Throughout the COVID-19 pandemic, shortages of scarce healthcare resources consistently presented significant moral and practical challenges. While the importance of vaccines as a key pharmaceutical intervention to stem pandemic scarcity was widely publicized, a sizable proportion of the population chose not to vaccinate. In response, some have defended the use of vaccination status as a criterion for the allocation of scarce medical resources. In this paper, we critically interpret this burgeoning literature, and describe a framework for thinking about vaccine-sensitive resource (...) allocation using the values of responsibility, reciprocity, and justice. Although our aim here is not to defend a single view of vaccine-sensitive resource allocation, we believe that attending critically with the diversity of arguments in favor (and against) vaccine-sensitivity reveals a number of questions that a vaccine-sensitive approach to allocation should answer in future pandemics. (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)

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)

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)

There is an ongoing increase in the use of mobile health technologies that patients can use to monitor health-related outcomes and behaviours. While the dominant narrative around mHealth focuses on patient empowerment, there is potential for mHealth to fit into a growing push for patients to take personal responsibility for their health. I call the first of these uses ‘medical monitoring’, and the second ‘personal health surveillance’. After outlining two problems which the use of mHealth might seem to enable us (...) to overcome—fairness of burdens and reliance on self-reporting—I note that these problems would only really be solved by unacceptably comprehensive forms of personal health surveillance which applies to all of us at all times. A more plausible model is to use personal health surveillance as a last resort for patients who would otherwise independently qualify for responsibility-based penalties. However, I note that there are still a number of ethical and practical problems that such a policy would need to overcome. The prospects of mHealth enabling a fair, genuinely cost-saving policy of patient responsibility are slim. (shrink)

The idea of using responsibility in the allocation of healthcare resources has been criticized for, among other things, too readily abandoning people who are responsible for being very badly off. One response to this problem is that while responsibility can play a role in resource allocation, it cannot do so if it will leave those who are responsible below a “sufficiency” threshold. This paper considers first whether a view can be both distinctively sufficientarian and allow responsibility to play a role (...) even for those who will be left with very poor health. It then draws several further distinctions that may affect the application of responsibility at this level. We conclude that a more plausible version of the sufficientarian view is to allow a role for responsibility where failure to do so will leave someone else who is not responsible below the sufficiency threshold. However, we suggest that individuals must exhibit “sufficient responsibility” in order for this to apply, involving both a sufficient level of control and an avoidable failure to respond adequately to reasons for action. (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)

Public debate about who or what is to blame for the rising rates of obesity and overweight shifts between two extreme opinions. The first posits overweight as the result of a lack of individual will, the second as the outcome of bodily drives, potentially triggered by the environment. Even though apparently clashing, these positions are in fact two faces of the same liberal coin. When combined, drives figure as a complication on the road to health, while a strong will should (...) be able to counter obesity. Either way, the body’s propensity to eat is to be put under control. Drawing on fieldwork in several obesity clinics and prevention sites in the Netherlands, this paper first traces how this ‘logic of control’ presents itself in clinical practices targeted at overweight people, and then goes on to explore how these practices move beyond that logic. Using the concepts of ‘will’ and ‘drives’ as analytical tools, I sketch several modes of ordering reality in which bodies, subjects, food and the environment are configured in different ways. In this way it appears that in clinical practices the terms found in public discourse take on different meanings and may even lose all relevance. The analysis reveals a richness of practiced ideals. The paper argues, finally, that making visible these alternative modes of ordering opens up a space for normative engagements with obesity care that move beyond the logic of control and its critiques. (shrink)

