Patients’ medical conditions can result from their own avoidable risk taking. Some lung diseases result from avoidable smoking and some traffic accidents result from victims’ reckless driving. Although in many nonmedical areas we hold people responsible for taking risks they could avoid, it is normally harsh and inappropriate to deny patients care because they risked needing it. Why? A popular account is that protecting everyone’s "decent minimum," their basic needs, matters more than the benefits of holding people accountable. This account (...) is deficient. Protecting the decent minimum is not always served by offering noncompliant patients either nonbasic or basic care. Nor is protecting that minimum always served by unconditional medical care better than by nonmedical interventions. To interpret the decent minimum in democratic terms is a futile response to these challenges. Ideas for new accounts are suggested. (shrink)

In this article, we focus at a key concept of today’s healthcare, namely responsibility. Personal responsibility is so important today because it is obvious that the way society is organized, many people are facing a lot of difficulties to live their lives in a responsible way. We explicitly obtain an analysis of responsibility from a view which avoids the binary thinking which is so remarkably present in today’s health care discourse. The aim of this pilot study is therefore to open (...) up the horizon of the use of responsibility in today’s healthcare. We develop the notion of ‘co-responsibility’ to understand how individuals, despite the fact they are responsible for their own agency, are always also affected by an ought which contaminates their efforts to fulfill their duties and obligations. We discuss co-responsibility not as conclusion or a magic formula to all problems, but as a new starting point of which we have to explore the opportunities for current and future health care dilemmas. (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)

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)

Many assume that theories of distributive justice must obviously take people’s lifetimes, and only their lifetimes, as the relevant period across which we distribute. Although the question of the temporal subject has risen in prominence, it is still relatively underdeveloped, particularly in the sphere of health and healthcare. This paper defends a particular view, “momentary sufficientarianism,” as being an important element of healthcare justice. At the heart of the argument is a commitment to pluralism about justice, where theorizing about just (...) principles demands paying attention to the role particular goods play in our lives. This means that different approaches to the temporal subject—as well as other relevant issues—may be appropriate for different goods, including different goods within healthcare. In particular, the paper discusses two central goods targeted by healthcare: life-saving and pain relief. The view is offered as complementary to, rather than competitive with, lifetime approaches. As such, the paper finishes by considering how a pluralist approach, which engages both with people’s lives as a whole and with their states at particular moments, can reconcile the potentially competing claims in healthcare that emerge from these two perspectives. (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)

Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal responsibility (...) would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters of institutional design and in real-world policy contexts. (shrink)

Die epidemiologische Morbiditätsverschiebung der vergangenen Jahrzehnte hat verhaltensassoziierte Erkrankungen in das Zentrum der Public Health-Arbeit rücken lassen. Sowohl die Prävention Lebensstil-bedingter Erkrankungen als auch die Behandlung ihrer Folgen gehören angesichts steigender Morbiditäts- und Mortalitätszahlen zu den größten Herausforderungen für moderne Gesundheitssysteme. Eine Beeinflussung von Gesundheitsverhalten sowie dessen Berücksichtigung in der Mittelverteilung – prominent verhandelt in der medizinethischen Debatte um gesundheitliche Eigenverantwortung – sind jedoch kontrovers. Bisher konnte dafür noch kein allgemein akzeptiertes theoretisches Modell entwickelt werden. Im vorliegenden Beitrag wird der (...) in letzter Zeit im angloamerikanischen Raum intensiv im Public Health-Kontext verhandelte libertäre Paternalismus als ein solches Modell untersucht und einer kritischen Untersuchung zugeführt. Es wird geschlussfolgert, dass dieses Modell zwar argumentativ in wesentlicher Hinsicht unterbestimmt ist, jedoch viele willkommene und sinnvolle Impulse für die moderne Public Health-Politik liefern kann. (shrink)

Die demografische Entwicklung und der medizinische Fortschritt werden die Problematik der Ressourcenknappheit im deutschen Gesundheitswesen in Zukunft weiter verschärfen. Soll nicht nur kurzfristig akuten Sparzwängen ausgewichen werden, steht – wie in verschiedenen Ländern bereits geschehen – auch Deutschland auf Dauer eine Prioritätensetzung im Gesundheitswesen bevor. Diese sollte in möglichst transparenter Weise nach klaren Kriterien erfolgen. Eines der seit einiger Zeit häufig öffentlich zitierten Kriterien der Verteilung von Mitteln in der Gesundheitsversorgung ist die Eigenverantwortung von Patienten. Deren Berücksichtigung in der Allokation (...) von Ressourcen birgt allerdings zahlreiche Probleme. Der vorliegende Beitrag untersucht die gerechtigkeitstheoretischen Grundlagen und die praktischen Probleme bzw. die möglichen Konsequenzen von Eigenverantwortung als Verteilungskriterium im Gesundheitswesen. Auf der Grundlage eines alternativen gerechtigkeitstheoretischen Vorschlags werden drei Möglichkeiten skizziert, Eigenverantwortung von Patienten im deutschen Gesundheitswesen in gerechter Weise stärker zu betonen. (shrink)

