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...

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 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)

Let us first thank the four commentators who have taken the time to read and thoughtfully reflect on our paper. In that paper, we discuss how responsibility concepts must be sensitive to the temporal ( diachronic ) and social ( dyadic ) aspects of health-related behaviour, if responsibility is to play a role in health policy. This ‘if’ is a big one, and Hanna Pickard rightly challenges our position of neutrality with regard to whether or not responsibility should be incorporated (...) into health policy.1 Pickard proposes that responsibility should play a forward-looking role in health policy—used as a tool to facilitate and encourage healthy behaviours where it is reasonable to expect people to adopt such behaviours. While the conditions for such responsibility are similar to those involved in the backward-looking, desert-based responsibility we invoke, they do not warrant responses such as praise, blame, reward and punishment that may follow from desert-based responsibility. Pickard argues that even asking the question of ‘what would desert-based responsibility look like in these health contexts’ risks encouraging moralisation, stigma and blame, all of which have no place in healthcare. We agree that forward-looking responsibility could be an important tool in healthcare. We have offered …. (shrink)