Eli Feiring has developed a concept of forward-looking responsibility in healthcare. On this account, what matters morally in the allocation of scarce healthcare resources is not people's past behaviours but rather their commitment to take on lifestyles that will increase the benefit acquired from received treatment. According to Feiring, this is to be preferred over the backward-looking concept of responsibility often associated with luck egalitarianism. The article critically scrutinises Feiring's position. It begins by spelling out the wider implications of Feiring's (...) view. Against this background, it shows that (i) Feiring's distinction between backward-looking and forward-looking responsibility is incompatible with the Scanlonian notion of responsibility she apparently endorses; (ii) her favoured forward-looking notion of responsibility is subject to the objections levelled against the luck egalitarian view (whatever the strength of such objections). (shrink)

The recent increased prevalence of diseases related to unhealthy lifestyles raises difficulties for healthcare insurance systems traditionally based on the principles of risk-management, solidarity, and selective altruism: since these diseases are, to some extent, predictable and avoidable, patients seem to bear some responsibility for their condition and may not deserve full access to social medical services. Here, we investigate with objective criteria to what extent it is warranted to hold patients responsible for their illness and to sanction them accordingly. We (...) ground our analysis on a series of minimal conditions for ‘practical’ and for ‘moral’ responsibility attribution. By applying these criteria consistently, we highlight that individual responsibility applies to risk-taking life choices rather than stigmatized sickness. We explain that responsibility is a matter of degree, that it varies across life-history, and can be affected by factors beyond the patients’ grasp. We point out that scientific knowledge about the effect of these factors generates responsibilities for other parties such as public health agencies and private industry. The upshot of our analysis is that health policies targeting the ‘liable’ undeserving sick are mostly unwarranted, and tend to increase unequal treatment of already vulnerable groups: the unlucky sick. (shrink)

Luck egalitarianism is a responsibility-sensitive theory of distributive justice. Its application to health and healthcare is controversial. This article addresses a novel critique of luck egalitarianism, namely, that it wrongfully discriminates against those responsible for their health disadvantage when allocating scarce healthcare resources. The philosophical literature about discrimination offers two primary reasons for what makes discrimination wrong (when it is): harm and disrespect. These two approaches are employed to analyze whether luck egalitarian healthcare prioritization should be considered wrongful discrimination. Regarding (...) harm, it is very plausible to consider the policies harmful but much less reasonable to consider those responsible for their health disadvantages a socially salient group. Drawing on the disrespect literature, where social salience is typically not required for something to be discrimination, the policies are a form of discrimination. They are, however, not disrespectful. The upshot of this first assessment of the discrimination objection to luck egalitarianism in health is, thus, that it fails. (shrink)

This paper argues against incorporating assessments of individual responsibility into healthcare policies by expanding an existing argument and offering a rebuttal to an argument in favour of such policies. First, it is argued that what primarily underlies discussions surrounding personal responsibility and healthcare is not causal responsibility, moral responsibility or culpability, as one might expect, but biases towards particular highly stigmatised behaviours. A challenge is posed for proponents of taking personal responsibility into account within health policy to either expand the (...) debate to also include socially accepted behaviours or to provide an alternative explanation of the narrowly focused discussion. Second, a critical response is offered to arguments that claim that policies based on personal responsibility would lead to several positive outcomes including healthy behaviour change, better health outcomes and decreases in healthcare spending. It is argued that using individual responsibility as a basis for resource allocation in healthcare is unlikely to motivate positive behaviour changes, and is likely to increase inequality which may lead to worse health outcomes overall. Finally, the case of West Virginia's Medicaid reform is examined, which raises a worry that policies focused on personal responsibility have the potential to lead to increases in medical spending overall. (shrink)

There is a long-standing debate concerning the eligibility of patients suffering from alcohol-related end-stage liver disease (ARESLD) for deceased donor liver transplantation. The question of retrospective and/or prospective responsibility has been at the center of the ethical discussion. Several authors argue that these patients should at least be regarded as partly responsible for their ARESLD. At the same time, the arguments for retrospective and/or prospective responsibility have been strongly criticized, such that no consensus has been reached. A third option was (...) proposed as a form of compromise, namely that responsibility should only be used as a tiebreaker in liver allocation. The present study provides an ethical investigation of this third option. First, we will provide an overview of the main arguments that have been offered for and against the use of responsibility as an allocation criterion. Second, we will explore the concept of responsibility as a tiebreaker in detail and discuss several types of situations, in which responsibility could be used as a tiebreaker, as well as the main ethical challenges associated with them. As we will show, an ethical justified use of responsibility as a tiebreaker is limited to a very restricted number of cases and is associated with a number of ethical concerns. For this reason, waiting time should be preferred as a tiebreaker in liver allocation, even though the criterion of waiting time, too, raises a number of equity-related concerns. (shrink)

