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[Lyn Farel]

To me it seems perfectly normal to force people to get that damn vaccine. Same for smokers, just banish those damn cigarettes. And deny the access to healthcare to morons that still continue to use them through contraband, but I know all of that ain't happening any time soon.... Just forbidden in public places.

To practice sport and eat properly to avoid obesity, diabete and cholesterol is a bit trickier of course, and that's a good question. I guess it's a strain that has to be expected, but it doesn't prevent the state to ideally encourage people to do so. Maybe they could finance more sport stuff in companies as they already do in schools where it's part of some classes, don't know...

That's a very american thing to focus so much on individual liberties. We don't care much here. Quite a different mindset. But tbh nothing of this is forced, everybody have the choice, even for vaccines. You are not forced to go see a doctor regularly, even for your children... And that can be a strain.

On another note, the social healthcare here is funded through taxes yes, but most of it is not actually paid by individuals. Most of its funding comes from taxes on salaries (on the companies side even more than the employee's side), taxes on alcohol, taxes on car insurances, etc. So eventually it costs more when you buy from those services, but it's not included in a tax everyone pays everytime. But well, the social healthcare has become a gigantic monster (covers health, retirement, family allowance, and a lot of other things) in debt due to laxist policies and bad management over years (contrary to the german one which has too much money...).

[Vikarion]

The last time I checked, making unwise health choices was not subject to the death penalty. Remember? The point of a societally funded health care system was that it avoids making us have to step over dead people in the street.

It would be better to spend money on finding a solution for the issue, like a smarter pancreas, than to deny healthcare in the hopes that the affected die off without causing too much of an eyesore.

Suppose some people are just determined to be obese. Let's say that they live for eating. They want nothing else out of life but to eat. They balloon up as far as they can go, and suffer the attendant health problems.

Or suppose someone smokes, and refuses to stop. Suppose someone is determined to drink, to the point of committing crimes to get at alcohol. Or suppose that...and so on and so forth.

On the other hand, I'm not obese, I'm not a smoker, I'm not an alcoholic, and I don't play with flammable substances for shits and giggles. Objectively, I am far less likely to inflict costs on the health system. Yet, you seem to think that I should be responsible for paying for the care of those who make choices that create an undue burden on others.

Why should I be responsible for the bad behavior of others? And why should behavior that is self-destructive be, essentially, subsidized? It's not like we are running out of people, and the fact of your existence does not grant you the right to make demands that others support your life.

[Etienne Saissore]

stuff

What may look like a choice, is not always a choice. The amount of support people get from the surrounding community, in the form of family, friends and work, varies wildly. You can't just simply make these factors to be the way you want them to be but they contribute a lot to how likely it is that you develop an addiction or some other problem.

Also, addictions are not rational decisions, it wouldn't make any sense and our brain doesn't work that way. It's just silly to try to apply the rational consumer theory to them. You can argue that in the beginning some degree of choice is involved but because not everyone who smokes or drinks casually develops an addiction, that can't be the entire truth about it.

I hope you get better soon, Katrina.

[Ollie]

As an Englishman, the horror stories of American healthcare make me extremely nervous about our Conservative government's work to privatise our national healthcare. I like the NHS as it is 

Don't let them.

I would argue as with most things there is a balance that can be achieved and may be necessary.

I very much agree with this, although not with the implications of the questions that follow it. There is a balance and it can be achieved, although it is a fine balance and its impacted on by numerous external and internal pressures.

To answer your hypotheticals from the view of someone who lives and works as a health professional within an entirely tax-funded health care system:

For example, in a entirely tax-funded system (cost is hidden from patient), if someone refuses to get a flu vaccine each year (which is free), then contracts the flu and puts a strain on the medical system (and larger society) to care for them, how is the behavior discouraged?  Is it fair to force everyone to have the vaccine?  What about other preventative care?

It's not discouraged, that's coming at it from the wrong angle. Individuals have a strong drive to ignore most negatively-framed advice that might be given to them. The key to achieving success in a public health campaign is to educate on, emphasize and encourage the positive outcomes of good preventative health strategies rather than discourage ignoring them. My apologies for the double negative, but successful outcomes in this area are very much about perception.

