Endogenous Disability

I recently came across a news story about a British legislator who proposed that patients suffering from life style illnesses, medical problems mainly due to behavioral choices such as being overweight, ought to have to pay for their own medicines rather than having them provided for free by the National Health Service. It is a proposal that I expect will provoke strong responses both against and for. 

It is also one that raises the more general issue of to what degree problems people have do or do not deserve our sympathy. Much of the support for policies that favor disabled people, public and private, comes from the assumption that disabilities are entirely exogenous, have nothing to do with choices the victim made, and so are entirely undeserved. In many cases that is surely true; birth defects are a clear example, injuries from accidents or military action only a little less clear. But not in all.

The first case that comes to my mind is a legally blind woman who was a new member of a group I was part of that had weekly meetings. For a while after she joined she succeeded in getting one person or another to stop by her home, pick her up, and drive her to the meeting. Eventually she ran out of people willing to do that—and started taking the bus instead.

Her disability was real; although she was not totally blind, it was clear that she could not see nearly well enough to drive. But how disabled it made her, how much it limited what she could do and thus to what degree it made her dependent on the help of others, was in part a matter of choice.

A clearer example is one that I have repeatedly observed, usually at science fiction conventions—people in powered wheelchairs who are very much overweight. I expect that in some cases the weight is a consequence of the disability—less exercise and less opportunity to do pleasurable things other than eating. But I suspect that in many others the causation went the other way around. Someone who could get around reasonably well on his own legs if he weighed a normal 150 pounds might find it very difficult at 300 pounds plus. For an extreme example in the other direction, I have one friend with cerebral palsy who walks with some difficulty; not only does he manage without a wheelchair, his hobbies include an active involvement in martial arts.

Looking at the matter as an economist, the logic of the situation is clear. If someone  makes choices that effectively disable him and pays all of the resulting costs, he presumably believes that the benefits are sufficient to justify that cost. But if a substantial part of the cost is born by others, whether taxpayers or sympathetic individuals, that is no longer true. Just as in other cases of externalities, the individual may find it in his interest to take actions that make him better off but make him plus the others affected worse off.

Looking at it from the standpoint of an individual judging those around him, something all of us do although some of us are reluctant to admit it, I get a similar result. I have no objection to someone who smokes in his home, even though it may shorten his lifespan—that is his decision to make. If someone chooses to be massively overweight and is willing to tolerate the resulting costs, there is no good reason for me to think less of him; I may be puzzled at his choice, but  my own experiences with the difficulty of losing weight and keeping it off suggest that perhaps it is even harder for him. But if someone both chooses to make himself to some degree disabled and expects other people to go to some trouble to compensate for that disability, I feel much less inclined to assist him.

Getting back to my original example of the proposed change in British health care policy, however, it is not clear just how the logic of endogenous disability can be dealt with in a governmental system such as the National Health Service. There is a serious problem of lack of bright lines. Many sufferers from type 2 diabetes, an example mentioned in the news story, may have it because they choose to be greatly overweight, but presumably not all. Similarly in other cases.