Managing risk, paying the cost

Managing risk, paying the cost

 

(apologies if this gets a bit long winded…)

Yesterday we had a quick discussion on the efficacy of wearing a bicycle helmet, choosing not to wear one, and the possible effects of making it mandatory. I finished off by suggesting that there was an analogy to be drawn between choosing not to wear a helmet and suffering a preventable head injury, and a similar situation that has been hotly debated in the medical profession for a number of years around the globe.

Now, assuming it can be shown that helmets can be effective in reducing head trauma, then it would seem logical that if someone is going to be performing an action that leaves them open to the possibility of head trauma, it would make sense to wear a helmet (for the record, I agree that if it were that simple, helmets would be worn by almost everyone at some point in the day regardless of the activity, but let’s leave that for another time).

This invites one to question whether or not someone should be held liable for putting themselves in a position that could result in injury, especially when it comes to treating that injury and paying for it with public funds. Here’s where it gets interesting…

Smokers pay a premium for health insurance (when they qualify in the first place), right (edit: wrong, as far as Australia is concerned, actually. See the comments)? They are choosing to perform an action that compromises their health and can introduce higher costs to the health system (not to mention clogging it up at the expense of people who are not suffering at their own hand) and the insurer, who knows this, and is hedging themselves against the increased chance that they will have to pay out for a problem in the future. Same goes for home insurance – if you have no locks on your doors, good luck with getting insurance, and the more secure the residence, the lower the premiums. We have no problem accepting this kind of arrangement in a general sense. These aren’t even public funds, as such (though they are still based on many people paying into one provider), but we still accept this as a reality.

There has been a debate going on for years over whether or not doctors have the right to refuse treatment to patients for smoking-related conditions until they commit to stop smoking – which would be the actual and best cure, long-term. Not to mention the unnecessary use of resources of the medical profession that could be spent on other patients without (as) self-inflicted conditions, and the cost that the general public is paying to basically support the ongoing treatment of a problem that is continuing to be voluntarily exacerbated by the patient.

This actually bears a similarity to the helmet debate in a broader sense. Listen to this, from Mr Maurice Swanson, the Heart Foundation’s national spokesman on tobacco control: “The focus of the debate should not be on these patients, but on the tobacco industry that continues to ruthlessly market, promote and make widely available a lethal and addictive product that kills more than 15,000 Australians every year”.

Sound like a familiar line of thought? Almost exclusively, those who are pro-cycling argue that the way to reduce injuries to cyclists is to improve the situation that allows conflict to occur between cyclists and motorists in the first place (infrastructure). It’s a more complicated situation when it comes to cycling, as there are many more factors than simply helmet or no helmet as it is with smoking or not smoking (I know it’s not quite that simple), but it’s interesting to think about.

Managing risk, paying the cost

Risky? Image source

Sure, if there were no cigarettes around to smoke, no one would smoke them and a significant number of people would be better off, as would the healthcare system. But as it stands, companies have a right to offer people their cigarettes, and people have the right to smoke them, even though we all know better. Because we know better, some medical professionals find it absurd that they should have to continue to fix a problem that the patient is not interested in fixing themselves.

This paper discusses the ethics of refusing care to smokers, and you can easily replace smokers with anyone else who chooses to act in a way that is potentially harmful to themselves at the cost of others. It is a very complicated issue and becomes quite sensitive when discussing a denial of medical care, which, when it comes down to it, is very difficult to do with good conscience. The slippery slope of refusing care in one situation (smokers) to then having to refuse care to other similar cases is real, such as procedures for problems related to obesity or other lifestyle choices where simply changing one’s lifestyle would be the cure, and in the end care is almost always granted regardless of how ridiculous or not the patient is.

It is the same with insurance policies. In the end, whether or not a person was wearing a seat belt, a life insurance policy is pretty much always paid out even though that person might have had a very good chance of living had they been wearing a seat belt.

Though it might be tempting to say, “if you choose not to wear a helmet when cycling, you must take responsibility for any head injuries that you incur”, it is extremely difficult to put that into practice, regardless of whether or not it is ever justified.

In the end I feel as though you have a duty of care, to yourself and those who must take care of you, to be managing risk to your best ability, but starting with those actions that are the easiest.

Wearing a helmet is no more a real barrier to cycling than wearing a seat belt is a barrier to driving. Personally, I believe that anyone who gets enraged about having to wear a helmet is really fighting against the notion of being controlled, to be made to do something that they don’t want to do (even though they are fine with this in other aspects of life). If you had to choose right now between preventing a brain injury and either your hairstyle or “not having that feeling of freedom”, you would choose preventing a brain injury. The issue is that some people are determined that they will never really need a helmet, and so feel that the risk is minimal enough that style and “that feeling of freedom” is worth it. In reality, you probably won’t ever actually need the helmet.

But is it worth the chance? For some it is, and for some journeys the risks are minimal enough to be quite reasonable.

