Is illness a choice?

food choice

During my years of medical training I learned about the many causes of illness, but evidently that understanding is outmoded. Sophisticated Americans know that illness is a choice. People bring it upon themselves by their own choices. This new understanding is incredibly liberating. No need to feel sorry for people who are sick because it is their own fault. No need to provide healthcare, since poor health is attributed to bad choices. Best of all, no need to worry about getting ill. If illness is a choice, all you have to do to stay healthy is slavishly follow the socially mediated goals for weight and exercise, and nothing bad will ever happen to you.

Unfortunately, illness is not, by and large, amenable to choice. The new understanding of healthcare, what everyone knows to be true, is that diet and exercise are magically protective, that preventive medicine is the only medicine that counts, and that illness is a sign of slovenliness and lack of self-discipline. This new understanding tells us more about the psychological needs of the people who believe it than it tells us about health and disease.

Only a small fraction of illness is caused by lifestyle choices. The leading cause of disease is aging. The wear and tear on the human body inevitably leads to breakdown, whether the breakdown is physical or cognitive. No one chooses to get shingles, suffer from Alzheimer’s or to succumb to diseases like the flu that would be far less serious in younger adults.

Infectious diseases, caused by viruses or bacteria, are not amenable to choice, either. Viral or bacterial illness is usually caused by nothing more than being in the wrong place at the wrong time, being exposed to an illness that someone else has. Fortunately, preventive care for infectious diseases is highly effective. It is called vaccination and it saves ten of thousands of American lives each year.

Some diseases are genetic. These include diseases with obvious genetic causes like sick cell anemia or Huntington’s Disease, but other diseases like cancer almost certainly have a genetic basis, too. That genetic basis may be a propensity to develop the disease through mechanisms that we do not yet understand. It is likely to turn out that cancer, auto-immune diseases, and even heart disease are mediated by our genes.

It is true that some lifestyle choices behaviors impact the chance of developing illness, in particular smoking, drinking to excess and eating to obesity. Yet it is far from clear that even these behaviors are entirely amenable to choice.

Many of the worst excesses are the result of addiction. People do not make a conscious choice to become alcoholics or drug addicts. Yes, the decision to drink for the first time or to use drugs for the first time is a choice, but being gripped by addiction is not a choice at all. Indeed, there is some evidence that there is a genetic predisposition to addiction. While most people can drink alcohol without any permanent effects, alcoholics have a different reaction, one that leads to an inability to stop drinking.

Even making the choice to engage is a behavior known to be harmful does not mean that one has chosen to become ill. Most people who smoke don’t get lung cancer, and many people addicted to tobacco assume that they will avoid that dreadful outcome; they certainly don’t choose to get lung cancer.

The bottom line is that there is no evidence that illness is a choice. So why do many people persist in believing that it is a matter of choice?

It’s not difficult to understand their rationale. If illness is a choice, then they can choose not to be ill. If illness is a matter of failing to meet socially mediated goals for weight and exercise, staying healthy is easy: just meet those goals by dieting and exercising. In addition there’s need to feel sorry for people who are sick because it is their own fault. And there’s no need to provide reform the healthcare system, since poor health is attributed to bad choices.

Pretending that illness is a choice minimizes both fear and guilt. Sadly, it is nothing more than wishful thinking.