Personal responsibility within health policy: unethical and ineffective

Refund: a defense of luck egalitarian policy in healthcare

Luck egalitarianism assigns a central role to personal responsibility in egalitarian justice. In the context of healthcare, luck egalitarianism is the view that the distribution of medical and healthcare resources-or common resources in general-should respond to the (im)prudence of individuals. Recently, Joar Björk, Gert Helgesson, and Niklas Juth have argued that it is impractical to use luck egalitarianism as a normative framework in healthcare because it has no reasonable way of dealing with the imprudent. In response to their argument, this paper first suggests that the epistemic problems of applying luck egalitarianism to the healthcare context raised by Björk et al. can be circumvented by using the exemption system as a policy application of luck egalitarian healthcare justice. This paper then shows that an ex ante policy, a tax system with refunds, can reasonably be adopted as a luck egalitarian institutional design of healthcare policy. We argue that the proposed conception of luck egalitarianism can deal with the problem of differential option luck. Finally, we show that the threshold problem for the definition of imprudence does not refute the proposed ex ante policy.

Discrimination Based on Personal Responsibility: Luck Egalitarianism and Healthcare Priority Setting

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.

Understanding the role of the state in dietary public health policymaking: a critical scoping review

Despite evidence that dietary population health interventions are effective and widely accepted, they remain the topic of intense debate centring on the appropriate role of the state. This review sought to identify how the role of the state in intervening in individuals' food practices is conceptualized across a wide range of literatures. We searched 10 databases and 4 journals for texts that debated dietary population health interventions designed to affect individuals' health-affecting food practices. Two co-authors independently screened these texts for eligibility relative to inclusion and exclusion criteria. Thirty-five texts formed our final corpus. Through critical reflexive thematic analysis (TA), we generated 6 themes and 2 subthemes concerning choice, responsibility for health, balancing benefits and burdens of intervention, the use of evidence, fairness, and the legitimacy of the state's actions. Our analysis found that narratives that aim to prevent effective regulation are entrenched in academic literatures. Discourses that emphasized liberty and personal responsibility framed poor health as the result of 'lifestyle choices'. Utilitarian, cost-benefit rationales pervaded arguments about how to best balance the benefits and burdens of state intervention. Claims about fairness and freedom were used to evoke powerful common meanings, and evidence was used politically to bolster interests, particularly those of the food industry. This review identifies and critically analyses key arguments for and against population dietary public health policies. Our findings should motivate public health researchers and practitioners to avoid unreflexively embracing framings that draw on the languages and logics of free market economics.

The Myth of Zero-Sum Responsibility: Towards Scaffolded Responsibility for Health

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.

Experiences of integrating and sustaining physical activity in life with multiple sclerosis, Alzheimer's disease, and ischaemic heart disease: a scoping review

PURPOSE

The effects of physical activity on health are well-established for chronic diseases such as multiple sclerosis (MS), Alzheimer's disease (AD), and ischaemic heart disease (IHD). However, sustaining physical activity in everyday life is difficult. Lifeworld knowledge can help qualify interventions aimed at resolving this public health issue, but there is a gap in regard to synthesized research on peoples' experiences with integrating and sustaining physical activity. Hence, the purpose of this review is to explore and present the available evidence on experiences with integrating and sustaining physical activity in a lived life with MS, AD, and IHD.

METHODS

We conducted a scoping review with qualitative analysis and narrative syntheses in accordance with PRISMA-ScR. Based on SPIDER we ran a systematic search in Cinahl, Embase, Medline, and PsychInfo for primary qualitative research papers published until December 2022.

RESULTS

43 papers were included. A thematic content analysis found that individuals who have MS, AD or IHD find integrating and sustaining physical activity in everyday life meaningful on several levels: Physical activity can facilitate meaningful movement with outcomes of physical, psychosocial, and existential importance.

