The most popular Gedanken (thought) experiment in contemporary ethics is the Trolley Problem. In the original version, an uncontrolled trolley is headed toward a switched junction. As the switch is set, the train will cross onto a track where five people are working (or are tied to the track) and they will all be killed. You are standing at the switch, and you can divert the trolley. But if you do, a single person on the other track will die. Do you throw the switch or not?
In the second version, you are standing on a bridge next to a fat guy as the trolley approaches from behind. The tubby leans over the rail and exclaims that the trolley is going to kill five people on the track ahead. Give him a little push, and he goes over and stops the train. Do you act?
Most of my students (about 3 or 4 to 1) throw the switch in the first example, but the numbers reverse on the second version. It's a great way to test utilitarian vs. deontological ethics. Is it the outcome that matters, or the moral act that matters? But my students have no trouble recognizing that prejudice against obese people plays a role in the decision making. It's easier to use someone if we don't like him, and, God help us, we find it easy to dislike fat people.
There's a move afoot to push Tubby over the rail in order to save healthcare reform. Daniel Engber has the story at Slate:
In recent days, the health care debate has shifted back to an idea that's been kicking around since Barack Obama first started talking about universal coverage on the campaign trail: Let's stick fatties with the tab. The director of the Centers for Disease Control and Prevention spoke out (again) this week in favor of a national tax on sugary drinks to fight the obesity epidemic and raise federal revenue. The Los Angeles Times spelled things out: "Tough love for fat people: Tax their food to pay for healthcare."
Those of us who thought that the campaign against tobacco would encourage similar intrusions into the personal lives of each and every person in these United States have their suspicions confirmed. Legislators and public busybodies who presume to decide for us whether we can smoke if we please (not) are now setting out to tell us what to eat and drink.
Of course anti-choice policies on cigarettes and Cheetos run afoul of the sacred idea of, well, choice. One has to argue that lighting up and reaching into the orange bag somehow burdens all the innocent bystanders. Unfortunately there is no such thing as second hand cholesterol, so the anti-obesity lobby has to argue that fat people are bad because they cost all of us a lot of money.
Well, that's easy, isn't it? The jumbo guy who smokes a pack before and after he gobbles up a double quarter-pounder with cheese, large fries, and a jumbo, sugar-laden Coke, is going to be a burden on the healthcare system. So we have to tax his burger, fries, and pop, in order to save this lost soul and fund Obama's healthcare proposals (if he had any proposals). If we could just encourage a lot of cigarette smokers and fat folks to kick the habit, slim down, and hit the gym, we'd have more money to fund health insurance for everyone.
The only thing wrong with this story is that it is false. Better yet, it is obviously false. The burden on the healthcare system is not smoking people or fat people, it is old people. Almost all the dollars spent providing medical care to someone will be spent during his last five or ten years of life. That five or ten years will come to all of us no matter how many push-ups we do or how many fruit smoothies we consume. The cancers that strike a man after eighty years of golf and good living will be just as expensive to treat as the lung cancer that lays low big Joe a few decades earlier.
Actually, healthy people are more expensive. Living longer, they soak up a lot more in social security payments. But don't let common sense and obvious facts be your guide. A Dutch study, published in PLoS Medicine, crunches the numbers.
Although effective obesity prevention leads to a decrease in costs of obesity-related diseases, this decrease is offset by cost increases due to diseases unrelated to obesity in life-years gained. Obesity prevention may be an important and cost-effective way of improving public health, but it is not a cure for increasing health expenditures.
Smoking and obesity don't put a burden on public finances. They save us money, mostly by kicking the bucket sooner. Lest I be accused of wanting people to die and reduce the surplus population, let me say that it is entirely a good idea to encourage people to stop smoking and keep a healthy weight. It makes for a better life, and that ought to be the object of all good policy.
But if reducing obesity is a good idea, it won't reduce healthcare expenditures. It doesn't help the cause of healthcare reform to base our policy on obvious nonsense. And while it is a good idea to encourage everyone to live a healthier life, maybe we shouldn't be so quick to tell people what they ought to order at the drive-through.