Die demografische Entwicklung und der medizinische Fortschritt werden die Problematik der Ressourcenknappheit im deutschen Gesundheitswesen in Zukunft weiter verschärfen. Soll nicht nur kurzfristig akuten Sparzwängen ausgewichen werden, steht – wie in verschiedenen Ländern bereits geschehen – auch Deutschland auf Dauer eine Prioritätensetzung im Gesundheitswesen bevor. Diese sollte in möglichst transparenter Weise nach klaren Kriterien erfolgen. Eines der seit einiger Zeit häufig öffentlich zitierten Kriterien der Verteilung von Mitteln in der Gesundheitsversorgung ist die Eigenverantwortung von Patienten. Deren Berücksichtigung in der Allokation (...) von Ressourcen birgt allerdings zahlreiche Probleme. Der vorliegende Beitrag untersucht die gerechtigkeitstheoretischen Grundlagen und die praktischen Probleme bzw. die möglichen Konsequenzen von Eigenverantwortung als Verteilungskriterium im Gesundheitswesen. Auf der Grundlage eines alternativen gerechtigkeitstheoretischen Vorschlags werden drei Möglichkeiten skizziert, Eigenverantwortung von Patienten im deutschen Gesundheitswesen in gerechter Weise stärker zu betonen. (shrink)

Die demografische Entwicklung und der medizinische Fortschritt werden die Problematik der Ressourcenknappheit im deutschen Gesundheitswesen in Zukunft weiter verschärfen. Soll nicht nur kurzfristig akuten Sparzwängen ausgewichen werden, steht – wie in verschiedenen Ländern bereits geschehen – auch Deutschland auf Dauer eine Prioritätensetzung im Gesundheitswesen bevor. Diese sollte in möglichst transparenter Weise nach klaren Kriterien erfolgen. Eines der seit einiger Zeit häufig öffentlich zitierten Kriterien der Verteilung von Mitteln in der Gesundheitsversorgung ist die Eigenverantwortung von Patienten. Deren Berücksichtigung in der Allokation (...) von Ressourcen birgt allerdings zahlreiche Probleme. Der vorliegende Beitrag untersucht die gerechtigkeitstheoretischen Grundlagen und die praktischen Probleme bzw. die möglichen Konsequenzen von Eigenverantwortung als Verteilungskriterium im Gesundheitswesen. Auf der Grundlage eines alternativen gerechtigkeitstheoretischen Vorschlags werden drei Möglichkeiten skizziert, Eigenverantwortung von Patienten im deutschen Gesundheitswesen in gerechter Weise stärker zu betonen. (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)

Background Whether patients' life-style should involve lower priority for treatment is a controversial question in bioethics. Less is known about clinicians' views. Aim To study how clinical doctors' attitudes to questions of patient responsibility and priority vary over time. Method Surveys of doctors in Norway in 2008, 2014, 2021. Questionnaires included statements about patients' lifestyle's significance for priority to care, and vignettes of priority cases (only in 2014). Results Attitudes were fairly stable between 2008 and 2021. 17%/14% agreed that patients' (...) lifestyle should count, while 19%/22% agreed that it should involve lower priority to scarce organs. 42/44% agreed that smokers should have lower priority. Substantially more agreed in 2014. Regression analyses showed that being male, working in hospital, and younger age increased the likelihood of agreeing. Conclusion A substantial minority of doctors agreed that lifestyle should be a priority criterion, possibly contrary to Norwegian legislation and professional ethics. The finding might be explained by the unspecified meaning of priority, increased scarcity-awareness, or socio-cultural trends towards individualism. The 2014 results indicate a framing effect; the vignettes may have primed the respondents towards accepting lifestyle as a criterion. We conclude that attitudes to normative questions are unstable and depend on context. A substantial minority of doctors seems to be positive to deprioritizing patients allegedly responsible for their illness. However, what deprioritization implies in practice is not clear. (shrink)

