One of the main reasons health care is such a problematic issue in Western countries is that it is a battleground for two competing cultures.

The first culture, present to the point of caricature in the US, is the culture of individual freedom. It says that if people want to lard up on junk food, smoke their way to emphysema, or engage in other perilous exploits, that is their unassailable right.

The second culture - call it the caring culture - says that it would be inhumane for governments not to provide health care for society's needier members, even when their illnesses are behaviour-induced and even when they reject treatment.

This classic conflict has been wonderfully highlighted for years by the English writer/physician/satirist Tony Daniels, aka Theodore Dalrymple. But Dr Daniels writes short. His columns, some of which have appeared in the weekend FT, lack the space for delineating the underlying policy dilemma.

Now another doctor, Sally Satel of the American Enterprise Institute, has taken up the challenge in a thorough fashion. In a new book, she spotlights one of the most controversial of medical debates, the use of crack cocaine by pregnant women.* Rarely have the stakes and costs of the rights-vs-entitlements battle been laid out so painfully and clearly.

Crack cocaine is terrible for pregnant women and their babies, causing uterine rupture, miscarriage, premature birth, and later, in the children, learning difficulties. (Older New Yorkers will recalls the 1980s, when tabloids carried headlines along the lines of "Crack Babies Turn Five: Kindergartens Brace Themselves...") Crack preemies, like other babies born to substance-dependent women, are a significant presence in Neonatal Intensive Care Units across America.

The babies' care routinely runs in the tens or hundreds of thousands of dollars, bills often paid by the government, yet the childrens' outlook is rarely good. Whatever damage occurs at birth is soon followed up at home by a drug-preoccupied parent. As for the crack-miscarriage connection, it is so well known and established that poor women have used crack in order to bring about abortion. At the Medical University of South Carolina at Charleston a study found that 10 of 119 crack mothers miscarried.

In the South Carolina instance, the hospital took the brave step of trying to do something about this. As Dr Satel reports, concerned medical officers approached the local police and the state solicitor and asked for help protecting babies. The solicitor unveiled a plan: "a woman could be charged with child neglect or delivery of drugs to a minor" if she tested positive for drugs more than once during her third trimester of pregnancy. The aim was to help families away from drugs.

The policy seemed to succeed: the rate of pregnant women testing positive for cocaine at the emergency room fell to five or six a month from 20, according to the Journal of the South Carolina Medical Association (The study was completed after seven months, but the evidence of drug abuse stayed lower, even when you consider fluctuations in overall crack use).

What's more, Dr Satel writes, "deliveries at the institution did not decline"; there was no evidence that women avoided treatment out of fear of arrest. Instead they altered their behaviour. But this improvement obtained only for the years when rules were in place.

For all this proved too much for the rights culture. The American Civil Liberties Union and the New York-based Center for Reproductive Law and Policy launched a political and legal attack on the program, filing a $3 million class-action law suit alleging violation of the mother's privacy and reproductive rights. The hospital officials, who felt they were trying to save babies, were labelled racists (because many of the mothers were black) and Nazis (who knows why?). Eventually the administrators caved, pressure and hostility being simply too great.

This story has many parallels. Seniors who contract lung cancer and whose care drives up the annual budgets of government programs such as America's Medicare and Medicaid are in the same category. Yet smoking remains a "right" of adults. Demographic trends mean the costs of this controversy will only escalate.**

The question often asked about such cases is whether those who have engaged in self-destructive behaviour "deserve" treatment. But this is a false question, at least when it comes to stories that don't involve babies and do take place in countries like the US, where individuals are still responsible for some share of their own health care costs.

Rather the salient question is: does the right to take risks also include the right to receive help from fellow taxpayers when things go wrong?

When this difference is established in the public mind, some of the world's public health dilemmas will be easier to solve.

*"PC MD: How Political Correctness is Corrupting Medicine" by Sally Satel, MD, Basic Books.

** "An International Perspective on Policies for an Aging Society" by Jonathan Gruber and David Wise (http://papers.nber.org/papers/W8103)

© Copyright 2001 Financial Times