Medical Morality

It’s been interesting to watch Hawaii raise cigarette taxes, this time to cover the budget gap. Usually, such sin tax increases are tied to arguments that the money raised will go to cover health care services, something the state has done before. This is all part of a national pattern, Hawaii is no different from any other American state on these issues. My lunchtime Web browsing took me a corner of the CNN.com site where Jack Cafferty discusses the latest move to raise cigarette and junk food taxes to raise money for national health care reform. Cafferty pointed out that such tax moves can be controversial, something we’ve seen locally with the recent hikes of cigarette taxes.

What caught my eye was this comment, posted there by “Mark,” which reminds me of everything I find most disturbing about the health care debates:

What is the controversy? Those who persist in creating a health care crisis by ingesting crap into their bodies should pay for their vices. Why should I, as a non-smoker, non-drinker, gym-goer pay higher health care costs for the indulgences of the mindless?

Well, sure, Mark. Hope your active lifestyle doesn’t include an injury from all that gym-going, or an accidental fall while hiking, or a tumble off a ladder you forgot to brace properly. Because the funny thing is, once we start looking for reasons why people don’t deserve the health care they need, there will be no end to the inquisitions.

I wonder if people like Mark realize how much they sound like Republicans from the 1980s and 1990s, grumbling about “welfare queens?”  The complaint then went like this, “Why should I have to pay for this person’s bad choices? I didn’t tell them to drop out of high school, have three kids out of wedlock and take up a crack habit!” This made so much moral sense that, under President Clinton, welfare was dramatically reformed so that it would not be an unending river of money for people making bad choices.

A lot of people are invested in the idea that moral living yields health and that health is a civic duty we owe each other. Why do they think it’s a civic duty? Because the cost of health care is paid collectively—now through insurance premiums and socialized programs such as Medicaid, perhaps in the near future through a universal single-payer scheme. As long we are paying for each other’s health care, of course we think we have a right to tell each other how to live.

Whether your contempt runs toward lazy welfare recipients or obese smokers, the only way out of the “Why should I pay for your bad choices?” conundrum is to have everyone pay for themselves. This draws the most direct line between a person’s choices and the true cost—moral or financial—of those choices. Then the Marks of the world should have no objection. Except, what I’ve just described is also known as free-market, cash-and-carry medicine, and we can’t have that. The prevailing sentiment is that it would be unfair and immoral, because some people can’t afford health care, which is something everyone has a right to. Unless they’ve been mindlessly indulgent, as Mark puts it.

So—we seem to be stuck with these people who would ration health care on the basis of moral worth. How certain can they be in their judgments? Some people do work quite hard to have the health problems that plague them, but treating this as an absolute law of nature is irrational and unscientific. Despite our arsenal of laboratories, MRI machines and electron microscopes, science does not always know why some of us get sick and some of us don’t. Even smoking refuses to prove the morality-equals-health equation. Lethal as it is, it kills some of it habitués, but not all, not even most of them. On what basis does lung cancer decide who gets a tumor and who does not?

Still, the Marks of the world would build universal health care on the foundational belief that the health care crisis is created by people who deserve to be sick. How could this build anything other than an institution more effective at punishment than healing? That’s what makes me so anxious—when I see a comment like Mark’s, I’m more and more convinced that punishment is actually the goal.