Flu vaccines don't offer 100% protection against all forms of influenza. They do offer some benefit in indices of time to recovery and time to return to work (ie, indices of morbidity/cost to health system and productivity) but only significantly in high-risk populations. Therefore in the system I have around me, the influenza vaccine is only offered free of charge to health care workers, diabetics, those at extremes of age, those with pre-existing health conditions that would worsen significantly under the effects of influenza (heart failure, lung/airway disease, cystic fibrosis and so on). There are a few other groups that get the benefit of free flu vaccine also.

Those patients outside these groups wishing to obtain a seasonal flu vaccine are able to do so at their own cost, which is usually subsidised by the government under what's called a Pharmaceuticals Benefits Scheme - the same scheme our government uses to make most medicines affordable to those needing them.

There are no mandatory vaccines in our health system although that is something currently being considered by various state governments to address lowered levels of herd immunity that studies have shown to be developing over the last decade.

What about the person who does not make good dietary or health choices, does not have an annual physical, and then is rushed to the hospital when their body final collapses and they are diagnosed with Type 2 Diabetes?   Once they are stable, is it society's burden to pay for the individual's choices?

Our society's view is that - as a developed first-world nation of reasonable affluence and social comfort - it is the role of our society and its government to provide support for its people across a variety of fronts. Support in health care is one of these fronts. In doing so we aim to effect the return of individuals to health and productivity as rapidly as possible without the need to enter into high levels of personal debt or forego basics of healthcare in the process. In those cases where a return to full or functional pre-morbid levels of productivity isn't possible we have other welfare networks in place to support them as well. Nothing occurs in a vacuum, ideally.

We seem to get by with this view. We have a good quality of life (a generalisation of course), a satisfactory level of infrastructure and an education system that ranks quite highly among similarly developed nations. We have good systems of 'free' (ie, user does not pay) health care and social support. We have welfare systems which public pressure forces continued review of. We have a 3-year election cycle at local, state and federal levels to ensure that if due diligence is not undertaken we can at least get rid of those responsible in favour of those who may be able to.

That said, two of the key obstacles to such a system are size of the population (larger populations obviously become exponentially harder to support in such a manner) stacked against GDP and national/international debt levels. What works for us with a population that approaches only 30 million will not necessarily work in some African, SE Asian, South American or North American nations without significant support from medical charities or NGOs and is almost certainly never going to be a viable option for nations like India and China each of whose populations exceed 1 billion people.

At the same time, when parents are making the right choices for their child, including annual checkups, and they rush to the hospital when the child is attempting to expel acid through their lungs due to Type 1 Diabetes, the last thing I want those parents to worry about is "can I pay for this?"   The same goes for the person working their job and having their hand crushed or leg broken.  These are generally not the result of a pattern of poor choices by the individual.

The point of a taxpayer-funded health system isn't to lay blame or pass judgement on who gets treatment and who doesn't. It's among the first tenets of the Hippocratic Oath, which - although it's fallen out of favour in the years since the Greek gods you swore it to faded from popular worship - is still a pretty good ethical document for physicians to bear in mind. Disease, in general, doesn't discriminate and while it can be argued that patterns of poor health choices inevitably result in some sort of adverse outcome related to them in my experience it's not that black-and-white in actual practise.

The morbidly obese smoker with diabetes and severe heart disease doesn't choose to be crushed in a multiple vehicle high speed motor accident, for instance, but his or her other comorbidities are going to have a serious health and dollar impact on their treatment and - if they survive - their recovery.

Those of us working inside these health systems understand this on multiple levels. I figure I've seen and treated in excess of 30 to 40 thousand individuals in the course of my career. I have empathy for all of them, even as I silently curse and rail against many of them for ignoring health advice that could have prevented or lessened their problems and saved the government's health bill anywhere from few hundred to thousands on thousands of dollars.

The problem for a health worker in that specific situation is you're there to deal with the issues that are facing you at that point in time. There's no point in wasting 10 minutes berating a 70-year old struggling for breath because of his emphysema about the smoking habit of 150+ pack years (3 packets a day for 50+ years) that brought him to your doorstep.

A) It's not going to help him breath any better.
B) He probably started smoking before he even knew exactly how bad it was for him.

Afterwards, you offer him nicotine replacement and tell him to quit smoking or he doesn't get the home O2 he desperately needs (because those are the barriers the government puts on that treatment), you tell him to get a regular chest x-ray (and network with his GP or arrange it yourself to make sure it's followed up on) because of his risk of lung cancer and you put what social supports he needs in place. But you still do whatever you can for him in all those respects.

