When it comes to discussing and evaluating fair criteria for rationing in healthcare systems, personal responsibility does not have a lot of good press.1^–5 Personal responsibility, if used as a reason for making decisions about the healthcare resources that patients receive, is often perceived as “blaming of the victim”6 and as contrary to intuitions of justice and compassion in medicine. Policies that use it as an allocation criterion, such as West Virginia’s Medicaid plan or the patient charter of the Scottish NHS, have been criticised as placing an unfair and undue burden on vulnerable patient groups.7^–9

Indeed, health-relevant behaviour belongs to the private sphere of individuals. Freedom to exercise the right to make independent choices about diet, fitness activities, the consumption of nicotine or alcohol, or professional and recreational activities is important to most people and is generally regarded as a central right. Much controversy surrounds the question of whether the state or a social institution such as the healthcare system is entitled to interfere with the private life of individuals by demanding personal responsibility for health. Hence, even indirect interference in the private sphere—for example, by withholding resources or services—is in need of well-argued justification.

PERSONAL RESPONSIBILITY FROM THE PERSPECTIVE OF THEORIES OF JUSTICE

From the point of view of several theories of justice, personal responsibility can be used as a criterion for allocating scarce healthcare resources.

1. Libertarian authors10 assume that the great plurality of values in modern societies makes it impossible to reach the kind of consensus on the ends and contents of healthcare that would be necessary in order to justify an obligation on the part of individuals to contribute personal resources towards a public healthcare system. In their view, all individuals have the right to decide about how to spend their funds according to their own life plan, and any kind of mandatory redistribution towards a societal endeavour such as universal healthcare is immoral. Apart from some kind of minimal public healthcare package, allocation has to be achieved via free market mechanisms. Hence, personal responsibility, while not explicitly stated as a criterion for distribution, has an important function within a libertarian healthcare system: beyond the minimal, basic care package, all citizens need to execute personal responsibility. Wealthy people may decide how much of their income they are willing to invest in additional healthcare services, while poorer people only have their health-related behaviour as a “health resource”.

2. Proponents of communitarian theories of justice11 call for a shift of focus in the healthcare system. According to them, the common good should play a greater role than interests and individuals’ preferences (which, to them, are wont to endanger any public system in the long run). In the face of rising costs produced by the individualistic quest for the best and longest life possible, communitarians propose a radical change of priorities in allocating healthcare resources. These should be used primarily to ensure that, on the whole, most people in a community can enjoy a reasonably good life of a “normal” length. Resources for expensive, high-tech medicine benefiting few people or interventions that merely prolong life beyond a certain age should be cut in favour of preventive, palliative and rehabilitative medicine, interventions that improve the overall quality of life across a population (“care instead of cure”). The primacy of the health of a community and of the common good justifies that the state or community require individuals to contribute to this common good by showing responsible health behaviours. It also legitimises a public system that exerts pressure and withholds resources in cases where individuals do not comply.

3. Finally, there are the so-called luck-egalitarians12^–15 —liberal writers committed to equality, who hold that inequalities warranting compensation are those resulting from factors that individuals have no choice about (so-called “brute luck”, such as genetic makeup, environmental circumstances and the like). As for inequalities resulting from freely chosen behaviour, such as lifestyle choices or risky behaviour (so-called “option luck”), these do not warrant compensation and individuals should have to buy private insurance against possible resulting negative consequences. In this theory, personal responsibility is one of the most important criteria for allocation in medicine. A public healthcare system need compensate only for treatment of conditions that do not result from chosen behaviour.

These accounts have been the subject of much controversy in recent years.1 3 I will sketch the most important problems associated with these perspectives and then briefly propose a fourth account that does not fall prey to these issues.

1. A libertarian healthcare market system results in a situation in which large portions of the population are left with minimal or no public support in case of illness. At least from the European perspective, which takes universal, publicly funded healthcare as a very desirable social institution, the extreme emphasis on ownership rights and freedom of disposal and the resulting complete opposition to making citizens pay some portion of their income into public healthcare is difficult to support. Even taking into account charitable impulses (often cited by libertarians as a means to finance a minimal or basic care package10), no public healthcare system as we know it would exist in a libertarian society. Thus, the theory is not directly relevant in a discussion of universal public healthcare.

2. The opposite argument can be voiced against communitarian healthcare systems: apart from proposing a rather paternalistic approach towards the lives people should lead, their proposals assign too little weight to the individual and too much to the community. The focus on the common good leaves too few opportunities for some individuals to make justified claims on public healthcare resources. A communitarian system—while ensuring that, on the whole, the health of the community is reasonably good—would produce many groups of losers: everyone with “self-inflicted” illnesses, and also those with rare diseases and those whose treatment is expensive or high-tech and who therefore place heavy demands on many commonly shared resources.

