A Looming Ethical Dilemma: Family Health Incentives

Over at The Juggle, Sue Shellenbarger examines the increasing tendency of employers to attempt to control health care costs by encouraging behavior and life-style changes on the part of employees and their families. I think this is inevitable, but it opens up a slew of ethical issues. Do we really want our employers trying to influence how we eat, exercise,and spend our free time? On the other hand, do we give up the right to complain when we expect them to pay for our health problems, even those that are self-induced? Where do we want to draw the lines regarding what is acceptable employer interference among such measures as…

  • incentives for the employee to lose weight and exercise
  • incentives for the exercise to involve safer activities (the treadmill and stationary bike) rather than riskier ones or exercise that is punishing on the body (X-treme skiing; super-marathons)
  • incentives for spouses and children
  • monitoring of unhealthy activities like smoking, drinking, and recreational drug among family members
  • monitoring of unhealthy activities like excessive computer use, videogaming, and gambling
  • institution of stress reduction, anger management and psychological health measures among family members
  • family planning instruction to limit the number of pregnancies
  • encouraging abortion when indications are that a child will have serious health problems

…and more. If you find these intrusions tolerable, will you feel similarly if the government is the one giving incentives, positive and negative, to encourage healthier conduct by member of your family? How long will we agree that all individuals should pay the same for workplace health insurance regardless of predictable genetic, actuarial and demographic factors, when cultural, personal and family activities are being monitored and penalized?

The unspoken dilemma that lies in the shadows of the health care debate is that autonomy and freedom are not compatible with dependency and shared costs. You can scream that it is outrageous for our mutual employer to demand that your kids lose weight and substitute jumping jacks for their rock-climbing, but when I have to start paying extra for your risky choices, I may find myself on the employer’s side. We are being slowly forced to confront an ethical dilemma pitting health and economics against autonomy and freedom, and the ethical course is anything but clear.

11 thoughts on “A Looming Ethical Dilemma: Family Health Incentives

  1. The only way out of dilemmas like this is to allow individual responsibility. If everyone has to pay for their own medical care, then it is up to them to decide if they want to participate in risky behaviors.

    The only problem is that we have such a hard time (as a society) allowing people to make bad decisions. We pass legislation to help people who have more children than they can care for, buy houses they can’t afford, sign up for ridiculous amounts of student loan aid, etc. Enough is enough. We have to resist the urge to try to erase the consequences of people’s actions by legislation. Some people will have accidents showboating on motorcycles and suffer horrible physical and financial consequences. Well, that is a shame and I feel sorry for them, but I didn’t tell them to do it so they shouldn’t get to force me to pay for the consequences.

    If we go rid of insurance, health care costs would have to fall to the level that people can afford (except for the very poor). It wouldn’t be cheap, but they wouldn’t be charging $50,000 for 10 minutes work anymore.

    • Health insurance pushes up the costs of health care, leads to over-treatment, and is a big part of the problem for those reasons, not just that companies try to avoid paying up. It would be nice if policy-makers were honest about it.

  2. Just wanted to ramble a bit. Health insurance used to be a benefit. Now it is a necessity. Health care was just another trade profession, but now with the amount of knowledge that is expected of the simplest of doctors and the amount of liability they suffer for mistakes – it has gotten out of control. If government wants to reign in health care costs – it should flood the market with health care professionals. Make it easier to practice simple medicine.

    I think the 2 greatest ideas I have seen in the past couple years are 1) Urgent Care facilities – for when you are injured, but you aren’t going to die. 2) Walgreen’s Take Care clinic – for when you have a question and want opinions on routine medical events.

    Congress and the President should stop looking for the silver bullet legislation that passes with one vote and start focusing on a series of legislative bills to fix individual problems. Some help is better than no help, and by taking it a piece at a time, we’ll feel more confident that what legislation is getting passed is going to Do No Harm.

  3. For a refreshing look at these and similar issues, I highly recommend Thaler & Sunstein’s , which strikes me as a well-thought-out and balanced resolution of some of the ethical dilemmas perceived here (which may not be such agonizing dilemmas after all). The book can’t be summarized with fairness to the authors, but a quick-and-dirty retelling might be: Totally free markets often lead to disasters because human individuals are not actually very good decision-makers. On the other hand, freedom of choice is a hallowed virtue of our culture and tradition.

