"It is a tempting idea that we could cut health expenses by letting patients suffering from so-called lifestyle diseases pay for their own treatment. But this requires that we as a society can justify the claim that these people actually are responsible for their own conditions -- particularly in a welfare state where we have free and equal access to medical treatment. It is not, however, a claim that is easy to justify if we accept that we are products of genetics and social circumstances," says PhD Martin Marchman Andersen from the University of Copenhagen.

Free will vs. genetics and social legacy

Is it our own responsibility?

A 2011 survey from the University of Copenhagen showed that almost 50 percent of the Danes believe that obese people should pay for their own obesity operations if they are shown to be responsible for their conditions. And according to Martin Marchman Andersen, these ideas are gaining ground as the Scandinavian welfare states struggle in the wake of the financial crisis and as we learn more and more about the causes of lifestyle diseases.

"The main argument of why we should be held responsible for our own health is the belief that we have free will; free will is the idea that we are the causes of our own actions and that our behaviour is not triggered by external factors. So if we say that a young man takes up smoking of his own free will, we also say that there is no previous cause. But it is very difficult to imagine that there is no previous cause at all, for instance that everybody the young man knows is a smoker and that he therefore would be an anomaly if he did not take up smoking," Martin Marchman Andersen points out and adds:

"The point is that the causal relationships within biology, sociology, and psychology we usually employ when we want to understand human behaviour must apply to lifestyle diseases too. It is not very likely that a young man who takes up smoking is immune to his genetic make-up or his social circumstances in such a way that we can justify the claim that he is responsible for smoking."

This does not mean that patients can never be held responsible, but we need other arguments than the ones we have used so far. And Martin Marchman Andersen underlines that even if we as a society decided that some patients in certain circumstances are to be held responsible for their own health, it would not automatically follow that we could just write out hospital bills to smokers in treatment for smoker's lungs.

Are smokers an economic burden?

Martin Marchman Andersen's research shows that if smokers are to be held financially responsible for their health problems, the condition must be that they are proven to be an economic burden for society even when the complex impact calculations have been made.

"Economists have tried to calculate whether smokers cost society more than non-smokers, but they have not been able to reach a conclusive answer. And all the studies suffer from the same problem; they compare the costs of smokers with the costs of non-smokers, and that is too simplistic a model," says Martin Marchman Andersen and expands the point:

"We know from numerous studies in social inequality within health that lower social groups have a higher probability of contracting a number of diseases -- even if they are non-smokers. Merely comparing the costs of smokers with the costs of non-smokers may lead to the conclusion that smokers cost more than non-smokers for reasons that have nothing to do with smoking."

If we want to know whether a smoker is an economic burden, Martin Marchman Andersen concludes, we should compare the costs of the smoker with the counterfactual costs if he had never been a smoker. Only in cases where the former costs exceed the latter costs, we can say the smoker is an economic burden. The smoker's financial responsibility is, in other words, the difference between the two types of costs.