Death by Chocolate by mattsteinglass
July 29, 2009, 7:58 pm
Filed under: Health

Yesterday Megan McArdle wrote a long post explaining why she opposes universal health care, on principle. It came down to a fear that government bureaucrats will tell her she can’t have more than one chocolate eclair. No, I shouldn’t make light of this; it’s a good post. I disagree completely with virtually everything she says in it, but I’m glad she wrote it. I now have a somewhat clearer sense of what it is I disagree with so completely.

Megan’s overarching anxiety about universal health insurance, the fear she raises at the end of her piece, is that it will ultimately force the government to start restricting behavior in order to control costs.

Once the government gets into the business of providing our health care, the government gets into the business of deciding whose life matters, and how much.  It gets into the business of deciding what we “really” want, where what we really want can never be a second chocolate eclair that might make us a size fourteen and raise the cost of treating us.

Let us note here in passing that Medicare has not attempted to ration chocolate eclairs for seniors, nor are these desserts exactly hard to come by in countries like France and the Netherlands, which have universal coverage and much lower costs than the US. (The Netherlands even has comparable obesity rates.) But moving on: the reason Megan thinks this intervention will be heavy-handed is that the government has no real idea how to make people less obese.

When you listen to obesity experts, or health wonks, talk, their assertions boil down to the idea that overweight people are either too stupid to understand why they get fat, or have not yet been made sufficiently aware of society’s disgust for their condition.  Yet this does not describe any of the overweight people I have ever known, including the construction workers and office clerks at Ground Zero.  All were very well aware that the burgers and fries they ate made them fat, and hitting the salad bar instead would probably help them lose weight.  They either didn’t care, or felt powerless to control their hunger.  They were also very well aware that society thought they were disgusting, and many of them had internalized this message to the point of open despair.  What does another public campaign about overeating have to offer them, other than oozing condescension?

But wait a minute. What Megan is saying here is the exact opposite of the conventional libertarian-conservative line against government restrictions on fatty foods, which is that people who don’t want to eat fatty foods should just not eat them. That line was memorably encapsulated in Morgan Spurlock’s “Supersize Me” by a conservative man in a Stetson hat who proclaimed that anyone who doesn’t want to eat at McDonald’s can just drive on by, and that it’s none of the rest of our business what McDonald’s puts into its food. That was also, unsurprisingly, the position taken by the fast-food industry lobbyists in the movie.

But Megan is saying this isn’t true. She’s saying that overweight people — like, for that matter, pretty much everyone else — are unable to control their eating behavior. And she’s absolutely right about that; in fact, you have to be a bit deliberately dense not to understand that most people do not have full voluntary control of their eating.

And contrary to what Megan writes, obesity experts and health wonks are not deliberately dense: they do not think that overweight people could lose weight if they just tried, or are too stupid to know why they are fat, or that they don’t experience enough social stigma. Health experts, like all behavior change specialists, understand very well that more information about health risks does not usually, by itself, lead to behavior change. They learned that lesson decades ago in the battle against smoking, and re-learned it in the battle against AIDS. Just knowing that something is going to kill you doesn’t make you stop doing it, not if it is deeply embedded in your social rituals, unconscious habits, or sense of self — or, obviously, if it is physically addictive.

And that is precisely why changing health behavior is usually not something that can be done by individuals. It has to entail a broader social effort to create environments in which being healthy is easier than not, and to discourage people and businesses from creating unhealthy environments. Megan writes that the overweight people she knew at Ground Zero “felt powerless to control their hunger,” were “very well aware that society thought they were disgusting,” “had internalized this message to the point of open despair.” The portrait Megan paints of is of people asking for help. They don’t want to be fat. But they can’t control their eating and exercise behaviors on their own. Almost none of us can. We need intervention to make it harder to eat lots of unhealthy food, and to make it easier to eat healthy food and to exercise. These people are essentially saying: “Mayor Bloomberg! Please ban trans fats, before I eat more of them!” And stop subsidizing corn syrup, and pave more bike lanes, and build more walkable neighborhoods, and put calorie labels on chain restaurant menus, and put PE and recess back in the school day for schools that have lost them, and ban deliberate “smell-vertisement” by fast food stores as a public nuisance, and go ahead with whatever other range of programs you think appropriate, some of which may help some people, some of which may help others, to reduce the constant temptation to eat cheap, fattening food that now surrounds us on the American streetscape.

Perhaps Megan thinks none of these interventions will work. If they won’t, it’s not clear to me why she thinks the government will face pressure to employ them to save money. Certainly, I can’t imagine anyone being so stupid as to think one can reduce obesity-related health care costs by further stigmatizing the obese. The US already engages in plenty of ineffective stigma-based ad campaigns to try to stop teenagers from having sex and using drugs, but the motivations are chiefly moralistic rather than fiscal, which is why their proponents don’t care that they don’t work. In any case, though, if Megan doesn’t think anything can help the obese to lose weight, what does she think society can do for them? Stop stigmatizing them? Because that ain’t gonna happen; it would be a quixotic project that would require a lot of, well, government-funded sensitivity training campaigns…

Situations where people are not rational and do not have autonomy over their own actions, or in this case even their own desires, are problematic for libertarians. Some libertarians cope with these kinds of issues by simply pretending that people are always autonomous, responsible actors; they might say that by not controlling their eating, obese people are displaying a “revealed preference” for eating lots of fatty food over being thinner, or something stupid like that. Megan doesn’t engage in that game. But in this situation where people are saying they’re psychologically unable to act in what they identify as their own interests, Megan seems to be unwilling to reach into the social toolkit to help them out, because she can’t see reaching into the social toolkit as anything other than coercive. I’d bet that when she so much as reads the phrase “reach into the social toolkit,” she shudders, even when it refers to paving more bicycle lanes. So what does she think can be done?

I think she thinks that nothing can be done. “Nothing can be done” is not an appealing political program. It doesn’t even seem to me like an appealing way of being in the world. But, in large measure because a lot of congresspeople share these kinds of unexamined quasi-libertarian ideas about health care, it seems possible that nothing is exactly what will get done about health care in the US.


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“I’m not hurting anyone but myself,” is a pretty common rationalization for addictions and other unhealthy behaviors. Perhaps a realization that we all have a stake in one-another’s health is a good thing. The healthier I am, the healthier the country is, fiscally, spiritually, and physically.

Comment by AC

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