Likewise with the obese, Type II diabetic whose leg is gangrenous and is rapidly entering septic shock with its attendant sequelae of multiple organ failure and death. What he needs immediately is stat antibiotics, a saline drip, a knife to release any abscess followed quickly by a high-risk general or spinal anaesthetic and a probable amputation. You can worry about the diabetic education, advice on weight loss and lifestyle changes, the problems he'll have achieving mobility and any level of pre-morbid independent function along with a full medical screen for other complications of diabetes if he survives and recovers from that.

In those situations, we don't get to sit in philosophically constructed ivory towers and decide who's worthy of treatment and who's not. And from my point of view as a health professional, we also shouldn't be adding up in some part of our heads how much we or our hospital/health institution stand to make off the poor rube for trying to stop him dying a bad, early death. To me, that's grossly unethical and one of the many things I cannot understand about systems that don't provide some measure of tax-funded support.

Nor is it enough for us to just treat the problems as they arrive. Health care professionals and administrators working in a taxpayer funded system are also responsible for two areas which grease the wheels of said system:

1) It's incumbent on us to be involved with preventative medicine and public health strategies either in actively promoting them, accessing them and following up on our patient's utilisation of them or in researching and developing them, making them cost-effective and then selling them to the government  for approval. It's not enough to be just a good doctor, nurse or allied health/social work professional in this type of system - you have to have vision and be able to innovate as well.

2) We have to be gatekeepers - we have to recognise that for every investigation/therapy we order and get approved for one patient there's another patient who's potentially going without or being forced to wait for that same investigation/therapy. Resources are finite. To my way of thinking this makes us, in general, far more efficient and better at our jobs. We don't order a slew of ineffectual investigations with a scattergun approach - we survey, determine the possibles and try to work through that list by process of elimination and careful choice of relevant investigations.

There's one further thing to add, in the context of the specific tax-funded health care system I'm part of.

We still have private health care. It doesn't really cost much, and it provides a great deal for those who can access it.

We encourage people to adopt private health care cover to decrease the utilization (and therefore cost/strain of resources) of the public health system for a number of reasons. These include access to surgeon/physician of your choice (rather than the on-call doctor of the day or even a physician/surgeon in specialist training), shorter waiting lists for routine non-life threatening procedures and treatments, local access to certain forms of treatment (radiation theraphy and chemotherapy for cancer where a patient might have to travel 800km+ to access the same treatments at public health facilities, as an example) and tax deductions/benefits that (in some cases) cover the cost of the health insurance itself.

[Nmaro Makari]

You know, society bears each other's burdens in more ways than one. Just by going about your day you can and do add to and take the strain from the burden. Absolutely no-one is purely just adding or taking the strain.

Which is why it's puzzling to me that folk complain so much at one of the best ways to make sure the strain of society's burden is lessened, i.e. ensuring your society is healthy. It's a universal plus, when last I looked.

It's called the social contract, and even America loves it. They just seem happy in the closet.

[Vikarion]

What may look like a choice, is not always a choice. The amount of support people get from the surrounding community, in the form of family, friends and work, varies wildly. You can't just simply make these factors to be the way you want them to be but they contribute a lot to how likely it is that you develop an addiction or some other problem

Well, unless you don't believe in choice, you still have to deal with moral hazard.

Ok, let's say it's not a choice.  So what? Let's say that we have a quadriplegic who can't provide for himself, and who also is suffering from a disease that will be terminal unless we spend one million dollars/euros on him. Why should we save this person?

If you are supporting this person, you aren't bearing each other's burdens. You're bearing his, and he isn't bearing anyone else's. This is essentially parasitism, where one party gains at the cost of others. Why does it matter whether it was a choice? It's still there. And how far are you willing to go with this? What if it's not 1 million, but two? Or ten? Or a hundred? Or a billion?

If you (rhetorical "you") really believe that life is so sacred that it is worth any material costs, then you should sell all of your luxuries, supply yourself with the basic necessities to live and work, and donate all excess to those who are in danger of dying, in whatever form will best sustain them. On what grounds do you argue that we should all be forced to do this, but not you in particular, who advocates it? The resources of society are finite, too.

Or if you do want to place a limit, what better spot than at the point of sustainability, the point at which the cost of treating someone is less than their further contribution to society? Of course, our current system in the U.S. does far less than this.

