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Britain’s “Fat and Fags” Health Policy


A terrible term has entered the healthcare debate now raging in Britain: “lifestyle rationing.” Given the predictability with which social trends cross the Atlantic, and given a looming Obamacare, Americans would be wise to eavesdrop closely on this conversation.

“Lifestyle rationing” refers to denying medical care to those who make unhealthy lifestyle choices, such as smoking and becoming obese. At the end of April, the term exploded in British newspapers due to a survey conducted by doctors.net.uk, in which 54 percent of 1,096 participating doctors approved of the National Health Service (NHS) withholding non-emergency treatment from smokers and the obese. (The NHS provides “free” public healthcare that is tax funded. Britain also has private healthcare paid for by private health insurance, employer packages, or directly by the patient. An estimated 92 percent of the British depend on the NHS.)

The accuracy of the doctors.net.uk survey is questionable. For one thing, the survey was a self-selecting opinion poll, or SLOP, and those are notoriously biased. Moreover, the question asked was broadly phrased: “Should the NHS be allowed to refuse non-emergency treatments to patients unless they lose weight or stop smoking?” Thus a doctor who would deny all medical care to a smoker was counted alongside one who would refuse only a lung transplant.

Nevertheless, a significant number of doctors clearly would deny some tax-funded care to taxpayers with unhealthy lifestyles. In fact, this is happening already.

The Guardian (April 28) reported,

Smokers and obese people are already being denied operations such as IVF, breast reconstructions and a new hip or knee in some parts of England. The medical magazine Pulse last month found that 25 of 91 primary care trusts had introduced treatment bans for those groups since April 2011.

(A “primary care trust” is the front-line organizational unit of the NHS; it constitutes the doctors and dentists a patient would go to in the course of normal health maintenance.)

In an article entitled “Should GPs Ration by Lifestyle? No — This Is Rationing Dressed Up as Science,” Pulse expanded on its findings with specific examples,

In Hertfordshire, patients are restricted from accessing surgery of any kind if they smoke, and orthopaedic surgery is restricted to those who qualify with an acceptable BMI. This “fat and fags policy” now seems to be rapidly spreading to other areas.

(“Fags” is British slang for cigarettes.)

The denial of service comes at a time when the healthcare system is desperate to cut spending. The Guardian (May 3) explained of one hospital,

The boss of the first private company to run an NHS hospital has promised to pay off £40m of public debt, prompting unions to warn that this will “hit patients and staff as drastic cuts will have to be made to health services and jobs.

Doctors.net.uk’s chief executive, Dr. Tim Ringrose, was blunter, stating that a shift in attitudes toward treatment criteria was the result of a need to make huge cutbacks.

Medical-rights groups have declared “lifestyle rationing” to be a violation of human rights, but they may well be speaking into the wind. If a further denial of medical care to smokers and the obese comes about, it will be the culmination of several powerful trends: an economic crisis, the demonization of smoking and obesity, the increasing socialization of costs for services, and an entrenched nanny state. These trends are equally apparent in North America, especially within Obamacare.

The moral issues

Doctors have a right to refuse treatment to anyone for any reason. In becoming a doctor, a person does not alienate his right to associate and to refuse association any more than he surrenders freedom of speech or religion. Equally, if doctors wish to charge smokers more for medical services, they have the right to establish the price at which they are willing to work.

The situation is made complex, however, when the services are tax funded. In a Spiked magazine article (May 1) entitled “The Rationing of Medical Treatment Is Really Sick,” deputy editor Rob Lyons explains,

When it comes to the NHS, there isn’t a box I can tick to say: “I like to drink and smoke and eat the wrong foods, so I will withdraw from the NHS and pay for my own healthcare. Please send my refund by cheque to my home address. (Oh, and please include all that excise duty I paid, too. Thanks.)” To charge someone for something, and then years later deny them the service in question because you have decided to change the rules arbitrarily, would provoke uproar in most areas of life. The BBC TV show Watchdog would be on the case in a jiffy, exposing the men responsible for this blatant fraud.

The fraud is being conducted in a self-righteous manner, under the banner of “helping” people to make healthy choices. In an increasing number of regions, smokers and the obese are targeted for exclusion from services for which they are forced to pay. Since many cannot bear the financial burden of both taxes and private medical care, they are being de facto denied medical treatment. Smokers and the obese are not being helped; they are being excluded. They are being blackmailed into complying with a political vision of the proper way to live, the correct way to deal with their own bodies.