An absolute decline in US life expectancy in low education whites has alarmed policy makers and attracted media attention. Depending on which studies are correct, low education white women have lost between 3 and 5 years of lifespan; men, between 6 months and 3 years. Although absolute declines in life expectancy are relatively rare, some commentators see the public alarm as reflecting a racist concern for white lives over black ones. How ought we ethically to evaluate this lifespan contraction in (...) low education whites? Should we care, or is it racist to care? Does it constitute an injustice or reflect justice being done? I argue that the lifespan contraction in low education whites violates key normative criteria used to make determinations of health justice, and that these judgments do not vitiate concerns about racism. I conclude with reflections on US population health policy and building an inclusive health equity movement. (shrink)

In many countries, there are health care initiatives to make smokers give up smoking in the peri-operative setting. There is empirical evidence that this may improve some, but not all, operative outcomes. However, it may be feared that some support for such policies stems from ethically questionable opinions, such as paternalism or anti-smoker sentiments. This study aimed at investigating the support for a policy of smoking cessation prior to surgery among Swedish physicians and members of the general public, as well (...) as the reasons provided for this. A random sample of general practitioners and orthopaedic surgeons as well as members of the general public received a mail questionnaire. It contained a vignette case with a smoking 57-year old male farmer with hip osteoarthritis. The patient had been recommended hip replacement therapy, but told that in order to qualify for surgery he needed to give up smoking four weeks prior to and after surgery. The respondents were asked whether making such qualifying demands is acceptable, and asked to rate their agreement with pre-set arguments for and against this policy. Response rates were 58.2% among physicians and 53.8% among the general public. Of these, 83.9% and 86.6%, respectively, agreed that surgery should be made conditional upon smoking cessation. Reference to the peri-operative risks associated with smoking was the most common argument given. However, there was also strong support for the argument that such a policy is mandated in order to achieve long term health gains. There is strong support for a policy of smoking cessation prior to surgery in Sweden. This support is based on considerations of peri-operative risks as well as the general long term risks of smoking. This study indicates that paternalistic attitudes may inform some of the support for peri-operative smoking cessation policies and that at least some respondents seem to favour a “recommendation strategy” vis-à-vis smoking cessation prior to surgery rather than a “requirement strategy”. The normative reasons speak in favour of the “recommendation strategy”. (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)

The majority of deaths due to tobacco in the twenty-first century will occur in the developing world, where over 80% of current tobacco users live. In November 2010 guidelines were adopted for implementing Article 14 of the World Health Organization’s Framework Convention on Tobacco Control (FCTC). The guidelines call on all countries to promote tobacco treatment programs. Nevertheless, some experts argue for a strict focus, at least in developing countries, on population-based measures such as taxes and indoor air laws, which (...) they consider more cost-effective than individual treatment. In this article we defend tobacco dependence treatment in developing countries. First, these experts understate the comparative cost-effectiveness of individual treatment programs. Second, they overlook numerous ethical considerations beyond cost-effectiveness that support individual tobacco treatment in developing countries. We conclude that the strict population-based focus in developing country tobacco control advocated by some experts is misplaced. In general, developing nations should combine population-based measures and individual tobacco treatment programs. (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)

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)

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)

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)

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)

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)

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)

In this paper we aim to demonstrate the enormous ethical complexity that is prevalent in child obesity cases. This complexity, we argue, favors a cautious approach. Against those perhaps inclined to blame neglectful parents, we argue that laying the blame for child obesity at the feet of parents is simplistic once the broader context is taken into account. We also show that parents not only enjoy important relational prerogatives worth defending, but that children, too, are beneficiaries of that relationship in (...) ways difficult to match elsewhere. Finally, against the backdrop of growing public concern and pressure to intervene earlier in the life cycle, we examine the perhaps unintended stigmatizing effects that labeling and intervention can have and consider a number of risks and potential harms occasioned by state interventions in these cases. (shrink)

El contexto de crisis y restricciones presupuestarias sirve de pretexto para promover en la Comunidad de Madrid la implantación de un modelo dual de gestión de los centros y servicios sanitarios, ampliamente contestado en la calle por profesionales sanitarios, asociaciones, pacientes y usuarios. Este proceso se inicia sin evidencia científico-técnica que avale las presuntas ventajas del modelo de concesión y carece de una evaluación solvente de impacto sanitario, conforme a estándares de transparencia, rendición de cuentas y calidad democrática. Entre los (...) aspectos éticos y jurídicos involucrados en este debate analizo los relacionados con el conflicto de intereses y las evidencias recientes que desaconsejan adoptar en España modelos similares. Tras analizar el desafío que supone el nuevo marco institucional para el ejercicio de la responsabilidad profesional conforme a criterios de equidad y buenas prácticas, se concluye aportando elementos para generar un marco más equilibrado de reformas. (shrink)

This volume bridges contemporary philosophical conceptions of risk and responsibility and offers an extensive examination of the topic. It shows that risk and responsibility combine in ways that give rise to new philosophical questions and problems. Philosophical interest in the relationship between risk and responsibility continues to rise, due in no small part due to environmental crises, emerging technologies, legal developments, and new medical advances. Despite such interest, scholars are just now working out how to conceive of the links between (...) risk and responsibility, the implications that risks may have to conceptions of responsibility (and vice versa), as well as how such theorizing might play out in applied cases. With contributions from leading scholars, this volume brings together new work examining the interplay between risk and responsibility, exploring its varied philosophical aspects and applications to contemporary issues in law, bioethics, technology, and environmental ethics. Risk and Responsibility in Context will be of interest to philosophers working in ethics, bioethics, philosophy of law, and philosophy of technology, as well as scholars and practitioners in law, health and science management, public policy, and environmental studies. (shrink)

According to relational egalitarians, equality is not primarily about the distribution of some good but about people relating to one another as equals. However, compared with other theorists in political philosophy – including other egalitarians – relational egalitarians have said relatively little on what role personal responsibility should play in their theories. For example, is equality compatible with responsibility? Should economic distributions be responsibility-sensitive? This article fills this gap. I develop a relational egalitarian framework for personal responsibility and show that (...) relational equality commits us to responsibility. I develop two sets of arguments. First, I draw on relational theories of moral responsibility – particularly Strawsonian views – to show that valuable egalitarian relationships require responsibility. Second, I show why relational equality sometimes requires that economic distributions be sensitive to responsibility and choice. I also defend a seemingly paradoxical result: being committed to responsibility, relational egalitarianism not only justifies some distributive inequalities but some relational inequalities too. Overall, relational egalitarianism gives a nuanced and coherent answer as to why and how responsibility matters from within egalitarianism. That it does should be an important argument in its favour. (shrink)

In this essay, we respond to Angelo Corlett’s criticism of our paper ‘Ethics, Brain Injuries, and Sports: Prohibition, Reform, and Prudence’. To do so, first, we revisit certain assumptions and arg...

Sowohl im System der medizinischen Versorgung als auch im Rahmen der Präventions- und Gesundheitsförderungspolitik stellt sich die Frage, welche Bedeutung dem Grundsatz der Eigenverantwortung zukommt. Der Beitrag vergleicht die Diskussionen in beiden Bereichen und stellt abschließend ihren Zusammenhang dar.

Angesichts der Zunahme chronischer Erkrankungen erscheint es geboten, vermehrt auf Präventionsmaßnahmen zurückzugreifen, die den Einzelnen zu einer gesundheitsfördernden Lebensweise anhalten und exogene gesundheitsschädigende Einflüsse reduzieren. Dabei ergeben sich zwei ethische Problemkonstellationen: 1) Welche Einschränkungen der Entscheidungsautonomie des Einzelnen sind gerechtfertigt, um bestimmte Präventionsziele zu erreichen? 2) Welche Verantwortung kann und soll der Einzelne für seine Gesundheit tragen? Fünf ethische Anforderungen sind an jede Präventionsmaßnahme zu stellen: 1) nachgewiesene Wirksamkeit, 2) günstiges Kosten-Nutzen-Profil, 3) akzeptables Kosten-Nutzen-Verhältnis, 4) möglichst geringe Restriktivität und 5) (...) faire Entscheidungsverfahren. Je nachdem, wie weit diese Anforderungen erfüllt sind, lässt sich eine unterschiedlich starke Beeinflussung der individuellen Entscheidungsautonomie rechtfertigen. Anstatt den Einzelnen für gesundheitsschädigendes Verhalten retrospektiv zu bestrafen, sollte er – im Sinne einer Stärkung der Gesundheitsmündigkeit – prospektiv in die Lage versetzt werden, Sorge für seine eigene Gesundheit zu tragen. (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)

In recent years, bariatric surgery has become an increasingly popular treatment of obesity. The amount of resources spent on this kind of surgery has led to a heated debate among health care professionals and the general public, as each procedure costs at minimum $14,500 and thousands of patients undergo surgery every year. So far, no substantial argument for or against giving this treatment a high priority has, however, been presented. In this article, I argue that regardless which moral perspective we (...) consider—greatest need, utility or personal responsibility—the conclusion is that we should give bariatric surgery a high priority when allocating scarce resources in health care. (shrink)

The American Journal of Bioethics, Volume 11, Issue 7, Page W1-W3, July 2011.

Some people argue that the distribution of medical resources should be sensitive to agents’ responsibility for their ill-health. In contrast, others point to the social determinants of health to argue that the collective agents that control the conditions in which agents act should bear responsibility. To a large degree, this is a debate in which those who hold individuals responsible currently have the upper hand: warranted appeals to individual responsibility effectively block allocation of any significant degree of responsibility to collective (...) agents. We suggest that a different understanding of individual responsibility might lead to a fairer allocation of blame. Scaffolded agency is individual agency exercised in a context in which opportunities and affordances are structured by others. Appeals to scaffolded agency at once recognize the role of the individual and of the collective agents who have put the scaffolds in place. (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)

The ethics of health incentive research—a form of public health research—are not well developed, and concerns of justice have been least examined. In this paper, we explore what potential long term harms in relation to justice may occur as a result of such research and whether they should be considered as part of its ethical evaluation. ‘Long term harms’ are defined as harms that contribute to existing systematic patterns of disadvantage for groups. Their effects are experienced on a long term (...) basis, persisting even once an incentive research project ends. We will first establish that three categories of such harms potentially arise as a result of health incentive interventions. We then argue that the risk of these harms also constitutes a morally relevant consideration for health incentive research and suggest who may be responsible for assessing and mitigating these risks. We propose that responsibility should be assigned on the basis of who initiates health incentive research projects. Finally, we briefly describe possible strategies to prevent or mitigate the risk of long term harms to members of disadvantaged groups, which can be employed during the design, conduct and dissemination of research projects. (shrink)

Healthcare providers face enormous pressure to save healthcare resources where possible. In this paper I explore the response that we should allocate resources fairly. What is a fair allocation of healthcare resources for children? First, I consider the luck egalitarianism approach of limiting resources to adult patients who are responsible for their conditions. A luck egalitarian distribution of healthcare resources to adults faces significant problems in application. I maintain that when we consider these problems with a focus on the just (...) distribution of healthcare resources to children, we gain valuable insights into the fairness of healthcare allocation for adults. (shrink)

Pre-natal-diagnosis technologies allow parents to discover whether their child is likely to suffer from serious disability. One argument for state funding of access to such technologies is that doing so would be “cost-effective”, in the sense that the expected financial costs of such a programme would be outweighed by expected “benefits”, stemming from the births of fewer children with serious disabilities. This argument is extremely controversial. This paper argues that the argument may not be as unacceptable as is often assumed. (...) In doing so, it sets out a more general framework for assessing the relevance of efficiency calculations to policy-making. The final section also investigates the relationship between the paper’s arguments and claims about parental responsibility for child-bearing and rearing, with reference to Scanlon’s work on “substantive responsibility”. (shrink)

Bonuses, as incentives or rewards for health -related behavior, feature prominently in German social health insurance. Their goal is centered around promoting personal responsibility, but reducing overall health -care expenditure and enabling competition between sickness funds also play a role. The central position of personal responsibility in German health -care policy is described, and a framework is offered for an analysis of the ethical issues raised by policies seeking to promote responsibility. The framework entails seven tests relating to: solidarity; equality (...) and equity; intrusiveness; attributability and opportunity of choice; evidence, rationale, and feasibility; affected third parties; and coherence. It is contended that a focus on tests, in particular from within contractualism, is the most appropriate way of addressing the question of health responsibility in pluralistic societies. However, taken by themselves, the tests also allow an identification of the key ethical issues by particular policies, which are illustrated by applying the framework to particular bonus polices. (shrink)

When individual patients' medical decisions contribute to population-level trends, physicians may struggle with how to promote justice while maintaining respect for patient autonomy. This article argues that this tension might be resolved by using the informed consent conversation as an opportunity to position patients as societal stewards.

This paper scrutinizes the tension between individuals’ rights and paternalism. I will argue that no normative account that includes rights of individuals can justify hard paternalism since the infringement of a right can only be justified with the right or interest of another person, which is never the case in hard paternalism. Justifications of hard paternalistic actions generally include a deviation from the very idea of having rights. The paper first introduces Tom Beauchamp as the most famous contemporary hard paternalist (...) by outlining his moral theory (principlism) and showing why it, as it stands, has to allow for hard paternalism. Secondly, the paper focuses on the notion of rights within principlism. I will employ traditional theories of rights to make sense of rights in principlism. Unfortunately, this attempt fails. In the third part, then, I claim that rights can only be limited with reference to the rights or interests of others. This structure is the very point of rights, it is their bite. I will argue for this claim and show its implications. The most important implication is that not only principlism, but every normative theory that includes rights of individuals, has to abolish hard paternalism. (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)