Taxpayers should not have to pay for those who choose risky lifestyles

IN 1993 Harry Elphick was admitted to a Manchester hospital with a heart condition. His doctors asked him to quit his 25-cigarette daily habit before undergoing heart surgery. Elphick initially refused. He subsequently relented but died before the surgery.

His widow said: ''It shouldn't have mattered whether he smoked or not, he should have been given treatment. It is wrong and quite disgusting.''

Elphick's case caused a worldwide furore. Few disagreed with Mrs Elphick that it is unethical for specialists to ration access to treatment based on their patient's refusal to modify an unhealthy lifestyle.

In contrast, the National Preventive Health Taskforce now advocates a comprehensive ''road map'' to make Australia the healthiest nation by 2020. Borrowing from the language of food advertising, the taskforce's prescription is ''chock full of goodness'', reflecting current preventive health wisdom, including assuming that poorer and implicitly ignorant people need protection from bad nutrition, smoking and drinking too much. It talks, for example, of higher taxes on cigarettes and alcohol to put these beyond reach of the less well-off for whom they count as affordable, if guilty, pleasures.

Health Minister Nicola Roxon already is legislating to establish a national preventive health agency. It will become the nation's nanny-in-chief. Roxon was echoed by Michael Smith in The Sunday Age. ''Tough government action runs headlong into another principle of democratic governments - freedom of choice, including the freedom to make unhealthy decisions,'' Smith wrote, arguing that governments should override individual rights in the fight against obesity.

Roxon and Smith both miss a key point. In making their choices, people like the tragically feckless Harry Elphick have responsibilities as well as rights.

The contrariness of human nature is such that government can't save people from themselves. The hard-core smoker will cough up regardless of the financial strain of a regressive tax. Indeed, Roxon's alcopops excise increase proves the point - to avoid it, the targeted younger drinkers can shift to cheaper alcoholic alternatives, or mix their own drinks with higher alcohol content than the premixed alternative. So much for nanny's good intentions.

As a general principle, people should be free to live their own lives unless they do harm to others. If we blight our own lives by our choice, including taking avoidable health risks, that's our problem. But if others have to clean up after us, including high-cost health care provided at public expense, our choices and behaviour affect others too.

Preventive health approaches, therefore, should be more focused on promoting personal responsibility. If you change for the better, you're rewarded. If you don't, and especially if you make an informed decision to ignore the risks, then don't expect to shift the costs to others.

Offering rewards is straightforward. If somebody quits smoking, follows a good nutrition plan or reins in their drinking, give them something of value. If a person is privately insured, this could be a discount on their premium, a waiver of their excess, or some other form of tangible benefit. If not insured, the Government could give them a lower Medicare safety net eligibility, or reduce or waive their Medicare levy as recognition that the personal decision has a wider community benefit as well.

A recent call by the Heart Foundation of Victoria for governments to pay poorer smokers to quit, rewarding their sense of responsibility, is well worth considering in this context. As Elphick's case highlighted, however, imposing penalties is a political and ethical hot potato. No politician or clinician wants to be branded a killer because they prevent someone's access to care or services.

Yet Elphick's tragic experience showed that tough love can work. Originally, he refused to bargain with his doctors, probably sharing the view that his widow expressed so angrily after his death. Yet he reversed his position, probably because he realised how he was the author of his own plight.

Had he survived, Elphick could have been a healthier man having, like Scrooge in A Christmas Carol, seen the error of his ways before it was too late.

If we as a community truly are serious about reducing the prevalence of lifestyle-induced health problems, we need to debate whether threatening penalties can encourage greater responsibility in people who haven't looked after themselves, or who don't clean up their acts. Should they be bumped down treatment queues, refused treatment altogether or charged for their otherwise free public health care?

Could private health funds reduce or withhold benefits for treatment linked to preventable causes, especially if the patient previously has refused or failed to comply with advice on tackling their self-inflicted risk factors? If life insurance can be withheld or be more expensive because of voluntary risk, why not health insurance?

These days most people understand the risks of drugs, tobacco, alcohol and bad nutrition and the benefits of moderation, if not abstinence. But if people choose freely to take health-threatening risks, unlike Harry Elphick, perhaps they should not assume that the community will always cheerfully clean up after them.

Terry Barnes is a policy consultant and was an adviser to former health ministers Michael Wooldridge and Tony Abbott.