Lifestyle plays a major role in most of the illnesses in industrialised nations.¹ Six of the 10 leading factors contributing to the global burden of disease are lifestyle related: unsafe sex, high blood pressure, tobacco use, alcohol use, high cholesterol and obesity.² Lifestyle-related illnesses also contribute to the rising costs of healthcare. Spending on healthcare accounts for about 16% of the gross domestic product in the USA, or US$1.9 trillion.³ Although smoking has declined steadily there since the 1960s, smoking-related medical expenses are still about US$75.5 billion per year.⁴ Obesity, which has been climbing in the past two decades, accounts for about US$75 billion in healthcare costs there each year.⁵ Alcoholism and drug addiction in the USA account for annual healthcare costs of about US$22.5 billion and US$12 billion, respectively.^6,7 Federal government spending on healthcare relating to HIV/AIDS is over US$13 billion per year.⁸

Given the well-documented relationship between lifestyle, disease burden and healthcare costs, it makes economic and medical sense to hold individuals morally responsible for their health-related choices. While this view has a great deal of intuitive appeal, it also faces numerous objections.^9–12 First, holding individuals entirely responsible for their own health conflicts with medicine’s obligation to treat the sick and society’s obligation to take care of vulnerable people.⁹ Second, it is unfair to hold individuals responsible for their own health if they cannot make sound health-related choices because of ignorance, mental incompetence, addictive behaviors or cultural pressures.¹⁰ Third, it would be exceedingly difficult to implement a system that holds individuals responsible for their own health, since diseases and disabilities result from a complex interplay of genetic and environmental factors.¹¹ Although individuals should play an important role in maintaining their own health, they should not be held entirely responsible for it. Assuming that responsibility for health rests either with individuals or with society, it follows that society should also help to promote health and prevent disease.^9,10

Assuming that society is partly responsible for the health of its members, however, does not settle the question of how it should fulfil this responsibility. Most of the discussion in bioethics and health policy has focused on society’s obligation to provide access to healthcare.¹³ Undoubtedly, ensuring access is an important social responsibility, but there are many other ways in which societies can promote health, such as through sanitation, pollution control, food and drug safety, health education, disease surveillance, urban planning and occupational health. Greater attention should be paid to strategies of promoting health other than access to healthcare, such as environmental and public health and health research.

In recent years, some scholars and professionals have begun to draw attention to a variety of other methods that societies can use to promote health.^14–16 These other methods address strategies for preventing disease through public or environmental health, or through health research. (For a partial list of strategies for health promotion, see Table 1.)

Since there are many different methods that a society can use to take responsibility for health, and resources are scarce, questions about priority-setting naturally arise. Where should society invest its resources? Which areas need the most money? Access to healthcare usually draws the lion’s share of society’s resources.

In 2006, the US federal government budgeted more than US$530 billion (20% of the federal budget) for Medicare and Medicaid, health programs for the poor and for senior citizens, respectively.¹⁷ By comparison, in the same year it budgeted US$28.4 billion for the National Institutes of Health, which funds biomedical research and education; US$7.9 billion for the Environmental Protection Agency, which protects the air, soil and water from pollution; US$5.98 billion for the Centers for Disease Control, which help to promote public health at national level; US$1.48 billion for the Food and Drug Administration, which helps to ensure the safety of foods, drugs, cosmetics and medical devices; and 0.47 billion for the Occupational Safety and Health Administration, which sets workplace safety standards—for a total of US$44.23 billion, or less than 10% of the amount allocated to government healthcare programs.¹⁷

Although promoting access to healthcare is a very important function of the government, society should consider placing a greater emphasis on other strategies for health promotion. There are several arguments for focusing more on these and less on access to healthcare.

(1) Many of the other strategies are highly cost-effective. Many of them focus on ways of managing the social and physical environment to prevent illnesses. Food and drug regulation, health education, pollution control, occupational health, pesticide/chemical regulation, and disease surveillance/epidemiology deal with disease prevention. Prevention is generally more cost-effective and medically efficacious than treatment, and it avoids unnecessary pain and suffering.¹⁸ It is far better—economically, medically and ethically—to prevent obesity than to try to treat it once it occurs. In addition, many of the other strategies help potentially all people, not just those who happen to be sick. Everyone can benefit from clean air and water, sanitation, safe food, control of infection and pests, urban planning and disaster preparedness. Cost-effectiveness is always an important consideration in social policy but becomes paramount when resources are extremely scarce. If a village must choose between building a reservoir for potable water and building a health clinic, the water may take precedence over the clinic, because more lives can be saved by ensuring access to clean water than by ensuring access to the health clinic.

(2) Many of the other strategies address problems that are beyond the ability of individuals to deal with. While individuals often have the ability to take care of their own health, they lack the ability to promote health at the population or environmental level. Government action is required to monitor diseases, control infections, engage in urban planning, guarantee the safety of food and drugs, minimize pollution and sponsor basic biomedical research. Even people who emphasize personal responsibility would admit that society should promote environmental health and public health, and even those who believe in a minimal government would admit that public health institutions are necessary to prevent sick people from harming healthy people.

3. Many of the other strategies are compatible with and may even encourage individual responsibility for health. One of the problems with emphasizing social responsibility for health is that this may encourage individuals to take less responsibility. Making society responsible for the health of individuals can further add to the passivity and dependence that happen when one becomes sick.^19,20 Even though modern medical ethics emphasizes patients’ autonomy, many people seek medical care to receive a pill or some other intervention that will make them well. Many of the other strategies for health promotion can empower individuals to take responsibility for their own health. Education in safe sex, for example, provides individuals with information about how to avoid sexually transmitted diseases. Urban planning can give individuals the ability to make healthy choices concerning transportation, work and recreation by allowing them to choose walking or other forms of exercise.²¹ People may still choose to drive a car to work or engage in unsafe sex, but they at least have the option of making a healthy choice.

Responsibility for health should be a collaborative effort among individuals and the societies in which they live. Individuals should care for their own health and help to pay for their own healthcare, and societies should promote health and help to finance the costs of healthcare. Though access to care tends to dominate discussions of social responsibility for health and often receives the largest portion of society’s resources, one should not forget the importance of environmental health, public health and health research.

These other strategies can be highly cost-effective and may even encourage personal responsibility, by creating social and physical environments that enable individuals to maintain health and avoid disease. Recognizing the importance of these other methods still leaves important ethical and political questions unanswered, such as how to decide the appropriate level of government funding for access to care, public health, environmental health and health research. I encourage others to address these issues.