Two years ago, the Cleveland Clinic stopped hiring smokers. It was one part of a “wellness initiative” that has won the renowned hospital — which President Obama recently visited — some very nice publicity. The clinic has a farmers’ market on its main campus and has offered smoking-cessation classes for the surrounding community. Refusing to hire smokers may be more hard-nosed than the other parts of the program. But given the social marginalization of smoking, the policy is hardly shocking. All in all, the wellness initiative seems to be a feel-good story.

Which is why it is so striking to talk to Delos M. Cosgrove, the heart surgeon who is the clinic’s chief executive, about the initiative. Cosgrove says that if it were up to him, if there weren’t legal issues, he would not only stop hiring smokers. He would also stop hiring obese people. When he mentioned this to me during a recent phone conversation, I told him that I thought many people might consider it unfair. He was unapologetic.

“Why is it unfair?” he asked. “Has anyone ever shown the law of conservation of matter doesn’t apply?” People’s weight is a reflection of how much they eat and how active they are. The country has grown fat because it’s consuming more calories and burning fewer. Our national weight problem brings huge costs, both medical and economic. Yet our anti-obesity efforts have none of the urgency of our antismoking efforts. “We should declare obesity a disease and say we’re going to help you get over it,” Cosgrove said.

Image Credit... Bob London

You can disagree with the doctor — you can even be offended — and still come to see that there is a larger point behind his tough-love approach. The debate over health care reform has so far revolved around how insurers, drug companies, doctors, nurses and government technocrats might be persuaded to change their behavior. And for the sake of the economy and the federal budget, they do need to change their behavior. But there has been far less discussion about how the rest of us might also change our behavior. It’s as if we have little responsibility for our own health. We instead outsource it to something called the health care system.