Why we punish charities that help bad lifestyle choices

01 April 2020

By Zvi Safra and Tigran Melkonyan

Is it fair that somebody who has been a heavy drinker for much of their life be given a liver transplant ahead of somebody who has been unfortunate to develop liver problems despite leading a teetotal lifestyle?

Or should somebody, who through mental illness has become dependent on binging with comfort foods, be denied a hip replacement because they are overweight?

These are the moral dilemmas overstretched healthcare systems around the world have been grappling with. Indeed, in 2014 the UK’s National Health Service decided to allow people with severe drink-related liver diseases to be considered for liver transplants. A decision that ignited a lot of media criticism.

But then in 2016 hospital leaders in North Yorkshire, UK, announced that overweight patients and smokers would be prohibited from most standard hip and knee surgeries for up to a year.

These two opposing views by different parts of the NHS indicate the confusion over what is right and what is wrong in making decisions about scarce resources for the good of society.

Indeed, the ‘justice’ argument is one philosophers, and politicians, having been debating over for many decades. At one end of the justice spectrum we have strict egalitarianism, which does not hold individuals responsible for any causes of inequality. According to the principle, social redistribution should be based solely on the outcome of people’s situation, no matter how they reached it.

Meanwhile, at the opposite end of the spectrum is libertarianism, which argues that individuals should bear full responsibility for their circumstances even if they are caused by bad luck.

Choice egalitarianism sits in the middle, combining some individual responsibility but also acknowledging that people can be unlucky, so it holds people accountable for their choices but not for their luck.

We wanted to find out where public opinion stood on these two different stances. Our research has found that the public largely agree with North Yorkshire doctors, they are, in the main ‘choice egalitarians’ – that is they reward good behaviour and punish bad.

We looked at donations to different cancer charities and found people will ‘punish’ charities that support cancers which are preventable through changes in lifestyle, rather than being down to bad luck. Either they will prefer not to give them money or will give them less than other cancer charities.

When people were asked to allocate $100 for the treatment of two different cancers, one for a hereditary cancer and the other for a typical lifestyle-related cancer, the average allocation was $66 to the former and $34 to the latter. We found up to 67 per cent of people exhibited choice egalitarian behaviour.

And women are willing to punish more for bad behaviour than men. In general women are more risk-averse than men, so this is in line with what we would expect of people who avoid irresponsible behaviour.

How do we decide which charity to give to?

In another study we analysed a year’s worth of data from Cancer Research UK’s website on donation patterns. Excluding contributions above $200, which were usually from organisations, we had 4,129 donations to analyse. There were more female donors, with breast cancer gaining the most money, but men’s donations were on average 16 per cent higher.

The website had 24 different cancer types and research projects that people could donate to and we discovered that donations to cancers which were due to lifestyle choices were 17.4 per cent lower. And the difference in charitable-giving from women was even larger, with the cancers for which lifestyle-related causes were mentioned in the descriptions having 27 per cent fewer donations, far lower than the corresponding number for men.

Also, when people have suffered a type of cancer or have family or friends with the cancer they are more likely to give money to that charitable project. Plus, women gave more to cancers that affected females and likewise men gave more to prostate cancer and others that only they suffered from.

Even when we asked people to distance themselves and give a purely moral viewpoint on deciding on which of two charities to donate to they couldn’t. Their own self-interest affected their choice. For example, the smokers tended to give more to charities that helped with lung cancer than the non-smokers.

Income also played a bearing on people’s choices, with higher earners giving more to cancer types of hereditary diseases rather than those cancers that are largely down to our own behaviour.

An online experiment with a representative sample of the UK population backed up these findings. It gave them a choice to donate to non-Hodgkin lymphoma (NHL) – a disease that only the unlucky suffer from - or a melanoma charity, a cancer caused in the main by too much sun-bathing.

The average donation to NHL was higher than the average donation to melanoma ($39.24 vs $32.82) for the respondents who decided to donate only to one of the two cancers. Similarly, for those who decided to donate to both cancers, the average donation to NHL was again higher ($33.10 vs $30.31), with 44 per cent giving choice egalitarian reasons for their decision.

We did find one caveat to people’s preference when altering the ‘choice architecture’. In another experiment we checked whether people would respond differently if celebrities were involved.

We used James Bond legend Sean Connery, a heavy smoker, and indeed people who knew about his alleged battle with cancer tended to give more to lifestyle-related cancers and so broke the choice egalitarian way of thinking. This suggests that when it is somebody we know our moral judgements are overtaken by self-interest and other considerations.

But without that caveat, overall, people do believe in giving more to charities that support cancers that are contracted due to luck rather than behaviour and this should inform policymakers’ decisions in the future, so they are aligned with public opinion.

Further reading:

Safra, Z., Ma, S. and Melkonyan, T. A. (2019) "Is allocation affected by the perception of others' irresponsible behavior and by ambiguity?", Risk Analysis, 39, 2182-2196.

Melkonyan, T. A. and Safra, Z. (2016) "Intrinsic variability in group and individual decision-making", Management Science, 62, 9, 2651-2667.


Zvi Safra is Professor of Behavioural Science and teaches Fundamentals of Economic Behaviour on the suite of MSc Business courses plus Analysis of Economic Behaviour on MSc Business with Accounting & Finance.

Tigran Melkonyan is Associate Professor of Behavioural Science and lectures on Fundamentals of Economic Behaviour on the suite of MSc Business courses plus Analysis of Economic Behaviour on MSc Business with Accounting & Finance.

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