[Katrina Oniseki]

What may look like a choice, is not always a choice. The amount of support people get from the surrounding community, in the form of family, friends and work, varies wildly. You can't just simply make these factors to be the way you want them to be but they contribute a lot to how likely it is that you develop an addiction or some other problem

Well, unless you don't believe in choice, you still have to deal with moral hazard.

Ok, let's say it's not a choice.  So what? Let's say that we have a quadriplegic who can't provide for himself, and who also is suffering from a disease that will be terminal unless we spend one million dollars/euros on him. Why should we save this person?

If you are supporting this person, you aren't bearing each other's burdens. You're bearing his, and he isn't bearing anyone else's. This is essentially parasitism, where one party gains at the cost of others. Why does it matter whether it was a choice? It's still there. And how far are you willing to go with this? What if it's not 1 million, but two? Or ten? Or a hundred? Or a billion?

If you (rhetorical "you") really believe that life is so sacred that it is worth any material costs, then you should sell all of your luxuries, supply yourself with the basic necessities to live and work, and donate all excess to those who are in danger of dying, in whatever form will best sustain them. On what grounds do you argue that we should all be forced to do this, but not you in particular, who advocates it? The resources of society are finite, too.

Or if you do want to place a limit, what better spot than at the point of sustainability, the point at which the cost of treating someone is less than their further contribution to society? Of course, our current system in the U.S. does far less than this.

Well since we're talking about millions and supposedly ridiculous uses for money - I can think of plenty of examples where $1,000,000, two, ten, a hundred, or a billion dollars have been spent on far stupider, far less helpful, and far more costly things. Tax dollars. Like, paying for the President's family vacations to Africa. Or, paying for my governor to have an affair in Brazil. Or paying for three or four failed attempts to replace the M16. Or paying for the entire Iraq, Afghanistan, and possible future Syrian war. Or how about my parents paying for Vietnam and Korea? What about paying for the countless other sorry attempts at things I don't agree with or don't see any benefit from?

After paying for all of that, am I supposed to feel okay with the logic that it's somehow wrong or stupid to save a stranger who has an otherwise terminal illness? Am I supposed to feel stupid for paying those taxes, after paying for wars and frivolity?

I'm sorry, but I can't agree with your logic. You say it's not worth paying millions to save a man from death. I say it's not worth it to pay The President's salary and vacations.

 Guess which one is mandated by law?

[Lyn Farel]

It is very easy to say that until you experience it yourself.

Don't agree ? Well, it has yet to happen to you, has it ?

[Pieter Tuulinen]

Can'st thou, who commands the beggar's knee, also commandst the health of it?

[Ollie]

Ok, let's say it's not a choice.  So what? Let's say that we have a quadriplegic who can't provide for himself, and who also is suffering from a disease that will be terminal unless we spend one million dollars/euros on him. Why should we save this person?

A population of 300 million people supporting a single person's 1 million dollar hospital bill comes out at a total cost $0.003 per person.

The reality is that the numbers in your hypothetical are arbitrary. This illustrates a hole in your reasoning - you've got no real idea of the costs incurred or the ways in which those working within a tax-payer funded system are able to manage that cost.

In the scenario you're talking about it's not the role of 'society' in general to make the decision on who gets their treatment or not - a tax-payer funded system has already decided that should the health professionals responsible for the person's care decide there is benefit in treating him the money is there to do so.

I can point from my own experience to multiple examples of the exact scenario you're describing. I've treated people with burns > 60% surface area where we decided it was best to do nothing and let them die rather than spending the ~50 million dollars it would have taken to give them even the slimmest chance of survival and been the one to communicate that to their next of kin and convince them it was the right decision for all involved. I've told cancer sufferers (on nearly a daily basis since I started working) that they're terminal and that no treatment was going to cure them and they most I could give the was time with some quality of life - and did they want it? I've made decisions on who to take off life support and who to keep on it in critical care situations. All of these decisions are based on a dual understanding of risk vs. benefit (for the patient) and outcome vs. cost (for the system), typically in that order of priority. The surprising thing is that far from being 'parasitic' most people are reasonable in these matters once they've had their questions answered and concerns explained.

It's the responsibility of the health system and its workers to make the decision to treat (or not) and then explain to the patient and their family why they believe their decision is the best course of action. In the system I work in, by and large, we manage that decision responsibly with respect to both the requirements of the patient/family and the resource limitations placed on us.

You seem to understand this in the last sentence of the quoted post, but the rest of your commentary seems to be based on needless scare-mongering and misinformation.

