by Gabriella Foe •
After a stressful day of work, or a frustratingly long commute home due to traffic or a crowd on the subway, no one would fault an individual for choosing to relax with Netflix instead of heading to the gym. Everyone has been found guilty of this too many times. The gym is often found to be just a little too far, a little too expensive, and requires a little too much work. But that is only half of the problem since it has also gotten more convenient to consume an unhealthy diet. Although it is cheaper and healthier to eat a home-cooked meal, it is easier and faster to purchase fast-food or take-out from a restaurant. The result is an increase in caloric intake and a decrease in caloric output—hence an increase in the rate of obesity.
Lifestyle choices such as these account for approximately 80% of healthcare costs in the United States, as stated by Dr. Harald Schmidt. What efforts should be made to decrease these costs? Can we blame individuals for not exercising enough will-power to live a healthier lifestyle? Or should we blame governments and food industries for creating a society that has made it harder to live a healthy life? Health and disease are sociological perspectives, dependent on cultural, social, and political values. Based on those values, nations put different weights on the four ethical principles: autonomy, beneficence, non-maleficence, and justice. Prioritization of these principles will determine how nations address health conditions such as obesity. Using obesity as a health problem, I will compare how a health system that prioritizes beneficence and justice will differ from a system that prioritizes individual autonomy with regards to the course of action taken to promote the health and well-being of individuals within the system.
Health systems in Europe tend to prioritize the principles of beneficence and justice; within those limits, individuals are then given the right to self-determination. Those who subscribe to this health system must recognize that they are a part of a larger community and are responsible for “pulling their own weight” to make sure that they do not become a burden to the community. Individuals are asked to consider justice as the primary ethical principle: since everyone is entitled to fair distribution of resources, each individual is responsible for making sure he or she does not use up more resources than necessary due to recklessness and poor choices. Since those who live within this health system subscribe to a more community-centered way of life, the main incentive (other than personal motivation) to care about health consequences would be how their lifestyle choices will affect others. “With great power, comes great responsibility” is the mentality behind this system: individuals are entrusted with power to make choices, but with the understanding that they will use that power responsibly.
Due to this mentality, governments are given power to ban the use or sale of food ingredients or products that are deemed unsafe or unhealthy. This is a safety net that will help individuals make more responsible choices. Although this limits individual autonomy, it is acceptable since they are acting under the principle of beneficence and non-maleficence—making sure that their citizens are not harmed by the introduction of these products into society. Incentives and penalties may also be used to influence individual choice and encourage them to form healthier habits, or act in a way that will benefit the community. With this health system, governments are given more responsibility to create environments that promote health, within which individuals can exercise their autonomy. If individuals continue to make choices that negatively affect their health, governments can be held responsible for not acting under the principle of beneficence (i.e. by failing to ban the product) and failing to do no harm to their citizens. Since they have significant control over the array of food products that can be consumed, they can focus on increasing incentives to maintain individual fitness, further promoting the health and well-being of their citizens.
This system will work only when those subscribed to it value the same principles, see themselves as part of the community, and are thus willing to give up some of their autonomy for the good of society. It is unclear what the government can do to those who continue to abuse the system, specifically those who use it to their own advantage and continue to be a burden to the system. Critics of this system will see the government as being too paternalistic, making decisions which should be left to individual choice. There is also the question of whether using incentives and penalties will be effective in influencing one’s habits.
An example of a health system which places individual autonomy above other ethical principles is the United States. Here, the burden of responsibility to make the right choices leading to a healthy lifestyle is placed on each individual. Thus, blame is also placed on individuals instead of the government. Until it was known that some were genetically pre-disposed to obesity, the obese individual is seen as someone who failed to exercise the will-power to stay healthy. Thus, there is a negative connotation associated with the word obesity; this also resulted in stigmatization of those who were obese.
Health systems which value autonomy above other principles seek to give individuals the ultimate choice to make decisions and deal with the consequences. Thus, the government is limited in the amount of regulating that it can do; too much regulation is seen as an infringement on the individual freedom to choose. To help individuals lead healthier lifestyles, the government can appeal to food industries and manufacturers to make information available so everyone can informally exercise the process of informed consent. Individuals consent to the health consequences of consuming certain food products by purchasing them. The problem is that this act of consent is not necessarily an act of informed consent, since making information about ingredients and nutrition available does not ensure that it is read or understood by consumers. When individuals are given the responsibility to make informed choices that can adversely affect their health, it is important that they are also given education and further resources to ensure understanding of the information. But more imperative is the need for individuals to care about the health consequences of what they consume; this is an essential piece that is missing from this health system, but is found in a system which prioritizes beneficence and justice.
One weakness limiting effectiveness is the inability of the government to ban certain ingredients or products that are deemed unsafe. As a result, the government must compete with food industries by incentivising individuals to choose responsibly. But the wealth and creativity of the food industry allows it to offer better incentives to individuals, making it almost impossible for the government to succeed. Thus, within this system, the government is given very limited power to affect the health outcomes of its citizens. Another way to get individuals to care about the health consequences of their actions for this health system (assuming a lack of personal motivation) still needs to be found.
Individuals have different values and prioritize ethical principles differently. Ideally, we would allow everyone their right to autonomy without setting limits through government regulations. We hope that each consumer would be responsible and make choices which promote healthy lifestyles. If personal motivation is inadequate, we would expect them to realize how their decisions affect society and act in beneficence to society. However, the world is far from ideal. Using a health system which prioritizes autonomy above other ethical principles does not maximize its ability to promote the health and well-being of individuals.
A health system which places individual autonomy within limits of beneficence, non-maleficence, and justice provides a more realistic way of fairly addressing the health needs of each individual. Those lacking personal motivation are given incentives and are encouraged to consider how their choices and actions affect others in society. Further, these individuals are unable to negatively impact healthcare costs too severely since the government has placed safety nets and banned extremely unhealthy food products. Since we cannot expect each consumer to truly be informed before consuming food products, it is more reasonable to give governments the ability to ban certain products and ingredients. Limits will be placed on individual choices, but these are reasonable limits to achieve a compelling interest.