Abstract:Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury (...) in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation. (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)

Carbon nanotubes (CNTs) are one of the first examples of nanotechnology, with a history of promising uses and high expectations. This paper uses the recent debate over their future to explore both ethical and value-laden statements which unsettle the notion of CNTs as a value-free nanotechnology and their regulation as purely a technical affair. A point of departure is made with the inclusion of CNTs on the Substitute-It-Now list by the Swedish NGO ChemSec, an assessment process that anticipates and complements (...) the Registration, Evaluation, Authorization and Restriction of Chemicals (REACH) regulation in Europe. An argument map is constructed to illustrate the core contention in the debate—should CNTs be substituted or not—which follows from a systematic literature review and content analysis of sampled journal articles. Nine arguments are articulated that bolster one of two camps: the pro-substitution camp or the contra-substitution camp. Beneath these arguments are a set of three implicit values that animate these two camps in prescribing competing interventions to resolve the dispute: (i) environmental protection and human safety, (ii) good science, and (iii) technological progress. This leads to a discussion around the regulatory problem of safeguarding conflicting values in decision-making under sustained scientific uncertainty. Finally, the study suggests further empirical work on specific nanomaterials in a pivot away from the abstract, promissory nature of nanotechnology and other emerging technologies in science, technology, and innovation policy. The examination of ethics and values is useful for mapping controversies in science and technology studies of regulation, even amongst experts in cognate research fields like nanomedicine and nanotoxicology. (shrink)

Lifestyle-induced diseases are becoming a burden on healthcare, actualizing the discussion on health responsibilities. Using data from the National Association for Heart and Lung Diseases ’s 2015 Health Survey, this study examined the public’s attitudes towards personal and social health responsibility in a Norwegian population. The questionnaires covered self-reported health and lifestyle, attitudes towards personal responsibility and the authorities’ responsibility for promoting health, resource-prioritisation and socio-demographic characteristics. Block-wise multiple linear regression assessed the association between attitudes towards health responsibilities and individual (...) lifestyle, political orientation and health condition. We found a moderate support for social responsibility across political views. Respondents reporting unhealthier eating habits, smokers and physically inactive were less supportive of health promotion policies. The idea that individuals are responsible for taking care of their health was widely accepted as an abstract ideal. Yet, only a third of the respondents agreed with introducing higher co-payments for treatment of ‘self-inflicted’ conditions and levels of support were patterned by health-related behaviour and left-right political orientation. Our study suggests that a significant support for social responsibility does not exclude a strong support for personal health responsibility. However, conditional access to healthcare based on personal lifestyle is still controversial. (shrink)

BackgroundThe idea that individuals are responsible for their health has been the focus of debate in the theoretical literature and in its concrete application to healthcare policy in many countries. Controversies persist regarding the form, substance and fairness of allocating health responsibility to the individual, particularly in universal, need-based healthcare systems.ObjectiveTo examine how personal health responsibility has been framed and rationalised in Norwegian key policy documents on priority setting.MethodsDocuments issued or published by the Ministry of Health and Care Services between (...) 1987 and 2018 were thematically analysed. We developed a predefined conceptual framework that guided the analysis. The framework included: the subject and object of responsibility, the level of conceptual abstraction, temporality, normative justificatory arguments and objections to the application of personal health responsibility.ResultsAs an additional criterion, personal health responsibility has been interpreted as relevant if: the patient’s harmful behaviour is repeated after receiving treatment, and if the success of the treatment is conditional on the patient’s behavioural change. When discussed as a retrospective criterion, considerations of reciprocal fairness have been dominant. When discussed as a prospective criterion, the expected benefit of treatment justified its relevance.ConclusionPersonal health responsibility appears to challenge core values of equality, inclusion and solidarity in the Norwegian context and has been repeatedly rejected as a necessary criterion for priority setting. However, the responsibility criterion seems to have some relevance in particular priority setting decisions. (shrink)