[Vikarion]

Well since we're talking about millions and supposedly ridiculous uses for money - I can think of plenty of examples where $1,000,000, two, ten, a hundred, or a billion dollars have been spent on far stupider, far less helpful, and far more costly things. Tax dollars. Like, paying for the President's family vacations to Africa. Or, paying for my governor to have an affair in Brazil. Or paying for three or four failed attempts to replace the M16. Or paying for the entire Iraq, Afghanistan, and possible future Syrian war. Or how about my parents paying for Vietnam and Korea? What about paying for the countless other sorry attempts at things I don't agree with or don't see any benefit from?

After paying for all of that, am I supposed to feel okay with the logic that it's somehow wrong or stupid to save a stranger who has an otherwise terminal illness? Am I supposed to feel stupid for paying those taxes, after paying for wars and frivolity?

I'm sorry, but I can't agree with your logic. You say it's not worth paying millions to save a man from death. I say it's not worth it to pay The President's salary and vacations.

 Guess which one is mandated by law?

This is a logical fallacy: that because X has happened, I must support Y, even though X is something that has no causal relationship with Y. I don't support X, either. If you want, you can go back and look at the Syria thread, where I was entirely opposed to those sorts of expenditures as well. The fact that those things have been done has no bearing on what should be done except in terms of practicality.

But my question remains: how much are you going to argue we should spend on those who are sick? The argument seems to be that human life is more important than economic considerations, including moral hazard. So how much would you impoverish everyone to save every last life? Or do you, like I, think that one must have a cut-off at some point?

[Vikarion]

Ok, let's say it's not a choice.  So what? Let's say that we have a quadriplegic who can't provide for himself, and who also is suffering from a disease that will be terminal unless we spend one million dollars/euros on him. Why should we save this person?

A population of 300 million people supporting a single person's 1 million dollar hospital bill comes out at a total cost $0.003 per person.

I picked numbers out of the air because I wanted to start relatively small. My question is, aside from sentiment, what is there to be gained in sustaining someone who contributes less to the rest of us than they consume?

[Ollie]

As I said, I believe that your question was irrelevant at best and scare-mongering at worst.

In the tax-payer funded system you're talking about that question isn't the responsibility of society to answer but that of trained health professionals who keep their eyes on both the costs involved as well as what benefit treatment will or won't offer to their patients. It's a decision that's made at every branching point of treatment for every patient on an individual basis.

Addit:
To answer the specific hypothetical you addressed, in the tax-payer funded system I work within we would explain to the patient that his/her disease is terminal and what we should be aiming to achieve with any treatment is adequate quality of life with whatever time he/she has remaining. Aggressive 'curative' treatment would not be put on the table as an option because it offers no benefit and comes at significant risk and cost. Treatment would be palliative with an intent to minimise the symptoms that bother him/her. Euthanasia would not be offered - it goes against the principal of what a doctor is there to do and it is also illegal in our country. Withdrawal of all treatment - which usually results in speeding up the demise of a terminal patient - would be offered if the patient or family (if the patient is incapable of making the decision) agreed to it.

That's how the system you're describing in your hypothetical actually works in practise, at least in my experience.

[Katrina Oniseki]

But my question remains: how much are you going to argue we should spend on those who are sick? The argument seems to be that human life is more important than economic considerations, including moral hazard. So how much would you impoverish everyone to save every last life? Or do you, like I, think that one must have a cut-off at some point?

You're right, you did say you were opposed to the war spending. I'll grant you that.

I just refuse to accept the concept that treating someone's health is less important than going to war. I realize that isn't what you meant, but that is what's happening. We spend on much worse things than healthcare, and I do feel it's very deeply wrong.

I would prefer a system where there are limitations on what can be paid for using taxpayer money, yes. I'm not willing or qualified to state what those limits would be. I'm just a poor kid in the back woods. I don't know enough to judge.

That said: I'm sorry, Vik. I just can't agree with you that healthcare financing should be remain almost completely privatized in the U.S. It's my political opinion, and I have and will continue to vote on it.

[Pieter Tuulinen]

It's not like this is completely intellectual as an exercise. Look at almost completely privatised healthcare (America) and various degrees of nationalised healthcare (the rest of the civilised world) and ask yourself which one is achieving the objective of providing the best averaged standard of health for the most efficient cost.

The problem with a privatised healthcare system is that it's objective is making money, not providing healthcare. That's why the US healthcare system is SO inefficient.