Sen’s approach. Governments have no business deciding what kinds of lives individuals have reason to value.


Thought Bubble Ten said...

It does seem that dictating what pleasure (or vices) an individual is allowed impinges on their personal freedom. However, when weighed against the drain on resources that sick individuals create, there might be reason to safeguard the common good, no?

It's a tough one like so many others that expose the tension between the freedoms of some and the freedoms of all.

Winton Bates said...

Thanks for raising that point, TBT. I was thinking about covering it in the post. I don't think it has been established that smokers actually do impose net costs on the rest of the community via the public health system. They impose higher costs through smoking related illness, but since they don't live as long this would be offset to some extent by lower public spending on other illness that they would otherwise suffer as they grew older.

It is also worth noting that smokers paid substantial excise prior to the recent increases.

My more general comment would be that if our public health system enables people whose lifestyles involve greater health risks to impose costs on the rest of the community, then perhaps we should be thinking about how the health system should be reformed to cover all those risks, rather than just picking on smokers.

Thanks again for giving me the opportunity to cover that issue.

Thought Bubble Ten said...

I'm all for reforming the health care system according to your reasoning. I mean, you could easily argue that people who refuse to exercise or are obese or do manual labour involving repetitive movements or who work in highly stress related jobs are also a potential burden to the health care system. Why stop at smokers? :)

Winton Bates said...

I think I agree, TBT. My reason for hesitation is that I am not sure about the costs of basing health insurance premiums on lifestyles. Calculating the additional risks associated with particular lifestyles would be the easy part.

In the case of risks associated with obesity it would be fairly easy to weigh and measure people to calculate a body mass index. The problem with smoking and drinking would be in establishing that people are actually maintaining a particular lifestyle, without excessive monitoring costs. I have a vague recollection of having read somewhere that in some part of the world some religious groups have been able to negotiate lower premiums from private health insurers because their members have healthy lifestyles.

Thought Bubble Ten said...

'The problem with smoking and drinking would be in establishing that people are actually maintaining a particular lifestyle'

Why is it a problem? The cost? Or something else?

Winton Bates said...

There is the cost of monitoring and also the willingness of people to be monitored. I don't know a great deal about either factor. If health insurance companies offered discounts to non-smokers and non-drinkers I don't think invasion of rights would be an issue. It seems fairly enough that if people want the discount they agree to the monitoring.

The way I see it, the best way to approach health insurance is set up a framework in which competing health insurance companies have incentives to offer the service at minimum cost. Government subsidies would be provided for those unable to afford private insurance (because of pre-existing health problems as well as low incomes). You would let the insurance companies decide premiums, discounts, no claim bonuses etc.

I think the Swiss may come close to a system like this. But I don't know whether they offer discounts for people with healthy lifestyles.