Wednesday, June 16, 2004

This is something I have wanted to rant about for awhile but just haven't had the time to do so. With the coming of summer there has been an emphasis on speeding and compliance with the seat belt law in Georgia. The "Click it or Ticket" campaign finished last week. While I consider myself a libertarian in many ways (for drug legalization, against government regulation of fast food, ect), there are some ways I diverge from libertarian orthodoxy. In other words when it comes to seat belt use requirements and motorcycle helmet laws I am a "small -l" libertarian, rather than a "large L" one. Some may think me hypocritical since I resent government interference with what people put in their mouths, how they educate their children, or do in their bedrooms; but am more than willing to go along with restrictions on how one rides a motorcycle or drives a car. They may be right. I'm sure it has to do with the patients I see in my trauma practice, and how many injuries and deaths could be avoided if people would buckle up or wear helmets. Now I've heard all the anecdotal stories about car crashes where the patients say that they would not have survived the collision had they been restrained. I'm sure that such things happen, but statistically in a crash you are safer in a car which has been designed with your safety in mind than flying out into the cold, cruel world.
What got me thinking about this was an article in Reason Online last month about this topic:

Who's the bigger threat to your safety, a murderer or someone who attempts suicide? The answer is obvious, and we'd certainly jeer any mayor who suggested lowering a city's death toll by cracking down on suicides. Yet something strange happens when death comes to the highway. Politicians lock arms with law enforcement, and come up with campaigns like "Click It or Ticket," which began Monday and aims to reduce highway fatalities through stricter seat belt law enforcement. Suddenly, the murder-suicide distinction vanishes, and it's perfectly acceptable to reduce deaths by punishing those who put only themselves at risk.

But given the recent problem of interstate bridge jumpers in Atlanta, not even those who wish to take their own lives operate in a vacuum.


But if an adult does something risky-like tightrope walking, smoking or driving without a seatbelt-that person alone is responsible for the consequences. And since drivers who don't buckle up aren't making anyone else less safe, laws that bear down on these people don't make other motorists any safer either. We should be allowed to ruin our own lives, but we shouldn't be allowed to ruin the lives of others. So, yes, it's tragic when someone dies because he refused to wear a seatbelt, but it's much more tragic when a reckless driver kills innocent people. Public policy should not concern itself with decreasing all highway deaths, but with decreasing the deaths of innocents.

Sounds great, but in the real world those people are not alone responsible for their consequences. They arrive at the ED and are treated the same if they were wearing a seatbelt or helmet or not. The physicians, nurses and hospital staff who take care of these patients suffer the consequences of their actions. If these people are uninsured, the hospital suffers from the consequences of their actions. If these people qualify for disability due to the collision, then everyone suffers from the consequences of their actions.

But can't the same be said for overeating or smoking? Yes, and I pay more for my life insurance because of my weight and risk underwriting may be coming to health insurance as well.

What about such programs like the one in Florida which mandates the purchase of at least $10,000 of insurance if they wish to ride a motorcycle without a helmet? Such policies are a good idea but ten thousand dollars would be inadequate to cover much of an acute hospital stay associated with a severe injury, much less the long-term care and rehab that would be required.

The argument can be made that seatbelt use can actually lead to worse driving habits:

And seat belt laws come with their own set of unintended consequences, which further complicates the principle that policy should protect the peaceful people from the dangerous. Seat belt laws may make drivers and children safer, but economists such as Christopher Garbacz suggest that greater safety can make drivers more comfortable with dangerous driving, which puts the lives of more innocents—like pedestrians, cyclists and other passengers—in jeopardy. Risk assessment researchers have long pondered this paradox, and some have even suggested (only half jokingly) that the best way to promote cautious driving would be to attach a twelve-inch buck knife to all steering wheels.

The same can be said of anti-lock brakes, airbags, and front and rear-end crumple zones. Are there people advocating the removal of those devices from passenger cars? Those features are also mandated by the government. Does the mere fact that seatbelt use requires active participation by the occupant of the vehicle make regulations regarding their use especially burdensome?

And what of consequences? In Georgia the only consequences seem to be fines and points on your license if stopped. Other than the injuries suffered by the unrestrained occupants in a crash, there is really no downside according to Georgia law:

Ga. L. 2000, pg. 764, Code 40-8-76.1, item D
The failure of an occupant of a motor vehicle to wear a seat safety belt in any seat of a motor vehicle which has a seat safety belt or belts shall not be considered evidence of negligence or causation, shall not otherwise be considered by the finder of fact on any question of liability of any person, corporation, or insurer, shall not be any basis for cancellation of coverage or increase in insurance rates, and shall not be evidence used to diminish any recovery for damages arising out of the ownership, maintenance, occupancy, or operation of a motor vehicle.

So if you don't wear a seat belt and are injured that fact cannot be used to reduce other's liability in any lawsuits that may arise. See this case for an example of this in action. (via Overlawyered). So this adds insult to injury by nannying us into wearing our seatbelts, but removes any real consequences if we don't. You want a seatbelt law with teeth, keep the fines and points, but also codify that any injuries you sustain if not wearing a seat belt are due to your negligence and other parties cannot be held responsible for them. Even more draconian measures would allow for the waiver of EMTALA regulations under those circumstances.

In writing this I continue to struggle with the difficulty, possibly delusional, in reconciling my libertarianism with my obligations as a physician. If we were to refuse to treat those patients whose conditions were brought on by self-abuse then our waiting rooms would be empty indeed.

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