There is a growing trend in policy making of holding people responsible for their lifestyle-based diseases. This has sparked a heated debate on whether people are responsible for these illnesses, which has now come to an impasse. In this paper, I present a psychological model that explains why different views on people’s responsibility for their health exist and how we can reach a resolution of the disagreement. My conclusion is that policymakers should not perceive people as responsible while health care (...) personnel should take the opposing view. (shrink)

As the rising costs of lifestyle-related diseases place increasing strain on public healthcare systems, the individual’s role in disease may be proposed as a healthcare rationing criterion. Literature thus far has largely focused on retrospective responsibility in healthcare. The concept of prospective responsibility, in the form of a lifestyle contract, warrants further investigation. The responsibilisation in healthcare debate also needs to take into account innovative developments in mobile health technology, such as wearable biometric devices and mobile apps, which may change (...) how we hold others accountable for their lifestyles. Little is known about public attitudes towards lifestyle contracts and the use of mobile health technology to hold people responsible in the context of healthcare. This paper has two components. Firstly, it details empirical findings from a survey of 81 members of the United Kingdom general public on public attitudes towards individual responsibility and rationing healthcare, prospective and retrospective responsibility, and the acceptability of lifestyle contracts in the context of mobile health technology. Secondly, we draw on the empirical findings and propose a model of prospective intention-based lifestyle contracts, which is both more aligned with public intuitions and less ethically objectionable than more traditional, retrospective models of responsibility in healthcare. (shrink)

This paper starts by introducing a tripartite conception of responsibility for health consisting of a moral agent having moral responsibilities and being held responsible, that is blamed, for failing to meet them and proceeds to a brief discussion of the nature of the blame, noting difficulties in agency and obligation when the concept is applied to health‐threatening behaviours. Insights about the obligations that we hold people to and the extent of their moral agency are revealed by interrogating our blaming behavior, (...) and to facilitate this, my own blaming attitudes and actions are analysed in respect of an imagined adult son who seeks thrills by jumping from a pier into the sea, an activity common around coastlines and intended to be analogous in varying degrees to a range of health‐threatening behaviours. I consider my responses to this imagined act in relation to some features of moralism, the excess of morality, concluding that blame can be justified when it is proportionate and within interpersonal relationships. There is evidence that some nurses hold negative blaming attitudes towards groups of patients considered to have caused or contributed to their illness, but this is not justified, not only because of impaired agency, but also because if there is responsibility for health, associated obligations are owed to those who share our lives, and it is those people who are entitled to hold individuals responsible. Nurses who hold negative blaming attitudes towards groups of patients are invited to identify the status of moral agency, the precise natures of their (failed) obligations, and of the patient–nurse relationship. It is concluded that reflection on these matters and the difference between justified blame and moralism demonstrates that blaming behaviour in the context of professional health care is built on nothing stronger than prejudice. (shrink)

The concept of responsibility for health is a significant feature of health discourse and public health policy, but application of the concept is poorly understood. This paper offers an analysis of the concept in two ways. Following an examination of the use of the word ‘responsibility’ in the nursing and wider health literature using three examples, the concept of ‘responsibility for health’ as fulfilling a social function is discussed with reference to policy documents from the UK. The philosophical literature on (...) moral responsibility is introduced, and in considering two versions, reactive attitudes and accountability, it is argued that in application both can be regarded, though with different emphasis, as being constituted in three parts: a responsible agent; having obligations ; and being susceptible to being held responsible if he fails to meet them. The three‐stage model is consistent with the examples of the word responsibility in use, but application to the social function model causes a number of problems for healthcare practice, especially for the reactive attitudes account. Apart from considerable problems in stating what exactly the obligations are and how they can be justified; and how blame might justly be apportioned and by whom, the very ideas of obligation and blame are in conflict within healthcare systems and professional nursing practice which have foundations deeply embedded in the notion of the supremacy of personal autonomy. It is concluded that current application of the concept of responsibility for health is conceptually incoherent, and if it is to retain its place in health policy and discourse, urgent remedy is required. (shrink)

Bill 20, An Act to Enact the Act to promote access to family medicine and specialized medicine services and to amend various legislative provisions relating to assisted procreation, was introduced to reduce costs associated with Québec’s healthcare in general and in vitro fertilisation in particular. Passed in November 2015, the new law introduces a number of exclusion criteria for access to and funding for IVF treatment. Remarkably, one exclusion criterion—prior voluntary sterilisation—has prompted little critical commentary. The two justifications offered for (...) restricting funding for IVF on the basis of voluntary sterilisation are that there are cheaper options than IVF for sterilised individuals who want children, and society should not have to pay for IVF for persons who are infertile by choice. I argue that both of these justifications are unsatisfactory, insofar as they contravene the chief value underlying, and current practices of, Canadian healthcare, and rely on problematic ascriptions of personal responsibility for health. (shrink)

Abstract:It is a common belief that obesity is wholly or partially a question of personal choice and personal responsibility. It is also widely assumed that when individuals are responsible for some unfortunate state of affairs, society bears no burden to compensate them. This article focuses on two conceptualizations of responsibility: backward-looking and forward-looking conceptualizations. When ascertaining responsibility in a backward-looking sense, one has to determine how that state of affairs came into being or where the agent stood in relation to (...) it. In contrast, a forward-looking conceptualization of responsibility puts aside questions of the past and holds a person responsible by reference to some desirable future state of affairs and will typically mean that he or she is subjected to criticism, censure, or other negative appraisals or that he or she is heldcost-responsible in some form, for example, in terms of demanded compensation, loss of privileges, or similar. One example of this view is the debate as to whether the obese should be denied, wholly or partially, free and equal access to healthcare,notbecause they are somehow personally responsible in the backward-looking sense but simply because holding the obese responsible will have positive consequences. Taking these two conceptions of responsibility into account, the authors turn their analysis toward examining the relevant moral considerations to be taken into account when public policies regarding obesity rely on such a conception of responsibility. (shrink)

One question that has sometimes cropped up in the debate on triage and the management of scarce healthcare resources concerns patients’ merits, demerits, and responsibility with regard to their own medical condition. During the current pandemic, some have wondered, when it comes to accessing healthcare, whether patients who have refused vaccination—despite the availability of vaccines and pressure to get vaccinated from the health authorities—should be given the same priority as patients who have diligently undergone vaccination in accordance with the authorities’ (...) recommendations. The issue of patients’ merits and demerits is not new, and it did not emerge with the pandemic for the first time. In the past, the question was often posed whether terrorists have the right to receive the same treatment as their victims, with the same degree of priority, all clinical conditions being equal. Another issue that has been raised concerns patients suffering from diseases caused by unhealthy lifestyles that they have freely adopted: drinking, smoking, eating fatty foods, practising extreme sports, etc. The conclusion reached in the present article is that it is indeed possible to identify certain general rules for cases of this sort, as is shown by the literature on the topic. However, slavishly following these rules, even in exceptional cases for which it is impossible to make detailed provisions, can lead to disastrous consequences. Therefore, following Aristotle, the article seeks to take account both of the rule of justice and of equity, which is a form of “situational justice” capable of filling the gaps of general norms in the light of concrete cases. (shrink)