3. Within the theory of luck egalitarianism, free choice (of action and of behaviour) is the only criterion to demarcate which conditions warrant compensation and thus public healthcare resources. The theory is one-sided in this respect. It ignores other important criteria of allocation and leads to many unfair consequences. There are, for example, cases in which a certain behaviour that is both free and socially very well accepted or even desired might lead to “self-inflicted” medical conditions—as in the personal decision to become pregnant or to care for a family member with dementia.16 Even more fundamentally, the concept of free choice not only has far too much significance in the theory: it also lacks differentiation. The focus on free choice ignores the fact that behaviour does not fall into one of two dichotomous categories, “freely chosen” and “not chosen at all”, but that there are many degrees of freedom of choice. Even without fully entering into the age-old discussion about freedom of will, it has to be pointed out that especially health behaviour and lifestyle choices are determined by many factors (see below). The failure to differentiate between these different factors and the assumption that every conscious choice of behaviour people make is free render the theory inapplicable in the healthcare context.

LIBERAL EGALITARIANISM-CUM-SOLIDARITY—AN ALTERNATIVE

Between the rather “radical” accounts of libertarianism and communitarianism, a fourth theory, which many have called liberal egalitarianism, presents a middle ground, which at the same time does not lead to the problems luck egalitarianism faces. The theory balances the needs and preferences of individuals with the necessity to protect a few important societal institutions in order to protect equality of opportunity. If it is supplemented by a strong dose of the principle of solidarity in the way outlined below, it presents an attractive theoretical framework that leaves room for taking into account personal responsibility.

Liberal egalitarians1 17^–19 underscore the importance of a high degree of individual freedom within modern pluralistic societies to pursue individual life plans. They are also committed to equality of opportunity, which justifies social institutions such as healthcare for everyone and substantiates compensative action (if needed to fulfil reasonable life plans). Unfortunately, the account has been accused of having a built-in problem of becoming a “bottomless pit”, because it does not provide a principle for setting limits to individual demands. Solidarity could be introduced as such a principle, and with it the notion of personal responsibility.20

Solidarity encompasses a sense of togetherness between the members of a specific society or community, reflecting the multiple interdependencies that obtain between people—even between those in liberal and pluralistic societies. It should not be confused with the idea of charity or welfare, meaning that only one special group—for example, the poor or the very needy—gets to be supported. Rather, people in a solidary system care for each other. In large, complex modern societies, the relevant kind of caring does not imply personal closeness, but expresses rather the abstract idea of being part of a system deemed precious and important (such as having a society with universal healthcare) and of supporting it. Solidarity thus is not a one-sided principle, but a dual principle that entails elements of reciprocity:21 of receiving, but also of giving and contributing. Its Latin root in solidum even involves an obligation of each individual to the whole. This does not have to mean that people have to give something to the community or do something for a public institution in order to have a claim to support, compensative action or shared resources, or that they are left alone if they do not “earn” their claims in this way. The aspect of caring for each other within a solidaristic system ensures at least basic help and support for everyone within the system.22 However, because of the commitment to the shared public institution, which solidarity also demands, people should not be only passive recipients of services but should actively contribute to and try to avoid harming the system. This means that they should act responsibly when it comes to their health and that it is justified to expect this to a certain reasonable degree.

Solidarity is a value that presupposes at least a certain level of agreement about the good life, a notoriously contested issue. As such, and at first glance, it seems to run counter to the liberal idea of neutrality towards the many and varied individual concepts of the good life to which people subscribe. However, solidarity is open to definitions and interpretations that go beyond understanding it as a “thick” substantive moral perspective, which presupposes a dominant theory of a shared common good.23^–25 A “thinner” interpretation of solidarity would involve accepting its central notion of reciprocity as a prerequisite for supporting a system with the highest possible degree of both individual liberties and equality of opportunity. In this interpretation, members of a liberal and solidary society owe one another a reasonable degree of effort and care, which are essential to support and preserve the system and its institutions in the long run. Hence, a moderate expectation that people contribute towards this system and behave responsibly within it is justified. On these grounds, personal responsibility can be expected and, for example, used as one guiding principle among others for setting priorities in shared societal endeavours such as healthcare. Of course, just as with many other distributing principles for the allocation of social goods (eg, cost-effectiveness, efficacy, need), much discussion and careful weighing of problems and arguments would have to follow in order to implement it fairly.

PERSONAL RESPONSIBILITY FOR HEALTH—PRACTICAL PROBLEMS

Even if on the theoretical level a general demand for personal responsibility for health can be justified by invoking solidarity, there are indeed oft-cited important practical problems linked to its use as a criterion of priority setting and/or rationing.1 4 6 19 26^–29

First of all, there is the problem of causal responsibility. We want to be sure that we know exactly what actions or behaviours lead to a certain condition before holding patients responsible for the consequences. While this is easy in many cases, the causes of several of the conditions most often cited as being preventable through healthy behaviour (diabetes, high blood pressure, some cancers) are multifactorial. Some factors are related to individual health behaviour or lifestyle, but others are environmental, societal or genetic. There is still controversy in the research community around the respective significances of various causal factors for many illnesses. It is also difficult to single out the one decisive causal factor when it comes to individual patients. Most of the time, a combination of causes contribute to an individual condition. Thus, making sure patients really are causally responsible is a great challenge if personal responsibility is to be justly invoked.

