A considerable literature has emerged around the idea of using ‘personal responsibility’ as an allocation criterion in healthcare distribution, where a person's being suitably responsible for their health needs may justify additional conditions on receiving healthcare, and perhaps even limiting access entirely, sometimes known as ‘responsibilisation’. This discussion focuses most prominently, but not exclusively, on ‘luck egalitarianism’, the view that deviations from equality are justified only by suitably free choices. A superficially separate issue in distributive justice concerns the two–way relationship (...) between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This paper outlines the degree to which this latter relationship between health and other social goods exacerbates an existing problem for proponents of responsibilisation (the ‘harshness objection’) in ways that standard responses to this objection cannot address. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. It ends by considering three possible solutions to this problem. (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)

For healthcare professionals and organizations, there is an emphasis on addressing moral distress and compassion fatigue among clinicians. While addressing these issues is vital, this paper suggests that the philosophical concept of agent-regret is a relevant but overlooked issue in healthcare. To experience agent-regret is to regret your harmful but not wrongful actions. This person’s action results in someone being killed or significantly injured, but it was ethically faultless. Despite being faultless, agent-regret is an emotional response concerning one’s agency in (...) a situation that results in death or significant harm. In healthcare, many clinicians are likely to experience regret for faultless actions that significantly harm or cause the death of a patient. The recognition of agent-regret in healthcare is significant because it differs, conceptually and practically, from moral distress and compassion fatigue. Building on the work of Wojtowicz (Citation2022), we should strive to understand clinicians’ agent-regret by recognizing their agency in the situation, not lessening or removing it. (shrink)

We propose a principle of sustainability to complement established principles used for justifying healthcare resource allocation. We argue that the application of established principles of equal treatment, need, prognosis and cost-effectiveness gives rise to what we call negative dynamics: a gradual depletion of the value possible to generate through healthcare. These principles should therefore be complemented by a sustainability principle, making the prospect of negative dynamics a further factor to consider, and possibly outweigh considerations highlighted by the other principles. We (...) demonstrate how this principle may take different forms, and show that a commitment to sustainability is supported by considerations internal to the ethical principles already guiding healthcare resource allocation. We also consider two objections. The first of these, we argue, is either based on implausible assumptions or begs the question, whereas the second can be adequately accommodated by the principle we propose. (shrink)

Luck egalitarianism, a theory of distributive justice, holds that inequalities which arise due to individuals’ imprudent choices must not, as a matter of justice, be neutralized. This article deals with the possible application of luck egalitarianism to the area of health care. It seeks to investigate whether the ethos of luck egalitarianism can be operationalized to the point of informing health care policy without straying from its own ideals. In the transition from theory to practise, luck egalitarianism encounters several difficulties. (...) We argue that the charge of moral arbitrariness can, at least in part, be countered by our provided definition of “imprudent actions” in the health area. We discuss the choice for luck egalitarianism in health care between ex ante and ex post policy approaches, and show how both approaches are flawed by luck egalitarianism’s own standards. We also examine the problem of threshold setting when luck egalitarianism is set to practise in health care. We argue that wherever policy thresholds are set, luck egalitarianism in health care risks pampering the imprudent, abandoning the prudent or, at worst, both. Furthermore, we claim that moves to mitigate these risks in turn diminish the normative importance of the ethos of luck egalitarianism to policy. All in all, our conclusion is that luck egalitarianism cannot be consistently applied as a convincing and relevant normative principle in health care policy. (shrink)

When it comes to determining how healthcare resources should be allocated, there are many factors that could—and perhaps should—be taken into account. One such factor is a patient’s responsibility for his or her illness, or for the behavior that caused it. Policies that take responsibility for the unhealthy lifestyle or its outcomes into account—responsibility-sensitive policies—have faced a series of criticisms. One holds that agents often fail to meet either the control or epistemic conditions on responsibility with regard to their unhealthy (...) lifestyles or their outcomes. Another holds that even if patients sometimes are responsible for these items, we cannot know whether a particular patient is responsible for them. In this article, we propose a type of responsibility-sensitive policy that may be able to surmount these difficulties. Under this type of policy, patients are empowered to change to a healthier lifestyle by being given what we call a ‘Golden Opportunity’ to change. Such a policy would not only avoid concerns about patients’ fulfilment of conditions on responsibility for their lifestyles, it would also allow healthcare authorities to be justified in believing that a patient who does not change her lifestyle is responsible for the unhealthy lifestyle. We conclude with a discussion of avenues for further work, and place this policy in the broader context of the debate on responsibility for health. (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)

