The public health practitioner is by now probably very impatient. The public health practitioner does not see the regulation of smoking as a matter of moral regulation, but simply as a matter of health promotion. And more importantly, even if the individual is free
to go‘to hell in his own way’, as Robert Frost put it, we are entitled to regulate the impact
his choices have on others. We will come to the latter part of the argument in due course. But there is a residual area of concern with the conduct of the individual which would bear on the public health practitioner’s interests.
We can argue that our health is our own, and that while we have a legitimate interest in controlling actions and policies of others which threaten that health, what we do to our own health is our business. Some religious believers do not accept this, holding that our lives, bodies and health are gifts from God, which we are to safeguard. Similarly, some communitarians would argue that care of our health is part of our general collection of obligations to each other in a moral community: only by maintaining ourselves in good health, so far as this lies within our power, are we able to discharge our responsibilities to the weaker members of society and to promote the common good. Neither of these lines of argument are especially widely shared at present. But it is commonly argued that someone who deliberately damages his health is less deserving of health care that could fully or partially remedy that damage to his health. The smoker is often argued to be a good illustration of this principle. Let us consider the arguments briefly.
Imagine a smoker of 60 years of age, who has advanced heart disease and would be a candidate for a heart transplant, other things being equal. One clinical approach would be to consider her for a transplant without regard to the smoking. She might be listed, or not, purely on the basis of likely chances of success and expected survival post-transplant, in the same way as any other transplant candidate. Another would be to distinguish between the smoking-related cause of the illness and the impact post-transplant smoking would have on the success of the transplant. She could be asked to agree to stop smoking as a condition of
the transplant. This might be understood as a moral requirement (damaging one’s donated
heart or one’s health could be seen as wilful self-harm or as damaging a scarce resource
of a transplant. She could be assigned to the transplant list with a lower priority than an equivalent non-smoker. Or she could be refused access to the list. Setting aside general issues of distributive justice in health care which concern duties to rescue, allocation by need or allocation by expected outcome, and so on, we can distinguish two claims about desert and access to treatment in this situation. The first claim is that past health behavior can affect the degree to which one deserves treatment for ill health resulting from that behavior. The second claim is that future health behavior can affect the degree to which one deserves treatment for ill health relating to that behavior. The first claim involves a claim that the behavior itself is discreditable. Most clinicians would express some discomfort about applying a retrospective judgement, perhaps because they believe it to be moralistic, or perhaps because they see it as involving a double jeopardy (you smoked, so you are ill, but because you smoked, we will not treat your illness). The second claim involves a judgement of relative desert between candidates for transplant which can be affected by the fact of smoking. This may be defensible, if the fact of continued smoking is taken on good evidence as a sign that compliance with other necessary treatment will be less likely. Although there are some arguments which might explain offering a transplant to a smoker on conditions, or not at all, which do not depend on moral judgement of their past or present smoking, it is more plausible to say that we do judge smokers, and to consider whether this is justified. Consider two people, one our smoker just described, another a lifelong non-smoker of similar age and ill health. Both need a heart transplant and there is just one heart available. If we think the non-smoker should have the heart because he is a non-smoker, rather than because of likely success or greater life expectancy or some other more general principle of distributive justice in health care, then why is this? It may be that the smoker is somehow responsible for doing the non-smoker out of the heart, if she gets it. How would this be? It may be because we think the non-smoker would be ill anyway, whereas but for her smoking, the smoker would not be. If so, we are considering that the smoker has caused her ill health, and also that by claiming a scarce resource to restore that health, she is denying someone else that resource. So she is displacing the consequence of her behavior onto another, blameless, person. Thus, her smoking cannot be considered a purely self-regarding behavior in this context, even neglecting (as we have so far) the third party effects of smoking. This is hard to defend, however. Any allocation of a scarce resource between parties with a claim on it will involve winners and losers. The losers suffer no wrong at the hand of the winners, other things being equal. If we admit desert into our allocation scheme for health care resources, we have three problems. First, we have little settled agreement on the conception of desert that we ought to use, or what its scope may be.
Second, people rarely come to allocation decisions‘clean’, in the sense that everyone has
some health-related habit which undermines our health to some extent, be it smoking, drinking, physical idleness, excess workplace stress, or even jogging. Adjudicating between
the claims of differently ‘compromised’ individuals is at least difficult to do objectively.
Third, we may be happy to transfer technical and professional responsibility to doctors. We
are much less happy to see them as moral experts who can adjudicate between patients’
differing degrees of desert.
In passing, another issue arises in connection with publicly funded health care. It is sometimes observed that the proceeds of taxation on tobacco products exceeds the costs to the National Health Service of smoking-related illness. This would require some justifica- tion. Imagine, however, that these two figures were more or less in balance. Then we could see this tax as a kind of insurance against eventual tobacco-related illness. In that case, we
would have no ‘scarce resource’ argument for non-treatment of smokers, save as regards those resources which are scarce on non-financial grounds (such as organs for transplant). Imagine, next, that the taxation income does not cover the costs to the NHS of smoking- related illness. Then we might say that smokers deserve lesser treatment because they have not paid their way. The basis of the NHS is solidary coverage of the nation’s health care costs; some pay more than they take out, others take out far more than they can contribute.
What could be objected to in the case of the smoker is deliberate‘over-drawing’. Of course,
the answer here would likely be to increase the duty on tobacco products, rather than to restrict smokers’ access to health services. So, if smokers are ‘over-contributing’, does this give them special claim to health resources? This possibility becomes even more probable if one considers not only the contribution made by smokers through taxation but also the way that smokers by dying earlier than average draw less than their expected entitlement from the pensions system over their post-retirement lifetime, given that that section of their life may well be shorter than average. The main reason for taxation is not to insure smokers against the risks of their smoking, but to raise revenue for the State, to fund the NHS, and to discourage smoking. The solidary basis of NHS funding through income taxation and national insurance does not allow for special claims related to level of contribution. So as a matter of public policy smokers are not entitled to priority treatment merely because they have paid more in. What the taxation issue points out is partly that there is indeed a degree of State moralism regarding smoking, but also that the State has other reasons for wishing to discourage smoking than the regulation of individuals’ self-regarding behavior (Wilkinson, 1999).