Fat People Got No Reason

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.

Comments

[caheidelberger]

Hmm... looks like there's no easy answer here. In pure economic terms of paying for health care, would you accept a tax on healthy food that requires those darn broccoli eaters to pay for the externalities they impose on society by living longer?

Are we at a point where we just can't reconcile the goals of good public policy and fiscal conservatism? Is it o.k. for me in the case of health care to say, "We're not going to save money, but it's money we have to spend, lest we turn into beasts"?

[E]

Unfortunately this study doesn't take into account the production value to our economy of those individuals who die ealier than their healthy counterparts. For example, if an individual dies at the age of 50 from a heart attack that is 15 years (more or less) of productivity that is unrealized to the economy.

My father was a 3 pack a day smoker as well as loving meat and potatoes for every meal. He had a heart attack at the age of 49, fortunately survived, and continued to work fulltime till the age of 65 and part time till 70. Had he passed away from that heart attack our econmony would have missed out on a lot of production value.

[A.I.]

We already are paying for health care for the elderly--if 65 and older qualifies as elderly. What a tax on soft drinks would help fund is health care for younger people who are, for example, developing Type II diabetes at an alarming and ever increasing rate. And I'm betting you won't find a dietician worth their "salt" that doesn't link Type II diabetes to obesity caused by over-consumption of sugars and fats.

I can say from both experience and observation that many smokers stay svelte even while consuming too much fat and sugar. Of course they are even less healthy than their over-weight peers, but damn, they look good--even if they don't smell all that sweet.

There is poetic justice in taxing smokers to pay for children's health care (S-CHIP) and the same would be true of a tax on soft drinks. It would not ban their consumption, it would simply offset some of the harm they do. And since the harm is to health, the offset would be direct.

As for objections, speeding tickets are an accepted incentive to drive at a reasonable pace while still allowing us to drive. A tax on soft drinks would be an incentive to reduce sugar intake while still allowing us to eat and drink. No big deal.

[KB]

Cory: Whadaya mean "we"? I think the question whether we should spend money on healthcare for everyone is not a useful question. We are spending that money. Maybe be should spend more and maybe we should spend less, but we aren't going to just cut people off cold.

But we ought not to base our plans on obvious falsehoods, and the common assumption that tobacco use and obesity cost the public money is one of those.

E: lost productivity from workers who die before retirement age is a consideration. However, it seems to me questionable to treat those lost years as a public cost. Do "we" own "your" labor? What if someone decides to retire early. Is he stealing from the rest of us. Should we put a surcharge on all the SOB's groceries to pay for the lost hours of work?

Even if we look at that way, the last years of work won't come close to making up for the healthcare costs and social security payments that come later.

A.I.: you are far more comfortable than I am deciding for other people how they ought to live. By your own previous arguments, the speeding analogy doesn't work. When someone drives recklessly, he endangers everyone else in his car and on the road. When someone drinks a jumbo coke, this hardly the case. That's why the second hand smoke myth is so useful, and why the "costs" of obesity and smoking keep getting repeated no matter how many times they are proven not to exist.

Your remark about "poetic justice" makes my larger point: that is the poetry of ingroup going wee wee on outgroup. No matter how enlightened we are, we all need someone we can wee on. For modern enlightened folk, that's smokers and tubbies.

[caheidelberger]

O.K., then if there are costs to be borne, who should bear them? Should we just get out of Medicare and let all those darn retired broccoli-eaters pay their own way for living longer and incurring more old-age health expenses?

[E]

KB, my point was/is that you can't chastise the health care reform proponents for only viewing one side of the equation when you yourself and this study are only looking at one side of the equation. There are multiple factors that should weigh into these decisions.

Back to your comment, “it seems to me questionable to treat those lost years as a public cost”, I don’t necessarily think it’s unquestionable to think that. 10-20 productive years making what should be the highest salary of your career is a substantial part of the economy. These are the members of society with the disposable income that fuel the economy. That’s a sizeable portion of the tax base as well suddenly gone at a minimum and depending upon what caused the death could be a significant drain to the economy as well.

[KB]

Cory: We know who will pay the costs: everyone who keeps working. You seem to be fond of medicare as a model for healthcare, but isn't clear that Medicare is going belly up, financially? And hasn't this been predicted decades in advance? The question is not who pays, but how we pay for medical expenses. The virtuous seniors will get their healthcare and everything else from people who are working. Now: how do we keep the services coming? Maybe fooling ourselves by thinking we can finance it by reducing smoking and weight reduction doesn't help.

E.: The problem isn't that healthcare proponents view the problem from "one side of the equation," it is that they keep getting the equation wrong. Lost years of productivity due to smoking is all smoke and mirrors. If a few more years of productive employment made up for the many years of shuffle board, we wouldn't have a healthcare problem.

[caheidelberger]

Related: "The prevalence of obesity rose 37% between 1998 and 2006....Obese people spent 42% more than people of normal weight on medical costs in 2006."

--WSJ, noted on Greg Mankiw's blog:
http://online.wsj.com/article/SB10001424052970204563304574314794089897258.html
http://gregmankiw.blogspot.com/2009/08/obesity-and-healthcare-costs.html

[A.I.]

Thank you caheidelberger for demonstrating the point KB wishes to deny, "drinking a jumbo Coke" does do harm, not only to the individual, but to all of us that pay health insurance premiums. To use a phrase you are fond of KB, I don't "give a rats ass" whether or not someone drinks ten quarts of Coke a day--so long as they pay the public toll for doing so. So yes, I want soft drinks taxed and the revenue used to offset the public cost of their consumption.

