Eavesdropping on a conversation between four 40-something women, I learned that if it came to a choice between paying for Botox or a mammogram, the women said they would choose Botox. This surprised me a little, especially with all the information that surrounds us about the risks of breast cancer and the benefits of early detection. But their reasons were interesting.

First, they considered mammograms “have to,” procedures for something they wished to avoid, while they looked upon Botox as a “want to” procedure they were eager to pursue. It’s clear from their conversation that the “want-to’s” won. The immediacy of looking good now, versus the abstract of breast cancer prevention later brings home an essential challenge framing the financial discussions about paying for health care.

It appears, from this brief discussion, that the women had no difficulty talking about cosmetic procedures, sexy stiletto heels and other discretionary expenditures they would save (or go into debt) to have. But when it came to taking about co-pays or fee-for-service mammograms, the conversation took a different turn.

One of the women said she knew she was supposed to get her annual mammogram, but she just wasn’t interested. In fact, she said she “didn’t want to know.” Another remarked that she’d only have it if her doctor insisted, but since he didn’t, she wasn’t concerned. Although they knew women who had experienced breast cancer, they preferred to focus on things that gave them pleasure (despite the temporary pain of Botox injections, the discomfort of wearing their “limousine shoes” and the damage to their pocketbooks).

I wondered, how is it that otherwise educated, middle-class women opt for fashion rather than health prevention? Perhaps it’s that, at the end of the day, the pleasure principle trumps all other considerations, overriding the rational in favor of the emotional. My thought is that breast cancer, while still of great concern, is now considered a “treatable disease” and that the fear of getting it, and dying from it, is greatly diminished. The medical profession has done an excellent job of raising awareness and improving treatment, and the survivor community has been effective in proving that there is life after cancer. In other words, fear and anxiety is gone, and has been replaced with other priorities, like where to get the next Botox treatment and when is the Spring shoe sale?

Following on the heels of the Botox discussion, the issue of health care reform generated a more controversial exchange, and divided the women by those women whose insurance was provided by an employer versus those who were self-employed and paying for their own insurance. While all gave lip service to “everyone should have access to health care,” opinions greatly diverge about who should be responsible for paying for it. Those with employer-based health insurance advocate for insurance reform that covers pre-existing conditions “no matter what.” Those who pay their own premiums are adamant they should not have to carry the weight of those who “refuse to buy their own insurance.”

They all agreed, however, on one important point: none of them really understands the complexities of health care reform, preferring instead to revert to positions about who should pay for it, who should have it, and ain’t it awful tropes. They know everything about Botox, including its high cost ($600 and up for a treatment) and don’t bat a Botoxed eye at “charging it.” Yet they complain about the high cost of premiums.

The truth is clear. People will gladly pay for what they want, but not for what they need. Protecting oneself from the devasting costs of a major illness is a “have to” not a “want to.” By separating these realities from the debate, we perpetuate the problem.