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Personal responsibility for health: conceptual clarity, and fairness in policy and practice
  1. Harald Schmidt
  1. Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA
  1. Correspondence to Assistant Professor Harald Schmidt, Department of Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, PA 19104, USA; schmidth{at}

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Rebecca Brown and Julian Savulescu1 focus on individuals’ responsibility regarding health-related behaviours. They rightly argue that paying attention to diachronic and dyadic aspects of responsibility can further illuminate the highly multifaceted concept of personal responsibility for health. Their point of departure is a pragmatic one. They note that personal responsibility ‘is highly intuitive, [that] responsibility practices are a commonplace feature of almost all areas of human life and interpersonal relationship [and that] the pervasiveness of this concept [suggest] the improbability of banishing it entirely’. Indeed, despite—or perhaps even quite independent of—decades of mostly sceptical conceptual analysis of the concept of personal responsibility by philosophers and others, it endures, if not flourishes. These separate dynamics raise the question of how, in years ahead, the debate on responsibility can be furthered most effectively, and how nuanced conceptual distinctions can effectively inform policy and practice.

The authors’ table 1 matrix illustrates how different levels of control and knowledge people had at different timepoints might be grouped in categories of low, moderate or high demandingness: for policy makers sympathetic to the authors’ proposal that high levels of demandingness should undermine responsibility attributions, or for advocacy groups seeking to lobby on their behalf, several questions likely arise, including: How should levels of control and knowledge, at different points in time, be measured? In deciding on rewards or penalties that may be tied to different levels of overall attributable responsibility, should lower knowledge levels be counted the same as reduced degrees of control, or should one weigh more heavily than the other? (Further, since it would seem that the influence of dyadic—or other—relationships can likewise vary over time, the question arises of whether there is some hierarchy among the three concepts.) And is the aim of the analysis to compute for each individual a unique overall score? Or rather, to determine certain threshold levels at which any, or perhaps just particular types of, responsibility-based sanctions should not be imposed?

Given that the stakes can be high for typically vulnerable populations, it would be useful to clarify whether the main point of the paper is to push policy makers to properly account for knowledge, control and social support, or whether, in the form of a reductio, its goal is more to show that given how difficult this likely will be using just these three dimensions, it would be best to abort any such attempts in general. The paper’s conclusion and other sections appear to suggest the former, but it would then be helpful to give further thought about how this might be done.

The authors may also find it useful to consider policy frameworks that seek to address some of the points raised. In the USA, the structure of financing healthcare can give personal responsibility appeals a prominent role. Around half of the population is covered by employer-based health insurance. For insurees with this type of coverage, 2010 health reforms permitted that so-called ‘wellness incentives’ may either reduce or increase one’s annual cost of insurance by up to 50% of the cost of coverage annually (around $2500).2 The 2013 Final Rules3 on these provisions included a noteworthy justification, surfacing another angle of the diachronic dimension of holding people accountable:

[W]ith respect to tobacco cessation, ‘overcoming an addiction sometimes requires a cycle of failure and renewed effort’ […] The same can be true with respect to meeting weight loss and weight management [standards. Consequently, for] plans with an initial… standard that an individual not use tobacco, a reasonable alternative standard in Year 1 may be to try an educational seminar… an individual who attends the seminar is then entitled to the reward, regardless of whether the individual quits smoking.3

This justification expressly acknowledges that changing health behaviour can be extremely difficult and that efforts may be required not just once, but sometimes over time. The Rules note that it is inappropriate to simply penalise people for failing to achieve particular health outcomes (or to reward only those succeeding). Penalties should only be permissible where people refuse to take reasonable steps to change their behaviour. This measure would seem to reset elements of control and knowledge that Brown and Savulescu are concerned about—are they sufficient?

The above section on the Final Rules, as well as Brown and Savulescu’s emphasis on considering the role of knowledge, control and relationships in making responsibility attributions, underline that opportunity of choice is critical, yet insufficiently acknowledged. But unfortunately, conceptual clarity by itself does not lead to fairness for those affected by wellness incentives or related policies.

Arguably, some division of labour between professions and disciplines makes good sense, and there are generally good reasons to separate academia from advocacy. But, as the authors note, personal responsibility for health is intricately tied to how the concept is set out by policy makers. How can conceptual thinkers make an offer to improve the fairness of personal responsibility policies that policy makers cannot refuse?

With rising levels of populism in many countries, the concept of personal responsibility looks only set to gain in attraction. For example, in the USA, mostly lower income populations qualifying for public healthcare through the Medicaid programme are now required to perform around 80 hours of work or community engagement each month to access healthcare.4 The conceptual case for why such and related measures should be abandoned due to their potential for cruel victim blaming is relatively easily made. But it will typically not persuade those who make the rules.

The main challenge for those working in personal responsibility for health in years to come appears to be not just to present clear arguments, but to present them in ways that make it as hard as possible to implement largely unfair policy. Going the extra mile in setting out in more detail how otherwise compelling conceptual distinctions can be implemented is one way in which those setting policies can be held accountable. A complementary strand to improve progress is likely found in empirical bioethics, by analysing the extent to which important ethical concepts are affected by actual polices.



  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; internally peer reviewed.

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