Thursday, January 03, 2008

Gracchi responds on the NHS and lifestyle choice

Gracchi has some criticisms of my post on the NHS and lifestyle freedom. I don't think any of his criticisms stand up to scrutiny. I'll take the risk of pulling some sections of his post out for brevity's sake. I'm sure he'll correct me if I've taken anything out of context or missed important arguments.

"Those who support the NHS and support drug legalisation today often overlap. Whereas those who want to privatise the NHS and support drugs being illegal often overlap as well."

This is certainly true. A prime example, that I mentioned in my post, is the Liberal Democrat party that both aspires to be liberal, in the libertine sense, and also to support the NHS. People are quite able to hold positions that make their other positions untenable in practice. They'll be frustrated if they ever try to put their policy platform into effect over the medium term but that's not a concern for a Liberal Democrat. Equally, there are plenty of reasons other than lifestyle liberalism to support NHS reform - better results for example. Gracchi misses the point I was making: not that supporting the NHS makes any given thinker less liberal with respect to lifestyles but that the existence of the NHS makes it harder to sustain lifestyle liberalism in practical politics.

His explanation for illiberalism is the 'yuck' factor. This could be important at the margin but I don't think it can really be the driving factor behind bans. If it were why would there be a new crusade against the relatively attractive behaviour of middle class drinking?

People need to rationalise their beliefs and the 'yuck' factor therefore requires rational justification. I've seen, countless times, the cost to the NHS of a particular behaviour used as justification for a prohibition on that behaviour, a ban on advertising or a new tax. Even if some people are just disgusted by the obese and using the cost to the NHS to rationalise the ability to do so is still important. Rational debate is still relevant to politics even if it is, too often, bent out of shape.

"Matt misunderstands wilfully Mill's argument and consequently misinterprets the zone of Mill's freedom. Mill's concept of freedom is very tricky to understand- but if it were as Matt suggests inclusive of all actions that affected others in any way, the area of free rights would be tiny. Afterall all our actions in some ways effect others- even actions taken in complete privacy- a choice of job afterall effects others sometimes more than a choice of lifestyle does (even in a system with an NHS)."

This seems to be an argument that I should be wrong rather than an argument that I am wrong. Gracchi's criticism is the one that makes Mill's sphere rather weak in theory. However, the harm principle, as summed up by Mill himself, is pretty much exactly how I expressed it:

"The only part of the conduct of anyone, for which he is amenable to society, is that which concerns others. In the part which merely concerns himself, his independence is, of right, absolute. Over himself, over his own body and mind, the individual is sovereign."

It is highly imperfect. All of our decisions do affect others in some way. If I am unhealthy and die as a result then no matter the healthcare system others will be affected as they will feel bad, if only for a short while. However, that weakness has not prevented the harm principle becoming vital to effective liberalism. Non-financial externalities that affect friends, family and other close acquaintances tend to be socially internalised in a manner described by the Coase theorem. If I live in an unhealthy fashion and it risks my health those who care for me risk an emotional loss. However, their closeness to me allows them to influence my decisions. Whose mother doesn't check that they're eating well and hassle them if they're not? The more people care the more they will socially police behaviour.

These kinds of strategies allow for the harm principle to function despite its theoretical weaknesses. As a result, an approximated version of Mill's sphere, allowing choices that have societal effects smaller than a certain magnitude, is an important popular justification for liberalism. It is the best simple guide to what the liberal position is in the first place. It is what people mean when they say "it's none of your business".

The NHS makes people's decisions over diet, smoking and drink, and a massive host of other choices, the business of everyone other Briton. The fat man in Glasgow concerns me because I will contribute to paying if he becomes unwell but there are few practical ways for me to influence the health behaviours of him and millions of others socially and without enlisting the power of the state.

We might still allow people some unhealthy choices, taking a stressful job for example, but perhaps that is just the way the societal cost/benefit analysis plays out? We don't respect people's right to take a stressful job - it is just good for us if they do.

"Genes matter as much as environmental factors- would Matt accept a system in which companies were allowed access to our genetic code and set different premiums based on that for various people, sometimes prohibitive premiums."

People don't choose their genes. That means you can't incentivise people. It makes the public policy debate completely different to the one I was addressing. Being genetically predisposed to poor health is more analagous to having a pre-existing condition or being old than to eating an unhealthy diet or smoking. There is an interesting debate to be had over whether insurance companies should be allowed to take account of things like genetic predispositions but none of the logic in my original post pertains to that debate at all.

"What about such premiums actively discouraging people for example from performing various important jobs- take for example those who volunteer to be part of the royal lifeboat association (something that involves them in great risk for a real public good and for free)- that would incur them a higher premium is that fair- the same thing might be said about special constables."

These would not be among the unhealthy behaviours that you would want to allow providers of compulsory social health insurance to attach a price to - just as it isn't one of the activities that might, under Government proposals, get people denied NHS treatment. I don't think this flaw is critical even if you want to implement a system that allows insurers to present higher premiums for any reason at all but, for the purposes of the debate we're having right now, it just isn't relevant. There is no reason why the slope, allowing certain information about health behaviours to affect insurance premiums, should be so slippery that any case for greater flexibility is a case for allowing perfect information.

The NHS cannot properly incentivise healthy behaviours and creates a very real imperative and justification for lifestyle illiberalism. A reformed healthcare system need not create those pressures for a less liberal society. I hope this post has helped to flesh out why.

No comments: