Wealth and income are highly predictive of health and longevity. Egalitarians who maintain that this “socioeconomic-status gradient” in health is unjust are challenged by the fact that a significant component of it is owed to the higher prevalence of certain kinds of voluntary risk-taking among members of lower socioeconomic groups. Some egalitarians have argued that these apparently free personal choices are not genuinely free, and that those who make them should not be held morally responsible for the resulting harms to (...) their health. I argue to the contrary that such choices usually are fully free, and that those who make them are responsible for their consequences. This does not imply, however, that society cannot also be responsible for those consequences. It is responsible for them if they are statistically foreseeable and avoidable outcomes of unjust public institutions and policies. I show that many of the harms to health that contribute to the voluntary behavioral component of the SES health gradient satisfy that description. Society can therefore be morally responsible for those harms, even though the individuals who suffer them are also fully responsible for them. (shrink)

It is unclear whether someone’s responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here (...) what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour. (shrink)

In this article, we outline a novel approach to understanding the role of responsibility in health promotion. Efforts to tackle chronic disease have led to an emphasis on personal responsibility and the identification of ways in which people can ‘take responsibility’ for their health by avoiding risk factors such as smoking and over-eating. We argue that the extent to which agents can be considered responsible for their health-related behaviour is limited, and as such, state health promotion which assumes certain forms (...) of moral responsibility should be avoided. This indicates that some approaches to health promotion ought not to be employed. We suggest, however, that another form of responsibility might be more appropriately identified. This is based on the claim that agents have prudential reasons to maintain their health, in order to pursue those things which make their lives go well—i.e. that maintenance of a certain level of health is rational for many agents, given their pleasures and plans. On this basis, we propose that agents have a self-regarding prudential responsibility to maintain their health. We outline the implications of a prudential responsibility approach to health promotion. (shrink)

Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these (...) philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities. (shrink)

Luck egalitarianism is often taken to task for its alleged harsh implications. For example, it may seem to imply a policy of nonassistance toward uninsured reckless drivers who suffer injuries. Luck egalitarians respond to such objections partly by pointing to a number of factors pertaining to the cases being debated, which suggests that their stance is less inattentive to the plight of the victims than it might seem at first. However, the strategy leaves some cases in which the attribution of (...) individual responsibility is appropriate . One such case is oral health or significant aspects of this. It is appropriate, the paper argues, to hold people responsible for a number of factors that affect their oral health. A luck egalitarian approach inspired by John Roemer can assess whether people have acted responsibly by comparing their choices to those of their peers. A luck egalitarian approach to oral health would recommend prioritizing scarce resources in a responsibility-weighted queuing system and include copayment and general taxation among its measures of financing. (shrink)

Rare diseases pose a particular priority setting problem. The UK gives rare diseases special priority in healthcare priority setting. Effectively, the National Health Service is willing to pay much more to gain a quality-adjusted life-year related to a very rare disease than one related to a more common condition. But should rare diseases receive priority in the allocation of scarce healthcare resources? This article develops and evaluates four arguments in favour of such a priority. These pertain to public values, luck (...) egalitarian distributive justice the epistemic difficulties of obtaining knowledge about rare diseases and the incentives created by a higher willingness to pay. The first is at odds with our knowledge regarding popular opinion. The three other arguments may provide a reason to fund rare diseases generously. However, they are either overinclusive because they would also justify funding for many non-rare diseases or underinclusive in the sense of justifying priority for only some rare diseases. The arguments thus fail to provide a justification that tracks rareness as such. There are no data in this work. (shrink)

People’s health is hugely affected by where they live, their occupational status and their socio-economic position. It has been widely argued that the presence of such social determinants in health provides good reasons to reject luck egalitarianism as a theory of distributive justice in health. The literature provides different reasons why this responsibility-sensitive theory of distributive justice should not be applied to health. The critiques submit that the social circumstances undermine or remove people’s responsibility for their health; responsibility sensitive health (...) policies would adversely affect those who are worst off and; the luck egalitarian approach to health distracts from the important task of rectifying socio-economic influences on people's health and provides individualistic solutions to collective problems. But for each of these variants of the critique luck egalitarianism provides suitable answers. The literature on social determinants is no detriment to the project of applying luck egalitarianism to health. (shrink)

Should we grant a fresh start to those who come to regret their past lifestyle choices? A negative response to this question can be located in the luck egalitarian literature. As a responsibility-sensitive theory of justice, luck egalitarianism considers it just that people’s relative positions reflect their past choices, including those they regret. In a recent article, Vansteenkiste, Devooght and Schokkaert argue against the luck egalitarian view, maintaining instead that those who regret their past choices in health are disadvantaged in (...) a relevant way and should receive compensation. Employing the ideal that people should be made equal as measured by equivalent resources, they purport to show the fairness of such an arrangement through a hypothetical scenario. Relaxing the implicit assumptions of this scenario brings forth several unattractive consequences of the fresh-start idea. The main problem is that in striving to ensure that people’s past choices do not affect their own opportunities, the authors must accept that these choices put heavy strains on the opportunities available to other people. Furthermore, the luck egalitarian position is more compelling than they admit. (shrink)

The exposure of doctors, nurses and other medical professionals to risks in the context of epidemics is significant. While traditional medical ethics offers the thought that these dangers may limit the extent to which a duty to care is applicable in such situations, it has less to say about what we might owe to medical professionals who are disadvantaged in these contexts. Luck egalitarianism, a responsibility-sensitive theory of distributive justice, appears to fare particularly badly in that regard. If we want (...) to maintain that medical professionals are responsible for their decisions to help, cure and care for the vulnerable, luck egalitarianism seems to imply that their claim of justice to medical attention in case of infection is weak or non-existent. The article demonstrates how a recent interpretation of luck egalitarianism offers a solution to this problem. Redefining luck egalitarianism as concerned with responsibility for creating disadvantages, rather than for incurring disadvantage as such, makes it possible to maintain that medical professionals are responsible for their choices and that those infected because of their choice to help fight epidemics have a full claim of justice to medical attention. (shrink)

Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of health rather (...) than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context. (shrink)

It is often assumed that, except perhaps in a few rare cases, people with addiction can be aptly held responsible for having acquired the condition. In this chapter, I consider the argument that supports this view and draw attention to a number of challenges that can be raised against it. Assuming that early decisions to use drugs were made in possession of normal-range psychological capacities, I consider the key question of whether drug users who later became addicted should have known (...) that addiction was a likely outcome of their decisions to use drugs in a way that makes them blameworthy for their lack of foresight. I focus on three different points of contention surrounding this claim: how likely the outcome to be predicted was, how tolerable risk should be weighed against the expected value of decisions to use, and how reliable the relevant predictive abilities of the average person are. Once we consider in some detail what would have to be true in order for someone to be aptly held responsible for becoming addicted, the prospects for making a convincing case to that effect look, I argue, somewhat more uncertain than they might at first appear. (shrink)

EPUB and EPDF available Open Access under CC-BY-NC-ND licence. We tend to hold people responsible for their choices, but not for what they can’t control: their nature, genes or biological makeup. This thought-provoking collection redefines the boundaries of moral responsibility. It shows how epigenetics reveals connections between our genetic make-up and our environment. The essays challenge established notions of human nature and the nature/nurture divide and suggest a shift in focus from individual to collective responsibility. Uncovering the links between our (...) genetic makeup, environment and experiences, this is an important contribution to ongoing debates on ethics, genetics and responsibility. (shrink)

After describing the disorder of psychopathy, I examine the theories and the evidence concerning the psychopaths’ deficient moral capacities. I first examine whether or not psychopaths can pass tests of moral knowledge. Most of the evidence suggests that they can. If there is a lack of moral understanding, then it has to be due to an incapacity that affects not their declarative knowledge of moral norms, but their deeper understanding of them. I then examine two suggestions: it is their deficient (...) practical reason or their stunted emotions that are at fault. The evidence supports both explanations. I conclude with an overview of the debate concerning whether they are morally or legally responsible for their actions. (shrink)

Vaccine hesitancy or refusal has been one of the major obstacles to herd immunity against Covid-19 in high-income countries and one of the causes for the emergence of variants. The refusal of people who are eligible for vaccination to receive vaccination creates an ethical dilemma between the duty of healthcare professionals (HCPs) to care for patients and their right to be taken care of. This paper argues for an extended social contract between patients and society wherein vaccination against Covid-19 is (...) conceived as essential for the protection of the right of healthcare providers to be taken care of. Thus, a duty of care is only valid when those who can receive vaccination actually receive it. Whenever that is not the case, the continuing functioning of HCPs can only be perceived as supererogatory and not obligatory. (shrink)