To clarify, this does not bar individuals from consuming soft drinks. If you drink a little, you pay a bit of tax. Drink more, pay more--kind of like most speeding laws that fine more for every mile over the speed limit one is going. Which basically means the greater the potential harm, the more the toll.

Claiming harm from second-hand smoke is a myth is getting into flat-earther territory, but I do agree with one claim you seem to make regarding smoking. Its net monetary cost to society, from the standpoint of the individual smoker, may well be zero or less. The point has been made often, whatever heath care costs are associated with smoking may well be offset by reduced nursing home and other elder care costs avoided because smokers die younger. That does not necessarily account for harm caused be second-hand smoke however.

As for your ins, outs and who wants to wee wee on whom analogy, wrong, at least from my standpoint. Most people who smoke come into contact with others including children. Their second-hand and third-hand smoke harms children and everyone else. Perhaps it isn't poetic, but certainly there is some form of justice in smokers, through taxes, helping to pay for some of the harm their habit causes. I'll admit they may be getting overcharged relative to the harm caused, but they certainly shouldn't get by with no charge at all.

[William]

Public Health has been defined too broadly, as the freedom to make decisions about one's lifestyle is pretty fundamental.

If, as is now the case with far too many, "Public Health" is viewed as one's obligation to live one's life in the manner the state deems best lived for society's sake, then what essential freedoms will be left to the individual?

[Miranda]

Would those of you who support taxing things like sugary drinks also support taxes on lawn mowers, fireplaces and cell phones? All of these things can contribute to poor health as well.

[KB]

Thanks to one and all for the great discussion.

A.I.: Cory's note does not demonstrate any point I wish to deny. Yes, obesity is bad for you. Given two individuals of similar ages, etc., one obese and the other not, the former will have more health problems and thus will put a larger burden on the healthcare system. But what is driving the increase of healthcare costs in the system as a whole is a pair of dynamically related factors: increased longevity and the accelerating development of healthcare technology. Since obesity shortens life spans, it necessarily reduces one of those factors among the obese. Thus it doesn't cost us all money, it saves us money. You seem to acknowledge the force of this argument for tobacco. But it has to work the same way for obesity.

Lost productivity is an issue that may affect this calculation, but it seems to me that it can't make a difference. If the productivity gain that comes from a healthy lifestyle were enough to make up for the costs of old age, we wouldn't have a healthcare finance problem.

Reducing obesity and its costs in health and longevity is a perfectly valid public aim, and if you can do it I say its well worth the long term costs. I am much less enthusiastic than you are about penalizing people for making choices that I do not approve of. I am also very skeptical that taxing soft drinks will effectively discourage their consumption. Fast food is already much more expensive than healthier, home cooked meals. But such taxes, if effective, would be an honest means of pursuing an honest goal: encouraging health. Taxing the jumbo coke because the guy drinking it is costing us all a lot of money sounds good, but it is based on a falsehood.

[A.I.]

KB: I considered the notion of over-weight and obese people dying younger as I wrote my comment, but didn't bother to pursue the thought. I have found no data to support the notion that life expectancy for such folks is shortened to the extent of smokers or that it is shortened to the extent of reduced elder care offsetting life-time medical costs. That is not to say such data doesn't exist.

What I did find is an article claiming weight-related health care costs account for 10% of total health spending which would amount to about $270 billion dollars currently http://louisville.bizjournals.com/louisville/stories/2006/04/10/editorial3.html. Smoking, meanwhile, costs about $100 billion: http://www.huffingtonpost.com/2009/04/08/how-much-does-smoking-cos_n_184554.html. The latter article says smoking reduces life expectancy by ten years. Other data show three years for those who are overweight and up to 13 years for obese males.

I do remember being told in a smoking cessation class many years ago that your general health and life expectancy is better being overweight and not smoking than thin and smoking. So my ghoulish bet is being overweight presents a greater cost to the economy than smoking.

I am not saying I disapprove of soft drink consumption on moral grounds or any other. Nor did I claim or do I believe taxing soft drinks will have a significant impact on consumption--unless the tax is extremely high, which would be politically untenable. What I am saying is imposing a reasonable tax on things that cause health problems and using that money to finance public health care is an appropriate approach.

[KB]

A.I.: We may have beat this one into the ground. But I began by citing a study that addressed precisely the question that still seems to be at issue: does obesity raise total healthcare costs for the society at large? It concluded that it does not. Almost all of the obesity alarmist studies I have seen focus on immediate costs and do not raise the larger issue. Until there is a definitive study that corrects the PLoS study, we have to say that the view that obese people raise the healthcare bill for the public is without foundation.

Since you agree that taxes on fattening foods is unlikely to result in behavior changes, what justification remains for such a tax? Only this: that we can confiscate the property of people who engage in behaviors we disapprove of, even when those behaviors entail no public cost and the taxation would achieve no public good other than increased revenue. I find that morally problematic.

[A.I.]

But have you considered the additional CO2 emissions from hauling around that extra weight in vehicles and planes? And a Dutch study, what with all the Tulip fumes? OK, I jest. And my bad for forgetting you had cited a study supporting your point.

[KB]

You left out the carbon emissions that result from the manufacture of wooden shoes.

[terry jones]

You ncan still be fat and healthy according to the excellent website for the obese www.yoiufatbastard.org

[kfreed]

"Logan's Run"... remember the film? All persons should henceforth be equipped with a compulsory buzzer which will sound an alarm the second one reaches the ripe old age of thirty-five. At which point, he/she will be put to death... humanely of course... in order to reserve valuable resources for the young and healthy. Naturally, all middle-aged persons will voluntarily adhere to this policy as it will have become an Amendment to the Constitution under the auspices of homeland security. Poetry and Patriotism...