Guest Post by Phoebe Friesen

Re: Personal responsibility within health policy: unethical and ineffective

If someone who has smoked two packs a day for thirty years and someone who has never smoked but is unfortunate enough to inherit a genetic condition are both in need of heart surgery, who should be given priority?

Should an alcoholic be placed on the liver transplant list, even if they continued to drink against their doctor’s advice?

Does someone who never works out and has poor eating habits have the same right to health care as someone who eats healthy and exercises every day?

Policy makers who are faced with the difficult task of distributing limited resources in health care need to determine which criteria are relevant, and questions related to ‘personal responsibility’ come up time and again. Within the field of medical ethics, many have argued that personal responsibility should be taken into account within health care policy. Advocates suggest that treatments will be more effective or provide longer-lasting solutions if illnesses are not self-caused, and argue that individuals who knowingly take health risks violate their obligation to take care of themselves and should therefore be treated differently. Others argue that there is no place for responsibility in health care policy, pointing out that there is no evidence for different treatment outcomes in individuals who did or did not contribute to their condition, and emphasizing the difficulty, if not impossibility, of determining how responsible someone is for a particular health problem.

In an extended essay in the Journal of Medical Ethics, I join those who argue against taking responsibility into account within health policy, by offering two arguments against such policies. My first argument makes the case that what’s at issue here isn’t so much assessments of personal responsibility, but a desire to penalize those who engage in stigmatizing behaviours.

This argument rests on an examination of the literature that endorses taking personal responsibility into account within health policy. Instead of focusing on the wide range of cases in which individuals knowingly put their health at risk – including dangerous sports or hobbies, stressful jobs, and elective surgeries – these arguments are concerned only with a small subset of individuals who knowingly contribute to their negative health outcomes. This subset includes individuals who have become ill as a result of smoking, drinking, drug use, eating poorly or attempting suicide. In the paper, I consider whether or not this subset might stand apart from other cases, whether through a difference in causal responsibility, moral responsibility, or culpability. After finding fault with each of these possibilities, I argue that what’s really at play in these discussions is a tendency to blame individuals for engaging in socially undesirable behaviours, while neglecting others who are just as responsible. This should certainly give us pause before embracing policies based on personal responsibility.

In a second argument, I look to the potential consequences of taking responsibility into account within health policy and ask: what would it look like if we were to incorporate some of these proposed measures and restrict care for those who have knowingly put their own health at risk?

Several authors have suggested that if such policies were put in place, individuals would be motivated to give up on unhealthy behaviours, health outcomes would be better overall, and health care costs would decrease. Each of these suggestions, however, does not hold up to scrutiny. There is little evidence that threats of future punishment are effective in motivating people to change behaviours, especially behaviours like smoking and drinking, which are not merely unhealthy habits, but often double as a coping tool for individuals. The likelihood of health outcomes improving as a result of these policies also looks dire. A robust link between inequality and negative health outcomes has been demonstrated using data from around the globe, and since policies based on personal responsibility would inevitably restrict care for those who are already the worst off, we could expect an increase in overall inequality, and a decrease in overall health outcomes. Finally, through an examination of West Virginia’s attempt to incorporate responsibility into Medicaid policies, I show that there is good reason to think that these kinds of policies will lead not to a decrease, but to an increase, in health care costs overall.

I hope to have raised some new worries for those seeking to hold individuals responsible for engaging in unhealthy behaviours, and welcome thoughts and comments at pfriesen@gradcenter.cuny.edu. I am currently engaged in empirical investigation of how moral judgments might inform the distribution of health care resources, and hope to contribute further to this discussion in the future.