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Perspective | globe magazine

The hidden costs of choice

Why bad personal decisions – not wearing a motorcycle helmet, not buying health insurance – endanger the rest of us.

Illustration by Matthew Hollister

Plenty of politicians like to talk about “personal responsibility,” but there seems to be disagreement about what those words mean. In 2009, President Obama gave a controversial speech telling schoolchildren they need to take responsibility for their educations. At a debate last month, libertarian presidential candidate Ron Paul said Americans should be free to make their own choices, adding that the government shouldn’t have to intervene to help a man who chose not to buy insurance and then got sick. The man should “assume responsibility for himself,” Paul said. “That’s what freedom is all about: taking your own risks.”

Those comments made me think back to my college days. After I graduated, I headed West to San Francisco. As a small-town kid from Kentucky, I was a little wide-eyed and excited by the freedom. So I bought a motorcycle, red and fast. I wish I could say I always wore a helmet, but I didn’t. I refused to think about the risks, instead focusing on the wind-in-the-hair joys of helmet-free adventure. Was I acting with personal responsibility?

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Of course not. My decision was stupid and shortsighted and put me at massive risk. Beyond that, those who loved me risked suffering emotionally, and society risked losing whatever benefits would have come from my economic productivity and general good humor. If “personal responsibility” means “being responsible,” then I should have made the smart choice to wear a helmet.

But to plenty of Tea Partiers, “personal responsibility” means that Americans should be allowed to make their own choices, even dumb ones. According to this thinking, I should be allowed to ride without a helmet – or remain in my home in the face of a hurricane-evacuation order or eat only Big Macs – as long as I also accept responsibility for the consequences.

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So these two meanings of “personal responsibility” – maturity and choice – seem to offer different implications for public policy. Yet they really don’t, especially when it comes to health care. Let’s say that as I return from a night out on the town I lose control of my motorcycle and hit a tree. The paramedics arrive and see I’m not wearing a helmet. As a policy matter, what does a respect for personal responsibility require? Should they help?

Most people would say yes. We simply do not live in a society where we leave injured people at the side of the road, even if they brought the injuries on themselves. If respect for choice required such hardheartedness from others, of course, it would extract a societal cost. A libertarian framework creates a choice for bystanders – help or don’t – but both are burdensome.

What does it mean, then, to require me to suffer the consequences of my choice? At the very least, it means I should pay my own medical bills. But medical care is expensive, and few of us could afford to pay for weeks of it out of our own pockets. Those costs would quickly make me insolvent, which means that other taxpayers would eventually have to pay for my decision.

A respect for choice, if taken seriously, does not translate into the simplistic libertarian prescriptions trotted out by Paul and others. It is impossible to be held accountable for our choices if there’s no one to force us to pay for them. The only way the Libertarians could make sure the financial costs of a person’s decisions are not borne by others is to require them to buy insurance. Think of it as making a down payment on the freedom to act stupidly.

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If personal responsibility means being responsible, then it is not inconsistent with that notion to require people to make the mature decision to purchase health insurance. Sometimes a respect for the autonomy of others means the government needs to step in with a law or regulation, if only to make sure we pay the costs of our own decisions.

But when people are allowed to make bad health choices and not have health insurance, Paul’s approach puts the rest of us in a bind. We can either choose to watch our neighbors suffer – drive by the scene of an accident without calling 911 – or we can help and foot the medical bills ourselves later. We shouldn’t let the Libertarians’ fixation on choice force the rest of us into making that kind of decision.


Kent Greenfield, a professor at Boston College Law School, adapted this essay from his new book, The Myth of Choice: Personal Responsibility in a World of Limits. Send comments to magazine@globe.com.