Responsibility in Health Care

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As well as reciprocity, solidary also requires a commitment to action. Taken together, these commitments make it clear why solidarity-based institutions may demand a degree of personal responsibility from their participants. On the other hand, a willingness to abandon those who make poor choices with respect to their own health seems to be the antithesis of solidarity. We can agree that those who knowingly place avoidable burdens on a public health system have in some cases failed an obligation of solidarity, without concluding that they have thereby forfeited their solidarity-based claims.

We therefore need to consider what the relevant obligations are, and whether they warrant penalties in cases where they are violated. In its simplest form, though, this cannot be correct. Buyx and Prainsack argue against using solidarity to ground health-related liabilities on such a basis. They suggest that any attempt to do so will focus on easily identifiable 7 failures of responsibility, obscuring the fact that all of us make choices that raise the risk of some health burden or other.

It would be unfair to refuse to externalise some kinds of freely chosen health burdens, and not others.

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Indeed, such a selective policy risks narrowing the range of conceptions of the good life. In our view, an argument for holding people responsible based on solidarity should identify types of burdens that people cannot expect others to shoulder in the name of solidarity. One option is to adopt a luck-based focus. A wide range of options are avoidable, will involve some health burdens, and yet are entirely reasonable to choose. This includes choosing to meet existing moral obligations, choices where alternative options also have significant costs, and choices which, despite being risky, also offer considerable prospective benefits.

It would be unreasonable, and in violation of solidarity, to refuse to support people who make such choices. Instead, we suggest that solidarity licenses sanctioning people who externalise costs to others when this externalisation is unreasonable. Solidarity requires us to take up common cause with those who are suffering only if they show a reciprocal concern for us, so long as they are able to do so. Those who choose to impose unreasonable burdens on others—or choose, unreasonably failing to consider the burdens on others—have failed to show this reciprocal concern. In practice, it will be difficult to determine whether a choice is aiming at a reasonable conception of the good life 12 or is fully autonomous.

However, we may restrict our scope to those who are responsible for their own health burdens under certain choice conditions. Even if we all make decisions that ultimately impact our health, it is not true that we all make such decisions under the relevant set of conditions, i.

This is not obvious. Some behaviours, despite carrying health risks, also carry considerable health benefits. If I end up worse off after following medical advice, this does not constitute a failure of solidarity in the same way as a decision to ignore, or to fail to attend to, medical advice. We thus cannot move from the fact that we all make choices that harm our health to the claim that it is unjustified to pick any subset of those choices as appropriately subject to substantive responsibility.

Some such choices are more reasonable than others. What this does suggest, however, is that we cannot consider solidarity in health-based decisions in isolation from our broader social context, or the conditions of choice. It is worth saying something at this stage about the relationship of solidarity to justice. Since we are concerned with the imposition of unreasonable costs, it may seem that the real topic of our discussion is distributive justice. There are three things to say about our view on this. Firstly, the requirements of justice are affected by solidarity.

Although solidarity is not itself always obligatory, the existence of solidary relationships affects the types of entitlements people may claim on grounds of justice.

Responsibility and Healthcare

Secondly, we earlier suggested that obligations of solidarity may exist even in the absence of relevant feeling. If people stand in certain relations to one another e. While our interest is in exploring the parameters of what solidarity requires of us, this is indeed intimately related to justice. Yet the centrality of justice to our discussion does not negate the importance of solidarity. Finally, however, we accept that justice is in some sense prior to solidarity.

This is both because minimal standards of justice are a prerequisite for solidarity e.


Krishnamurthy, , and because justice sets boundaries on what solidarity can demand of us. However, we assume that in the allocation of health care resources, we cannot treat everyone who would benefit, and that justice may not offer comprehensive, decisive instruction on which individuals should lose out. This means that considerations of justice e. Some choices that affect our health meet the highest standards of autonomy: they are made with full knowledge of consequences, using well-functioning rational capacities, in circumstances where a reasonable array of options is available.

The case of Inactivity 13 meets these criteria. By stipulation, the patient could exercise more but chooses not to, and does so with reasonable understanding of the potential risks over a considerable length of time. Other choices fail to meet these standards. Other health-affecting choices are impulsive errors of judgement or mistakes. Seatbelt is a case of this type.

Smoking and Seatbelt present problems for many standard analyses of responsibility because they exhibit a mixture of failure and success with respect to features that make decisions responsible.

Roles and responsibilities in healthcare

For instance, neither is chosen after a period of reasonable reflection, 14 nor are they we stipulate endorsed by second-order desires. Seatbelt is out of character in both senses. While there are cases of inactivity that also involve these barriers see fn7 , the patient in our case, we stipulate, faces more favourable conditions. He faced many opportunities, and no special barriers, to doing more exercise, including having the spare time and money such that doing so would not be burdensome.

He also, we imagine, reflected on whether to exercise, knowing its effect on his health. But he decided that he would rather avoid exercise and risk poor health.

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  • One argument in favour of solidarity-based penalties is that participation in solidary practices or institutions generates obligations, and failure to meet those obligations can justify either exclusion from the practice, or penalties within it. A system of tax-funded healthcare is such a practice. For instance, Buyx suggests that, while solidarity places a constraint on the degree to which we may hold people substantively responsible for their own health, it does not ground an absolute objection to the inclusion of personal responsibility in healthcare, since solidarity cuts both ways. If my decisions demonstrate a failure to show due regard to other members of my community, I fail to demonstrate appropriate solidarity. In none of our cases is there an intention to betray solidarity or violate obligations. If anything, this absence is even starker in cases involving neglect. The smoker might consider the alternative and intentionally reject it. Not so the person who neglects to put on their seatbelt because they are distracted and in a hurry: even their failure to act appropriately seems unintentional. With respect to solidarity, then, these cases are all marked not by intentional refusal to fulfil an obligation, but by failure to consider that there is such an obligation at all, and possibly by further failures of intention as well.

    Indeed, many failures of practical rationality doing what you should do are attributable to failures of theoretical rationality believing what you should believe. There are cases where it is not only legitimate but required to apply substantive responsibility to failures of intention. If a company fails in implementing appropriate safety measures, leading to an accident, it cannot escape liability by protesting that it did not plan the accident. If I cause a car crash because I am distracted, I cannot escape criminal penalties or compensation for victims for this reason alone. In both cases, an obligation exists, and failure to fulfil it is not intentional, but negligent.

    One problem with many potential ways of involving responsibility in healthcare is their excessive simplicity. This applies to the behaviour required to trigger a penalty: one bad habit, or even one mistake, is sometimes seen as enough to justify considerably different treatment. This problem also applies to the finality of the decision to penalise.

    One thought to “The Unhealthy Return to Individual Responsibility in Health Policy”

    This latter issue has led to several related proposals around how we should think about responsibility in healthcare. However, as Albertsen notes, there is something paradoxical about this proposal: even if the conditions that we set upon commencement of treatment are forward-looking at that point, they become backward-looking if we later penalise patients for failing to meet them. Golden Opportunities involve patients being given concrete, health-promoting behavioural changes. What is most relevant about Golden Opportunities is not whether the relevant behaviour is in the past or future, but whether it is performed under circumstances that are conducive to responsible choice.