And yet smokers and the obese are commonly viewed as the immoral ones, because they “force” other taxpayers to support their unhealthy choices. They willfully consume more medical care than they “deserve” and so deprive others of a scarce good. Lyons continues by pointing out,

this argument doesn’t stack up. There is plenty of research to suggest that if obesity, smoking and the rest really do shorten your life, then you will end up costing the rest of society less than if you selfishly live to a ripe old age with all the demands that will place on the Treasury in terms of pensions, social care and healthcare.

If the argument does stack up, however, then it becomes another argument against socialized medicine. When a person is directly responsible for his own bills, there is a strong and natural incentive to curb behavior that makes those bills soar. When other people pay for the consequences of his behavior, however, that incentive disappears.

The quality of care disappears as well. As Sheldon Richman observes,

When people have responsibility for their own well-being, spend their own money, and face the tradeoffs inevitable in a world of scarcity, they have incentives to demand clarity and simplicity from competing health insurers and medical providers, who in turn have to accommodate them to win their business. Competition is key, and what makes competition possible is freedom.… To have freedom, government must back off and permit people to engage in transactions as they see fit. This is precisely what is lacking today.

A cautionary tale

Among the disastrous consequences of socialized medicine is the creation of an artificial scarcity. When a service or good is “free” to the user, there is no incentive to limit consumption. Quite the opposite. At the same time, if the service is tax funded, then there is a stiff limit on how much of it can be provided.

Private medical care can expand indefinitely in the presence of market demand. But public care becomes scarcer as demand increases, because tax money remains limited. Rationing in some form becomes inevitable. Thus, Pulse concludes that lifestyle rationing is merely “trying to justify rationing and reduce referral rates.”

Actually, the lifestyle criteria is about more than rationing and referral rates. It is a tool for social engineering by which bureaucrats induce a person to substitute their judgment for his own concerning his own body. Public medicine is a form of social control. The economic commentator John Aziz observed,

It [medical care] becomes a carrot or a stick for interventionists to intervene in your life. Its delivery depends on your compliance with the diktats and whims of the democracy, or of bureaucrats. Your standard of living becomes a bargaining chip. Don’t conform? You might be deemed unworthy of hospital treatment.

When people are dependent upon the state for the means of life, including medical care, then the state can and will dictate the terms on which life is to continue. It is not surprising that a medical system controlled by a political process is imposing a political agenda. In Britain today, medicalized social control aims primarily at smoking, obesity, and excess alcohol consumption. Tomorrow, it may target carbon footprints, sexual promiscuity, mental illness, or criminal inclinations. By their nature, bureaucracies grow and ignore the boundaries of their own absurdity.

Spiked quoted one doctor as commenting,

By extension [of lifestyle rationing], should we refuse treatment to those who do not exercise enough, do not eat their five a day, or drink alcohol? If a rugby player breaks their finger, should we refuse to treat them because they should not have taken the risk to play? People make lifestyle choices and who are we to withhold care as a result?

Unfortunately, what sounds absurd today often becomes politically expedient tomorrow.


The NHS is unlikely to propose an outright ban on the medical treatment of smokers and the obese. The fact that lifestyle rationing is being actively debated is ominous, but the prospect of abandoning people en masse to die because of their lifestyle choices would probably still cause a public backlash. Doctors who still believe in healing rather than judging would also rebel. Instead, the NHS is likely to continue drifting in its current direction of refusing more and more procedures to smokers and the obese. The goal is ultimately the same, but progress toward it will be incremental.

A medical rationale will always be stated for denying treatment to the wayward. For example, the smoker takes longer to recover from surgery; the obese are more likely to reject a transplanted organ. The rationales may be valid and sincerely stated, or they may not. But other powerful motives are at work. How else can you explain the fact that the obvious solution to this dilemma will not even be considered? The shunned patients should be allowed to drop out of NHS and keep their tax money to provide for their own medical needs.

Bureaucrats will not consider this solution because, for them, it moves in the wrong direction. It takes power and funding out of their hands. And this is the raw message of “lifestyle rationing.” Socialized medicine is a process of power and funding that sets factions of society against each other in competition for a scarce good. Obamacare would be no different.

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    Wendy McElroy is an author for The Future of Freedom Foundation, a fellow of the Independent Institute, and the author of The Reasonable Woman: A Guide to Intellectual Survival (Prometheus Books, 1998).