America’s Top Killer: Us

With the dawn of a new and potentially difficult year upon us, many Americans will swear that this is the year that they'll eat better, exercise more, or quit smoking. Of course, most of us will fail to stick to these healthy resolutions. And, while we know that getting in shape is good for us, a new study shows the true cost of our tendency not to make wise decisions about taking care of ourselves. According to Duke University's Ralph Keeney, whose work was published last month in the journal Operations Research, America's top killer isn't cancer or heart disease, or even smoking and overeating—it's our inability to make smart choices that leads us to engage in those and other self-destructive behaviors.

"Each year more than a million people needlessly die because of their own personal decisions," says Keeney, whose work gives new meaning to the cliché we're our "own worst enemies." That means more than half the population will make a decision leading to an early grave, he reports, including a full 55 percent of people who die between the ages of 15 and 64. Most alarming, that figure has jumped fourfold since 1900, despite the world becoming a safer place overall thanks to seat belts, smoking laws, health food and a host of other tools to help people stay inside the lines.

Keeney's work raises a philosophical quandary: If we continue to kill ourselves with poor decisions, are we consciously opting for short, zestful lives over long, abstemious ones? Or is it that we simply need a stronger hand prodding us to make better choices? Keeney and a number of public-health advocates say the answer may be more governmental guidance in everything from what kind of food we buy to whether we contribute to our retirement savings. And if Keeney is right, and much of our health and life expectancy is a reflection of our own decisions, are these things we can change or choices shaped by genes and other forces outside our control?

To generate his numbers, Keeney took national death statistics from 2000 and tried to trace the official cause of each death (ranging from cancers, diabetes and AIDS to fatal accidents, suicides and homicides) back to some personal call, such as the decision to smoke, drink, drive without a seat belt or have unprotected sex. Because the numbers can't show for sure that a person's smoking, for instance, caused their lung cancer, he used risk data to make reliable guesses—smoking is known to triple the risk of cancer, for example, which lead Keeney to conclude that roughly two thirds of all smokers who got lung cancer brought it upon themselves.

That's not so controversial when identifying three packs a day as the cause of cancer or the choice to speed as the cause of a fatal crash, but Keeney is on thinner ice when counting all suicides as examples of death by personal decision. His reasoning: the decision to kill oneself may not be rational, or even clearheaded, but it's definitely personal. But with evidence accumulating that many mental illnesses have genetic or physiological origins, labeling the suicidal impulses of someone suffering from major depression or bipolar disorder a "choice" may not be exactly fair. The same goes for certain addictions to drinking, smoking and overeating, which all have significant genetic triggers—yet Keeney holds firm. "Prior to having these habits," he writes, "the individuals made decisions that lead to [them] and these are the personal decisions that are of concern in this paper."

Another of the study's limitations: it ignores the environmental baggage that constrains people's choices. Keeney says he appreciates the importance of peer pressure, poverty and education as well as the fact that fatal decisions aren't necessarily "bad" ones. (Yes, you end up dead but perhaps you had no real choice and were speeding to escape a murderer. Or perhaps you made a conscious choice to live an interesting life, burning out early like Elvis rather keeping to a rigid fitness routine like Jack LaLanne.) It's just that in most cases, he says, people could have reasonably saved their own lives if they had taken a different path. "If it's under a person's control," he tells NEWSWEEK, "I say it's up to them."