It is natural to think that there is a tight connection between whether someone is responsible for some outcome and whether it is appropriate to hold her accountable for that outcome. And this natural thought naturally extends to health: if someone is responsible for her health, then, all else being equal, she is accountable for it. Given this, some have thought that responsibility for health has an important role to play in distributing the benefits and burdens of healthcare. But there (...) is a reason for caution. That health is influenced by social, economic, and environmental factors is a matter of consensus. And some have argued that in light of these social determinants of health, individuals are not typically responsible for their health, rendering inappropriate policies that employ a responsibility‐for‐health criterion. This debate implicates a number of overlapping concepts and questions that are often difficult to pull apart. And I worry that those who maintain that social determinants undermine responsibility for health have latched on to the wrong target. The social determinants of health are relevant to such policies, but, I argue, not by globally undermining responsibility. Rather, social determinants are sometimes responsibility‐undermining, sometimes responsibility‐preserving, and often relevant to whether we should hold individuals accountable for their health regardless of their responsibility. This calls for a more nuanced appraisal of the ways in which the social determinants of health are relevant to such policies. And here I attempt to provide one. (shrink)

BackgroundPatient advocacy organizations (PAOs) have an increasing influence on health policy and biomedical research, therefore, questions about the specific character of their responsibility arise: Can PAOs bear moral responsibility and, if so, to whom are they responsible, for what and on which normative basis? Although the concept of responsibility in healthcare is strongly discussed, PAOs particularly have rarely been systematically analyzed as morally responsible agents. The aim of the current paper is to analyze the character of PAOs’ responsibility to provide (...) guidance to themselves and to other stakeholders in healthcare.MethodsResponsibility is presented as a concept with four reference points: (1) The subject, (2) the object, (3) the addressee and (4) the underlying normative standard. This four-point relationship is applied to PAOs and the dimensions of collectivity and prospectivity are analyzed in each reference point.ResultsUnderstood as collectives, PAOs are, in principle, capable of intentionality and able to act and, thus, fulfill one prerequisite for the attribution of moral responsibility. Given their common mission to represent those affected, PAOs can be seen as responsible for patients’ representation and advocacy, primarily towards a certain group but secondarily in a broader social context. Various legal and political statements and the bioethical principles of justice, beneficence and empowerment can be used as a normative basis for attributing responsibility to PAOs.ConclusionsThe understanding of responsibility as a four-point relation incorporating collective and forward-looking dimensions helps one to understand the PAOs’ roles and responsibilities better. The analysis, thus, provides a basis for the debate about PAOs’ contribution and cooperation in the healthcare sector. (shrink)

The anti-doping policies of the World Anti-Doping Agency (WADA) aim to promote a level playing field and protect the health of the athlete. Anti-doping policy discourages research using performance enhancing drugs (PEDs) or methods and prohibits athlete support personnel, including healthcare providers, from providing advice, assistance, or aid to an athlete or others seeking to use, or using PEDs until harm has occurred. Athletes are individually responsible for the presence of a prohibited substance in their bodies and face sanction regardless (...) of knowledge or intent. I will argue (i) that WADA policies fail to meet the epistemic and control conditions needed to adequately assign individual responsibility and (ii) that transferring responsibility for use of PEDs solely to the athlete results in harm. WADA is drifting perilously close to the morally impermissible ‘doing of harm’ to athletes by initiating or sustaining a causal sequence of events that can result in harm. (shrink)

Proposals for regulating or nudging healthy choices are controversial. Opponents often argue that individuals should take responsibility for their own health, rather than be paternalistically manipulated for their own good. In this paper, I argue that people can take responsibility for their own health only if they satisfy certain epistemic conditions, but we live in an epistemic environment in which these conditions are not satisfied. Satisfying the epistemic conditions for taking responsibility, I argue, requires regulation of this environment. I describe (...) some proposals for such regulation and show that we cannot reject all regulation in the name of individual responsibility. We must either regulate individuals’ healthy choices or regulate the epistemic environment. (shrink)

Governments, physicians, media and academics have all called for individuals to bear responsibility for their own health. In this article, I argue that requiring those with adverse health outcomes to bear responsibility for these outcomes is a bad basis for policy. The available evidence strongly suggests that the capacities for responsible choice, and the circumstances in which these capacities are exercised, are distributed alongside the kinds of goods we usually talk about in discussing distributive justice, and this distribution significantly explains (...) why people make bad health choices. These facts suggest that we cannot justifiably hold them responsible for these choices. We do better to hold responsible those who determine the ways in which capacities and circumstances are distributed: they are indirectly responsible for these adverse health outcomes and possess the capacities and resources to take responsibility for these facts. (shrink)

