Tuesday, November 27, 2012

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.


Anonymous said...

Where does this reasoning stop? Is a WV coal miner choosing an unhealthy lifestyle by taking a mining job (instead of, say, abandoning family to work in a safer environment elsewhere?

Does choosing to live in CA mean that dying in an earthquake collapse is a personal fault which doesn't deserve sympathy?

Driving is a choice with inherent dangers. Perhaps that car accident victim should have changed careers for a telecommuting position, or moved to a walk able city. But then, city dwellers consume, on average, more pollutants, and are (in some places) at greater risk of crime, so...

Eventually, this gets down to problems with proposals for a la carte insurance. Slice the risk pool thin enough, and it makes no economic sense, in either one direction or the other.

Xerographica said...

"I may be puzzled at his choice"

Speaking of "puzzling" behavior...here's the concluding paragraph from Peter Leeson's recent paper...Law, Economics, and Superstition: Human Sacrifice...

"It's unnecessary and, I would argue, unhelpful, to approach the institutionalized purchase and ritual slaughter of innocent persons by abandoning rational choice theory. Not only does such abandonment leave one of history's most well-known and intriguing institutions unexplained. It suggests that puzzling human behaviors and practices are beyond the power of economics to illuminate."

Economic imperialism into the study of religion is one of my favorite subject areas. So if you get a chance...I'd really enjoy reading your review of Leeson's paper.

William H. Stoddard said...

I mentioned this issue to my girlfriend; as science fiction fans, we know a number of people with high body weight, and one or two who smoke. She asked something I wouldn't have thought of: What about health care for people who engage in sports? Her niece was on her high school soccer team, and had leg surgery more than once, which her parents paid for. In the UK, I suppose the NHS would have paid for it. I haven't heard of any outcry in the UK for leaving athletes out in the cold for health care (I edited a book on bioethics last month that discussed attitudes toward overweight people and smokers)—and yet, apart from cultural biases, engaging in certain sports is raising your expected health care costs just as much as smoking is. I'd be interested to see someone arguing for this being discriminatory treatment.

(I posted about this over on livejournal not long ago. . . .)

jdgalt said...

Like other forms of discrimination (or elitism), holding people responsible for the health results of their own choices would be a lot more acceptable if a private insurer does it than if government does it -- especially if the profession of medicine were not licensed in a way that has been so captured by the doctors that they are all effectively a cartel.

It seems to me that many of the loudest advocates of socialized medicine see it as a means to be able to dictate most of our private choices, whether of food, drugs, or exercise. This must not happen, and the parts of it that have already happened must stop.

As far as the causes of fat: I'm in the camp that says it is mostly something the person could not have helped. Where there isn't a preceding medical cause such as allergies, it's usually the result of tastes such as not liking vegetables, which one is born with.

Certainly the nannyist camp keeps redefining "obese" so as to include just about everybody, and coming up with pejoratives like "pink slime" to use as the target of each week's new phony emergency. We all need to stop listening to people like that, and to media that do.

William B Swift said...

>engaging in certain sports is raising your expected health care costs just as much as smoking is.

More, probably much more. There were estimates I saw about a decade ago that suggested smokers actually have reduced lifetime healthcare costs, because they die earlier.

jimbino said...

The greatest costs to society are those caused by wanton breeding, defined as bring into the world a pentelinho whose upbringing costs others a pretty penny--in Amerika, some $15,000+ per year.

Sure, smokers pollute my air, fatsos take more than their share of airplane seats, but it is the breeders that not only cost me a bundle to support their brood, but whose brood irritates me constantly in the grocery store, in Walmart or on the airplane.

They are also a burden on the air, water and wildlife of the entire planet.

I'd rather pay my taxes to put birth control in the world's water than pay for them to inflict misery on everyone.

David Friedman said...

"The greatest costs to society are those caused by wanton breeding"

It is not at all clear that producing another child has net external costs--external to the family that chose to produce him. That was part of the topic of my first piece of published economic research, a pamphlet I wrote for the Population Council. It's webbed:


So far as the costs to the parents, they have chosen to bear them, presumably because they think they get a benefit that at least pays for them.

John Fast said...

Hey, everyone, I have an M.A. in economics and I also do excellent Tarot readings. :-P

Eric Rasmusen said...

An interesting case is that of the Down's Syndrome child. I've heard that some people moralistically criticize the parents because they didn't kill the child before it was born.

Mike L said...

It appears smokers do cost less in the long run... http://www.nejm.org/doi/full/10.1056/NEJM199710093371506