Unhealthy lifestyle contributes significantly to the burden of disease. Scarce medical resources that could alternatively be spent on interventions to prevent or cure sufferings for which no one is to blame, are spent on prevention or treatment of disease that could be avoided through individual lifestyle changes. This may encourage policy makers and health care professionals to opt for a criterion of individual responsibility for medical suffering when setting priorities. The following article asks whether responsibility-based reasoning should be accepted as (...) relevant for fair and legitimate healthcare rationing. The luck-egalitarian argument that inequalities in health expectancies that derive from unchosen features of people’s circumstances are unjust and should be compensated, while inequalities that reflect personal choices of lifestyle may not, is discussed. It seems that while a backward-looking interpretation of individual responsibility cannot be relevant as a criterion of priority setting, a forward-looking conception of responsibility may be approved.Within all modern societies healthcare authorities are facing difficult priority setting problems. Various criteria for rationing medical intervention have been proposed due to scarcity of resources. Until now, individual responsibility for medical suffering has been given little attention in the public or in academic debate. This is about to change. As Alexander Cappelen and Ole Norheim have pointed out in a recent article in this journal, unhealthy lifestyle contributes increasingly to the burden of disease. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge.1 In this article the following question is addressed: should responsibility-based arguments be accepted as relevant to meeting healthcare rationing fairly and legitimately? I will argue that while a backward-looking conception of individual responsibility should not be endorsed, a forward-looking notion of responsibility may be approved. (shrink)

Everyone wants to be healthy, but many of us decline to act in healthy ways. Should these choices have any bearing on the ethics of clinical practice and health policy? How may personal responsibility for health be manipulated in health policy debates.

After a unilateral focus on medical professional obligations to patients in most of the 20th century, there is a growing, if modest, interest in patient responsibility. This article critiques some public assertions, explores the ethics literature, and attempts to find some consensus and moral grounds for positions taken on the question, "Does a patient have moral obligations in the process of interactions with medical and other professional caregivers?" There is widespread agreement on a few responsibilities, such as "truth telling" and (...) "avoiding harm to others," but no apparent consensus either on the list of duties or on the appropriate justification for such duties. The context and clinical realities of patient interactions are noted to suggest that feasibility is important in making judgments of patient obligations. (shrink)

We analyse solidarity as a mixture of social justice on the onehand and a set of cultural values and ascriptions on the otherhand. The latter defines the relevant sense of belonging togetherin a society. From a short analysis of the early stages of theDutch welfare state, we conclude that social responsibility wasoriginally based in religious and political associations. In theheyday of the welfare state, institutions such as sick funds,hospitals or nursing homes became financed collectively entirelyand became accessible to people of (...) all denominations. Solidaritywas transformed in a more general category, related to the statusof Dutch citizenship. Responsibility was transformed tocollective responsibility.Financial pressures on the Welfare State have resulted in adebate on choices in health care and in a number of systemreforms, so far relatively small. In the surrounding discourse,justice was linked to private responsibility. Both fromgovernment officials and from participants in the societaldebate, moralistic overtones could be heard concerning the threatof overburdening of the health care system by citizens.In this paper, we develop a concept of reflexive solidarity thatlinks elements of social justice to conceptualisations ofresponsibility that address policy makers and health careinstitutions as well as citizens, in their role of carereceivers. A short analysis of the phenomenon of personal budgetsin care services should prove that our concept of reflexivesolidarity is not empty. Linked to, but beyond the concept ofjustice, issues of social responsibility can be addressed withoutmoralistic overtones. (shrink)

The American Medical Association has provided a list of patient responsibilities, said to be derived from patient autonomy, without providing any justification for this derivation. In this article, the virtue of moral responsibility is proposed as a way to justify these kinds of limits on respect for individual autonomy. The need for such limits is explained by examining the traditional principles of health care ethics. What is missing in health care decision making, and can be provided by the virtue of (...) moral responsibility, is a careful consideration of the impact of individual decisions on particular others and the community, as a whole. The concept of moral responsibility as a virtue is then developed and examples of its application to health care decision making are provided. Finally, the roles of both physicians and health care ethicists in promoting the morally responsible exercise of individual autonomy are explored. (shrink)

Lifestyle diseases constitute an increasing proportion of health problems and this trend is likely to continue. A better understanding of the responsibility argument is important for the assessment of policies aimed at meeting this challenge. Holding individuals accountable for their choices in the context of health care is, however, controversial. There are powerful arguments both for and against such policies. In this article the main arguments for and the traditional arguments against the use of individual responsibility as a criterion for (...) the distribution of scarce health resources will be briefly outlined. It is argued that one of the most prominent contemporary normative traditions, liberal egalitarianism, presents a way of holding individuals accountable for their choices that avoids most of the problems pointed out by the critics. The aim of the article is to propose a plausible interpretation of liberal egalitarianism with respect to responsibility and health care and assess it against reasonable counter-arguments. (shrink)

The medical profession and medical ethics currently place a greater emphasis on physician responsibility than patient responsibility. This imbalance is not due to accident or a mistake but, rather is motivated by strong moral reasons. As we debate the nature and extent of patient responsibility it is important to keep in mind the reasons for giving a relatively minimal role to patient responsibility in medical ethics. It is argued that the medical profession ought to be characterized by two moral asymmetries: (...) (1) Even if some degree of responsible behavior from patients is called for, placing the dominant emphasis on professional responsibility over patient responsibility is largely correct. The value of protecting the right to refuse treatment and arguments against paternalism block a more expansive account of patient responsibility and support a strong notion of professional responsibility. (2) Insofar as we do want to encourage an increase in patient responsibility, we have good reasons to emphasize prospective rather than retrospective notions of responsibility in clinical practice. Concerns about patient vulnerability along with the determined factors in disease leave little room for blame at the bedside. These two asymmetries generate normative limits on any positive account of patient responsibility. (shrink)

This article examines the ethical basis for the patient's duty to adhere to the physician's treatment prescriptions. The article argues that patients have a moral duty to adhere to the physician's treatment prescriptions, once they have accepted treatment. Since patients still retain the right to refuse medical treatment, their duty to adhere to treatment prescriptions is a prima facie duty, which can be overridden by their other ethical duties. However, patients do not have the right to refuse to adhere to (...) treatment prescriptions if their non-adherence poses a significant threat to other people. This paper also discusses the use of written agreements between physicians and patients as a strategy for promoting patient adherence. (shrink)