What happens when there is an accident or collision?

In most of the world, helmets are recommended, but optional. In Australia and New Zealand, it is mandatory. Given that, when it comes to an actual collision between a cyclist and… well, anything, really, the only form of protection that they have at their disposal is a helmet, it would seem pretty straight forward that using one is managing risk in an obvious and intelligent way.

Keep in mind that I’m not talking about the host of incredibly important factors that contribute to preventing a collision in the first place – I’m talking specifically about when there is a collision.

Managing risk, paying the cost

Image source

Of course, this is a discussion based on theory. There are many contributing factors involved in a collision, and it may well be impossible for anyone to determine what effect a helmet had or could have had in preventing injury. In principle, though, if a helmet could have prevented a serious head injury that necessitated time and money to treat, should the victim be liable for covering that cost?

I used the term victim purposely. Everybody gets really, really upset when anyone says anything that even suggests victim blaming, but hear me out.

You are actually ok with this, if you’d only care to admit it. The question is rather, at what point is the victim to be held responsible for their own misfortune?

This is seriously, seriously, contentious stuff. Of course there are situations where it is ludicrous to apportion blame to the victim (violence against women is usually the first to come to mind), but there are others that seem so commonplace and logical that we would be baffled to consider that it should be otherwise.

There are a million examples, but they pretty much all fall into the broad categories of negligence, due care, improperly managing risk, etc. If you go to work on a building site wearing thongs and you lose your toes, that’s pretty much your fault. If you weld without wearing goggles and you go blind, that’s your fault. If you go boating without a life jacket and drown, that’s your fault. If you are a smoker and have vascular pain, that’s your fault. If you drive under the influence, or more likely these days, while texting, and cause a crash resulting in death, that’s your fault. If you make a car journey without enough fuel and get stranded, that’s your fault. If you are killed in a car accident due to not wearing a seat belt, that’s your fault. If you leave your windows open and your doors unlocked while not home and your stuff is stolen, that’s not directly your fault, but it’s pretty stupid, and your insurance policy says “that’s your fault”.

If you cycle without a helmet and suffer a head injury – is that your fault?

If you are mountain biking without a helmet and you come off and hit your head, everyone would agree that you should have been wearing a helmet and that it’s your fault. If you are riding a road bike and take a corner too fast, come off and hit your head, that head injury is your fault (as much as a helmet could have helped, of course, given the severity of the impact).

As soon as you introduce another party to the equation, it gets difficult. If someone driving a car knocks you off your bike and you hit your head on the ground, is that your fault? Getting hit may not have been your fault (but it might have been…), but if you could have prevented the head injury by wearing a helmet but chose not to, strictly speaking, that choice directly contributed to your head injury. Which sounds a lot like: your fault.

Should it matter if someone else started the chain of events? That’s an interesting one to think about. Where does fault lie and how can that shift between those involved in a chain of events?

It’s all about taking a sufficient level of precaution, which can go all the way down the spectrum to criminal negligence in the worst cases.

Managing risk, paying the cost

Image source

If you are cycling in a controlled environment and choose not to wear a helmet, then the risks are very slim that you will have a collision. If you are cycling in an uncontrolled environment the risk increases that you will have a collision. Due to the increased risk (the odds are statistically slim, but the potential is relatively high) and a readily available and easy solution to decrease the harm if that risk reaches 100%, it seems unreasonable to not wear a helmet.

Anyway, we’ll never really get to the end of this debate until it’s just dropped, which it won’t be, because there are real issues on both sides. I’m not even sure what I’m arguing for. I’m not in support of mandatory helmet laws, but I am in favour of wearing helmets. The cause of collisions needs to be the focus of any discussion rather than helmets, but it still strikes me as such a simple method of reducing your risk of head/brain injury that it nearly seems reckless to choose not to. Maybe all I’m reacting to are those activists who militantly put forth weak arguments in favour of not wearing helmets like it’s the final nail in the coffin of cycling, when I can’t understand how it’s a big deal at all.

Maybe I’m the weird one who just doesn’t get it. Maybe I’ve already been brainwashed. Maybe I’m misinterpreting this whole thing. Maybe it really isn’t a big deal, and maybe really doesn’t make any difference to injuries or death either way. Who knows.

The cost to treat a few injured but helmet-less cyclists as compared to the huge number of non-helmeted motorists, smokers, obese, and inactive people would hardly even register as a blip, so even if one does argue that a person should be held liable for their own actions, you would tend to think that cycling would be pretty far down the list of things to crack down on.

I’m not interested in making a bad situation worse for accident victims. I just want people to think critically and realistically about the choices they make.

Then again, we enjoy and even pay athletes to beat the snot out of each other on a daily basis and expect them, and everyone watching, to appreciate that they perform for us knowing the risks involved. Why should we expect anything different from cyclists?

Your thoughts?

 

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