"Who determines destructive personal choices? "

"
Which do you weight more heavily? The cost on the system or the destructiveness of choice"

Actuaries just as they do now with insurance.

If I want to drive a $100k car that does 200 + MPh and I have 20 tickets I will most likely be unisurable. If I smoke 4 packs a day and have a lump on my liver and 5 other symptoms of smoking related illness I cannot buy life insurance.

A sense of right or wrong does not change statistical outcomes and their related costs.

I you want to somke drink/drug or eat yourself to death you should foot the bill.