Another important problem has already been mentioned in passing: the freedom of health behaviour. We justly hold people responsible for consequences of their behaviour only if they had control over it and chose it freely. While most health-related behaviours are not uncontrollable impulses but instead are subject to conscious choice, these choices are in turn often influenced by multiple factors: socioeconomic status, socialisation and education, family influence, social and peer values, advertisement, addictions, and so forth.2 6 18 27 30^–32

Moreover, many unhealthy behaviours are socially accepted or regarded as desirable. There is also good evidence that modern societies create a “toxic environment”33 that is conducive to the consumption of unhealthy food, nicotine, alcohol, and so on. In order to introduce personal responsibility in a just way, the degree of determination influencing freedom of choice when it comes to health behaviours is important to identify, and as many steps as possible should be taken to counter these influences.

CONCLUSIONS

While the problems mentioned above are important, they do not justify a knee-jerk refusal to think more deeply about responsibility for health as a criterion for allocating scarce resources. As shown above, in liberal healthcare systems based to some degree on solidarity (such as European systems), personal responsibility can be legitimately demanded. However, the problems surveyed in this paper must be taken into account when it comes to practical implementation. Instead of either abandoning personal responsibility altogether1 4 26 34 or ignoring the difficulties resulting from these problems and introducing it in a piecemeal way (as has been done for example in German health policy35), two other possibilities should be considered.

The first option is an inclusion of personal responsibility as one criterion among others in a matrix or algorithm for priority setting (see the Swedish model, which includes several criteria36) or in the decision-making process about which interventions should go into a basic care package. At some point in the future, all countries with universal healthcare will have to determine a basic healthcare package or start a priority-setting process; many are already in the middle of this. Personal responsibility could figure as one distributive criterion in these processes.

The second possibility consists in introducing bonus and/or malus systems—for example, insurance bonuses for people who engage in programmes designed to tackle problematic health behaviours such as smoking, sedentary lifestyles or bad diets. (For this to be compatible with the theoretical framework described above, these health-improving programmes would have to be readily accessible to everyone.) Maluses could be introduced as incentives for those who exhibit risky health behaviour. To protect opportunity and to honour the solidarity commitment, a reasonable malus should mean an additional co-payment or a malus on the insurance premium but not lead to an exclusion from care (an important difference from some bonus-malus systems already in place).

Both options take personal responsibility into account only moderately and on a higher level of allocation. They avoid microlevel rationing at the bedside based on the evaluation of the health behaviour of individual patients by their doctor. Thus, the delicate situation where physicians have to judge the behaviour of their individual patients is avoided.34 Both options also presuppose a systematic review of the available data on the causal relationship between behaviours and illnesses and on the various factors determining and influencing health-relevant behaviours. The evidence on the accountable impact of behaviours on illnesses gained from public health studies is actually growing quite rapidly, as are insights into the determinants of health behaviour.37 Including new results from neuroscience about degrees of addictiveness of certain behaviours could also be interesting in this respect and help single out the most promising route towards improving health behaviours.38 Finally, none of the options amounts to an “all-or-nothing” allocation based solely on personal responsibility. In both instances, personal responsibility would be one criterion among several.

If personal responsibility were to be used as a criterion for allocation in the one of the ways described, a few other conditions or side constraints would have to be met. Efforts would have to be made to change the “toxic environment” and ameliorate social impact on health behaviour, and, furthermore, measures would have to be taken to ensure that people are adequately informed about healthy behaviour. Personal responsibility requires knowledge, and the health literacy of large parts of the population remains insufficient. Continuing and increasing efforts to educate people on what they can do to protect and improve their health are necessary. These also have to take into account the social stratification of health behaviours. Additionally, in order to minimise the toxic environment, changes in regulations about addictive substances, advertisements, and the selling and offering of certain foods and the like should be further discussed.

In this paper, I have defended personal responsibility on a theoretical level and proposed possible ways to avoid some of the practical problems connected with implementation. The theoretical account may appear to be programmatic and the proposed practical route may seem very complex—but then again, using criteria for allocating scarce resources in a principled way always is. The proposal also requires a significant amount of investment and of reallocating resources. A lot remains to be done, but I believe it is worth it in order to use personal responsibility alongside other criteria for allocating scarce resources. Not the least reason for this is the very positive effect that personal responsibility has in practice: it leads to better health.