There is a lively debate over who is to blame for the harms arising from unhealthy behaviours, like overeating and excessive drinking. In this paper, I argue that given how demanding the conditions required for moral responsibility actually are, we cannot be highly confident that anyone is ever morally responsible. I also adduce evidence that holding people responsible for their unhealthy behaviours has costs: it undermines public support for the measures that are likely to have the most impact on these (...) harms. I claim that these two facts—the fact that we cannot be highly confident that anyone is morally responsible and the fact that holding people responsible for their unhealthy behaviours has costs—interact. Together they give us a powerful reason for believing, or acting as if we believed, that ordinary people are not in fact responsible for their unhealthy behaviours. (shrink)

In this article, we provide an ethical analysis of the first porcine cardiac xenotransplant, performed in Maryland, USA in early 2022. David Bennett was offered the experimental procedure after he was deemed ineligible for human heart transplantation and mechanical circulatory support, based on a history of non-compliance. It was reported that Mr Bennett’s previous instances of non-compliance were for medically non-life-threatening conditions years earlier, where the risks of non-compliance were not as high. We argue that, in Mr Bennett’s case, a (...) history of non-compliance in a different context, should not necessarily rule him ineligible for a potentially life-saving treatment now. Furthermore, using previous non-compliance to exclude individuals from donor organs may have the unintended effect of placing the burden of testing xenotransplantation on those who are already disadvantaged. We then argue that it is not enough to rely on patient consent to ethically justify xenotransplantation research. Taking a broad ethical perspective is crucial when mapping a clinical pathway for xenotransplantation. (shrink)

In a well-known passage from 'The Red Lily', Anatole France retorts ironically: “The law, in its majestic equality, forbids rich and poor alike to sleep under bridges, to beg in the streets, and to steal loaves of bread”. The passage highlights the different burdens experienced by different people when deciding to act or not act in certain ways. This paper critically analyzes this problem; specifically, how we ought to allocate personal responsibility for actions performed by agents who each experience different (...) social, economic, political, and internal and external influences. First, the paper outlines some prevailing conceptions of personal responsibility in the literature. Second, it offers a critique of these views, arguing that they each suffer from a variety of conceptual and practical flaws. Third, a basic framework I call the continuum- threshold account of responsibility is proposed. The account distinguishes between responsibility and blameworthiness, addresses many of our objections against other prevailing conceptions of responsibility, and takes into account background structural conditions while retaining the scope for responsibility and moral agency. (shrink)

In this paper, we start by comparing the two agents, Ann and Bob, who are involved in two car crashes. Whereas Ann crashes her car through no fault of her own, Bob crashes as a result of reckless driving. Unlike Ann, Bob is held criminally responsible, and the insurance company refuses to cover the car’s damages. Nonetheless, Ann and Bob both receive emergency hospital treatment that a third party covers, regardless of any assessment of personal responsibility. What warrants such apparent (...) exceptionalism with respect to personal responsibility in the healthcare context? We turn our attention to an understudied aspect of the debate on personal health responsibility, namely, the conceptualisation of the person in need of emergency hospital treatment. Drawing on the research of Joshua Knobe and Shaun Nichols, we propose that a context-dependent conceptualisation of the person may help explain a reluctance to ascribe responsibility to the individual for negative health outcomes. (shrink)

Access to state-funded fertility treatments is age-restricted in many countries based on epidemiological evidence showing age-associated fertility decline and aimed at administering scarce resources. In this article, we consider whether age-related restrictions can be considered ageist and what this entails for a normative appraisal of access criteria. We use the UK as a case study due to the state-funded and centrally regulated nature of in vitro fertilization provision. We begin by reviewing concepts of ageism and age discrimination in gerontological scholarship (...) and contend that it is analytically useful to differentiate between them when considering age-restricted health services. We then argue that criteria to access IVF could be considered indirectly ageist so far as they rely on an age-related evidence base that manifests ageist categorizations of persons. Lastly, we examine whether there could be more normatively desirable alternatives to devise criteria to access fertility treatment, considering “lifestyle” as a potential candidate. We conclude, however, that lifestyle-based discrimination is problematic because, unlike age-based discrimination, it risks exacerbating existing socioeconomic and ethnic inequalities. (shrink)