Ashton Kutcher recently remarked on Real Time with Bill Maher in talking about healthcare, "Frankly, I don't want to pay for the guy who's getting a triple bypass because he's eating fast food all day and deep-fried Snickers bars."
As promised in my previous post, we need to understand the factors behind noncompliance. Almost half of all patients in the United States don't comply with the medical advice from their physicians. Perhaps we can begin to unpack why this is so, sidestepping the typical media rhetoric.
Although overeating and poor nutritional habits are important issues, other factors in how people compromise their health should be considered as well. Many people refuse to take their medications as prescribed. Others simply forgo therapies that cause discomfort (such as devices which control sleep apnea), even when they know that such treatment will prevent more serious illness. Some people even decide that Western medical care is not useful and decline allopathic treatment altogether in favor of alternative therapies, or worse, seek no treatment at all.
Noncompliance divides roughly into two broad issues: problems within the practice of modern medicine itself, and the reasons why people are unwilling to follow medical advice or simply don't want to take care of themselves. We all know what's involved in the first issue: the restrictions of managed care, lack of time and attention from physicians, limitations of insurance coverage, to say the least. The second issue is more complicated.
Self-care can be overwhelming: taking medications regularly, managing weight, and getting enough exercise require time and energy, and become more difficult as we age. Though health habits are hard to change, some people feel so nervous about growing old and becoming ill that they actually engage in behaviors that will hasten illness. Though contrary to common sense, consider the image of a doctor who smokes, as in the popular television shows Weeds and Nurse Jackie, and not unheard of in the medical profession overall. Why do people engage in deliberately self-destructive behaviors?
Even people who "know better" can find it difficult to take care of themselves. Psychologically, smoking can be related to the anxiety people feel about the random occurrence of illness---something bad could happen to my body. If we can't bear the uncertainty of not knowing what will happen, then people take matters into their own hands. It is as if the smoker is saying, I might get lung cancer, but at least then I know what's making me sick.
So, although Ashton Kutcher's comment may echo popular public opinion, where do we draw the line regarding healthcare behaviors? The Snickers Bar Standard is a straw man---it falls down on closer examination because compliance is unenforceable. Human psychology is far too complex to separate the villains from the victims.
Perhaps if we try to understand why people don't take care of themselves and consider all of the complicated issues at play (including a healthcare program which integrates long-term psychotherapy), then we can design and establish a healthcare system that helps people stay healthy instead of pathologizing the very people it's meant to benefit.