    Why not adopt what the authors call “libertarian paternalism” by using principles of choice architecture to tell people, when they are faced with complicated choices, that they are free to do whatever they want to, but they might want to know (if they’re interested) about some of the simple and relatively uncontroversial consequences of their options. People can benefit from “nudges” for decisions that are difficult and rare, for which they do not get prompt feedback, and when they have trouble translating aspects of the situation into terms that they can easily understand, especially when much their information is presented from sources that have a personal, rather than societal, interest in the result.

    To those who raise the inevitable cry of “This won’t solve anything, because who decides which way to nudge?” all I can say is — read the book, because areas of broad agreement are more common than you might think. If you want to look good, you can go to a haircutter and say that you want a mullet, or a mohawk, or a buzz cut, or a pageboy, and leave the execution and details up to the expert. You’re always free to cut your own hair if you want to; a look in the mirror afterwards might convince you that the connection between your choice and a consequence of movie-star or total mess might not be as controversial as you think.

    I get no cut from sales of this book. I just think it’s a thought-provoking way to reduce some large ethical challenges to a more manageable and comprehensible size. And if you’d rather not be nudged, you are still perfectly welcome to spend as much time as you want to with brochures and websites about your health care plans, prescription reimbursement programs, 401(k) investment profiles, and the education options for your children (containing an awful lot of information prepared and presented by people who are trying to make money and aren’t terribly concerned about whether you make good choices).

    In short, we don’t usually have ethical dilemmas between (1) removing all choice or (2) granting maximum freedom of choice. These are the easy answers because they require the least thinking. Instead, let’s invest the (admittedly heavy) time and effort in designing systems that allow people to decide how hard they want to think about any particular choice, and what they might want to consider if they’d rather spend their thought effort on something else.

    • “Totally free markets often lead to disasters because human individuals are not actually very good decision-makers. On the other hand, freedom of choice is a hallowed virtue of our culture and tradition.

      I think “full disclosure” free markets would tend to increase good decisions made… What I mean by that is that consumers may have a right to know as much behind-the-scenes information about a product and the company providing that product as possible to make an informed decision. Then let the buyer deal with the consequences of not making the best decision.

  4. In this case (and perhaps only in this case) many of the insurance companies have got it right. When they ask questions like “Do you skydive?” “Do you work for the circus as a trapeze artist?” “Are you a human cannonball?” “Are you a performance artist on top of the Empire State Building?” “Are you a NASCAR racer?” “Do you create art with a chain saw?” ” “Do you have/care for more than 13 children?” “How many people live in your trailer?” “How tall are you and what is your weight?” “Can you stand and walk for more than ten minutes at a time?” “Do you routinely surfboard during hurricanes?” “When did you last go to the dentist?” Or alternatively, “How many of your own teeth do you have?” “When is the last time did you see a doctor?” Or alternatively, “Do you know what a doctor is?” “When did you last take a bath?” Or alternatively, “Do you have a bathroom?” “How long do you keep uncooked hamburger in your refrigerator?” “When did you last wash your underwear?” “Do you fly private planes?” “Have you ever had a DUI?” “Do you chase tornadoes?” “How many times has your home been rebuilt because you live on the Mississippi floodplain?” “Have you ever barbequed indoors?”

    All of these questions can help an insurance company (or any insuring agency) assess your risk. How about a national registry of the number of times an uninsured person has visited an emergency room for assistance after either stupid accidents or untreated illness? How about “three strikes and you’re out?” Not that you don’t get treatment, but that you’re put on a payment plan (a la the IRS) and if you don’t make you payments your paycheck /welfare check is garnished in some way?

    Sounds rough, but something’s gotta give…

    • I don’t think it’s rough at all. There’s no reason to only apply risk principles to drinking and smoking. I don’t want to pay higher premiums because Gary Busey won’t wear a motorcycle helmet, nor should I have to.

  5. Thanks, Jack. For some reason — maybe because I tried to italicize it — the actual name of the book doesn’t appear in the comment as reproduced above. It’s a one-word title: NUDGE.

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