Hospital acquired infections (HAIs) are a major threat to patient safety. This paper addresses the following question: given what is known about the causes of and possible interventions on HAIs, to whom or what should the moral responsibility for preventing these infections be attributed? First, we show how generating robust evidence on the effectiveness of preventive hygiene measures is a complex endeavour and review the existing evidence on the causes of HAIs. Second, we demonstrate that the existing literature on the (...) ethical aspects of infection control has focused on responsibility at the individual-level. Thirdly, we argue that these accounts do not accommodate systemic factors relevant for HAI prevention. We show that the notion of collective responsibility is useful for making understandable how systemic factors, such as employment conditions in hospitals, are both causally and ethically relevant in infection control. (shrink)

A disaster is an occurrence disrupting a community’s normal functioning and existence. The disruption may render it impossible to comply with principles and to respect, protect, and fulfill rights as it happens in ordinary times; it may induce an overwhelming shortage of resources and make tragic decisions unavoidable. From its very beginning, the COVID-19 pandemic evoked the scenario of disaster medicine, where triage is likely to imply not simply postponing a treatment but letting someone die. However, it is not only (...) the health care system that faces disruption risks. Lockdown measures and other restrictions were imposed to curb the pandemic, impinging upon individual freedom as well as economic activities. The proposal of mandatory vaccination implied a suspension of the principle of autonomy, which is a fundamental pillar of modern medicine. Out of the ordinary balancing efforts may be required, and two questions arise. Do such exceptional circumstances suggest reconsidering the criteria to apply, especially when essential, life-saving treatments are at stake? Who should decide? Science offers the premises to build on, but the last word does not belong to science. It remains the province of ethics and politics. (shrink)

Peterson, Karlawish, and Largent’s “Supported Decision Making with People at the Margins of Autonomy” brings welcome attention to the rights of people with cognitive impairment and provides...

Chater & Loewenstein make a persuasive case for focusing behavioural research and policy making on s- rather than i-interventions. This commentary highlights some conceptual and ethical issues that need to be addressed before such reform can be embraced. These include the need to adjudicate between different conceptions of “effectiveness,” and accounting for reasonable differences between how people weight different values.

Supported decision making is a model of decision making in which an adult with impaired capacity enters freely into an agreement with a closely trusted person or persons (the “s...

Peterson, Karlawish, and Largent’s “Supported Decision Making with People at the Margins of Autonomy” not only elucidates the conceptual framework but also the practical importance of suppor...

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 …. (shrink)

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed by the ethics (...) of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice. (shrink)

The question of whether any of us can truly be held responsible for what we do is an issue that occupied the ancient Greeks and continues to entertain our leading thinkers. Whether we can be held responsible for our health, or lack thereof, has additional layers of complexity because of the way in which what we do over time impacts our health. Those of us who have ever self-deceptively wondered about the apparent shrinking of our belt or at the fact (...) that the stairs seem to have multiplied are familiar with the idea that our health can change gradually over time as a result of successive choices that we have made. While there are one-off behaviours that can have an impact on health, for example, a single exposure to a very high level of radiation, in general, ill health develops over time, within an environment and complex set of interactions with other people. The implications of that complexity are central to this issue’s Feature Article by Brown and Savulescu.1 They note that there is debate over whether responsibility should play a role in the allocation of healthcare, and, rather than taking a view on that issue, make a number of suggestions about how the concept of responsibility used in healthcare can be enriched by attending to the complex relationship between behaviour and health. …. (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)

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)

Emerging parallel to long-standing, academic and policy inquiries on personal responsibility for health is the empirical assessment of lay persons’ views. Yet, previous studies rarely explored personal responsibility for health among lay persons as dynamic societal values. We sought to explore lay persons’ views on personal responsibility for health using the Fairness Dialogues, a method for lay persons to deliberate equity issues in health and health care through a small group dialogue using a hypothetical scenario. We conducted two 2-h Fairness (...) Dialogues sessions (n = 15 in total) in Nova Scotia, Canada. We analyzed data using thematic analysis. Our analysis showed that personal choice played an important role in participants’ thinking about health. Underlying the concept of personal choice was considerations of freedom and societal debt. In participants’ minds, personal and social responsibilities co-existed and they were unwilling to determine health care priority based on personal responsibility. The Fairness Dialogues is a promising deliberative method to explore lay persons’ views as dynamic values to be developed through group dialogues as opposed to static, already-formed values waiting to be elicited. (shrink)