The concept of personal responsibility in health has an odd habit of falling in and out of fashion.
Galen, the ancient Roman father of medicine, once declared it was shameful for a man to “suffer a pain in the colon” if he could have taken steps to avoid it. Victorian author Samuel Butler wrote in his novel Erewhon about a modern dystopia where the ill were treated like criminals and punished.
Personal responsibility is now back with a vengeance and has become a core element in the current political and cultural zeitgeist.
This is hardly surprising given the welter of published data which suggests that human behaviour plays a substantial role in a vast array of chronic diseases.
If you suspect this is not the case, ask your GP what would happen to your predicted life expectancy if you never smoked; drank alcohol only in moderation; exercised for a couple of hours every day; ate a balanced diet (and avoided processed meat and foods high in salt, sugar and saturated fat); avoided unprotected sex (but engaged in plenty of active, protected, intercourse); and had regular health screening.
Depending on your basic behaviour the answer could be as much as a decade.
None of this means that human action and inaction is the only cause of diseases such as obesity, lung cancer and Type 2 Diabetes. Income, wealth, education, socio-economic inequality, government policy, the availability and accessiblity of cheap or nutritious food and health services all play a part. Not to mention the substantial marketing budgets of food, beverage and tobacco industries.
Still, the claim that human behaviour plays a key casual role in disease is now beyond dispute.
After a bit of a slow start, the political establishment has started to react to this, and with a fair degree of urgency.
Until relatively recently the primary health policy solution was to provide more health information for the general public. Recent efforts to inform consumers about the calorific and nutritional quality of food and drink show this is still partly the case.
But given the relentless rise of chronic diseases – the rate of adult obesity in the UK has increased from 16% in 1995 to 26% in 2010 and might reach 55% by 2050 – more radical measures are being adopted. Perhaps the most interesting and controversial are “risk tax” policies; Hungary and Denmark recently pioneered taxing higher fat foods - though Denmark subsequently u-turned.
A number of other countries, such as Peru, are considering bringing in their own versions of a the tax.
There is nothing new about taxing products which can harm health. King James I was an early enthusiast. In his Counterblaste to Tobacco he described its consumption as:
A custome lothsome to the eye, hatefull to the Nose, harmefull to the braine, dangerous to the Lungs, and in the blacke stinking fume thereof, neerest resembling the horrible Stigian smoke of the pit that is bottomelesse.
More to the point, he also presided over the levying of an excise tax on tobacco products – something which, along with the taxation of alcohol, is now routine.
However, two things are new about risk tax policies. First, the scope of tax policies have been extended from the old “sins” of smoking and drinking to the new “sins” of unhealthy eating.
Second, the rationale for imposing taxes has partially and subtly changed too. The traditional reason for taxation was to decrease consumption - though the increase in the tax man’s coffers was probably never just an incidental. The goal was better public health and the underlying rationale was more than just faintly utilitarian and paternalistic.
This is still true to an extent. However, Vicktor Orbán, Hungary’s right-of-centre prime minister, defended his “junk food tax” in a very revealing way. “Those who live unhealthily have to pay more,” he said.
Orbán’s comment suggests his rationale has more to do with the distribution of economic burdens and the concept of distributive justice, in which rewards and costs are fairly shared between everyone.
A number of left-of-centre political philosophers and economists, such as Cappelen and Norheim, have also recently defended risk tax policies on the basis of a theory of justice known as luck egalitarianism. These academics essentially claim that society doesn’t owe its resources to people who suffer negatively from choices that they are morally responsible for. Instead, they should pay their own way. Translated for healthcare, this theory of fairness recommends taxing risky behaviour such as smoking.
Of course, not everyone is happy with this approach. Some on the political right, especially those of a libertarian persuasion, cry foul and point aggressively at an overreaching nanny state. Some on the political left, meanwhile, argue that these taxes effectively penalise the poor and may even prevent the most disadvantaged from engaging in their favourite “vice”.
An awful lot of people will also dispute the implicit claim that people are sufficiently morally responsible for their ill-health to bear the costs of dealing with it.
Corporations, wherever they might sit on the political spectrum, will not be happy either. Denmark’s fat tax policy was aggressively criticised by the business community - criticism which seems to have helped to bring the policy down. More generally, neither the tobacco nor the alcohol companies have ever been exactly enthusiastic about taxes on their products and they are likely to fiercely resist further taxation.
Nonetheless, the underlying luck egalitarian rationale for tax is elegant and, for public health paternalists, there is also growing evidence that the high rate of tobacco taxes is a key contributor in the decline in the prevalence of smoking in the UK and elsewhere. Perhaps, then, it is time we faced taxing risk head on.