CONCLUSION

The research literature presents a meaning to physical activity that extends the idea of physical fitness to one of existential movement and personal growth. In addition, our review finds that people are more likely to integrate and sustain physical activity if they feel acknowledged, supported and believe that physical activity has a meaningful purpose reflecting their sense of self. Taking a more person-centred approach in rehabilitative care might help qualify the content of physical activity in terms of integration into everyday life, but more research is needed on how to implement a person-centred approach in practice.IMPLICATIONS FOR REHABILITATIONThe research literature presents an experiential meaning to physical activity that extends the idea of physical fitness to one of more existential movement and personal growth.To ensure the integration of physical activity in people's everyday life, future rehabilitation interventions might benefit from adapting a more person-centred approach.People are more likely to sustain physical activity when they feel acknowledged, supported through social relationships, can access activities adapted to their specific needs and preferences, and believe that physical activity has a meaningful purpose reflecting their sense of self.

The complexities of integrating evidence-based preventative health into England's NHS: lessons learnt from the case of PrEP

BACKGROUND

The integration of preventative health services into England's National Health Service is one of the cornerstones of current health policy. This integration is primarily envisaged through the removal of legislation that blocks collaborations between NHS organisations, local government, and community groups.

AIMS AND OBJECTIVES

This paper aims to illustrate why these actions are insufficient through the case study of the PrEP judicial review.

METHODS

Through an interview study with 15 HIV experts (commissioners, activists, clinicians, and national health body representatives), we explore the means by which the HIV prevention agenda was actively blocked, when NHS England denied responsibility for funding the clinically effective HIV pre-exposure prophylaxis (PrEP) drug in 2016, a case that led to judicial review. We draw on Wu et al.'s (Policy Soc 34:165-171, 2016) conceptual framing of 'policy capacity' in undertaking this analysis.

RESULTS

The analyses highlight three main barriers to collaborating around evidence-based preventative health which indicate three main competence/capability issues in regard to policy capacity: latent stigma of 'lifestyle conditions' (individual-analytical capacity); the invisibility of prevention in the fragmented health and social care landscape related to issues of evidence generation and sharing, and public mobilisation (organizational-operational capacity); and institutional politics and distrust (systemic-political capacity).

DISCUSSION AND CONCLUSION

We suggest that the findings hold implications for other 'lifestyle' conditions that are tackled through interventions funded by multiple healthcare bodies. We extend the discussion beyond the 'policy capacity and capabilities' approach to connect with a wider range of insights from the policy sciences, aimed at considering the range of actions needed for limiting the potential of commissioners to 'pass the buck' in regard to evidence-based preventative health.

Making psychiatry moral again: the role of psychiatry in patient moral development

Psychiatric involvement in patient morality is controversial. If psychiatrists are tasked with shaping patient morality, the coercive potential of psychiatry is increased, treatment may be unfairly administered on the basis of patients' moral beliefs rather than medical need, moral disputes could damage the therapeutic relationship and, in any case, we are often uncertain or conflicted about what is morally right. Yet, there is also a strong case for the view that psychiatry often works through improving patient morality and, therefore, should aim to do so. Our goal is to offer a practical and ethical path through this conflict. We argue that the default psychiatric approach to patient morality should be procedural, whereby patients are helped to express their own moral beliefs. Such a procedural approach avoids the brunt of objections to psychiatric involvement in patient morality. However, in a small subset of cases where patients' moral beliefs are sufficiently distorted or underdeveloped, we claim that psychiatrists should move to a substantive approach and shape the content of those beliefs when they are relevant to psychiatric outcomes. The substantive approach is prone to the above objections but we argue it is nevertheless justified in this subset of cases.

On the Anatomy of Health-related Actions for Which People Could Reasonably be Held Responsible: A Framework

Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities.

Rationing, Responsibility, and Vaccination during COVID-19: A Conceptual Map

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.

Moral and Social Values in Evidence-Informed Deliberative Processes for Health Benefit Package Design Comment on "Evidence-Informed Deliberative Processes for Health Benefit Package Design - Part II: A Practical Guide"

An evidence-informed deliberative process (EDP) is defined as "a practical and stepwise approach for health technology assessment (HTA) bodies to enhance legitimate health benefit package design based on deliberation between stakeholders to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values." In this commentary, I discuss some considerations for EDPs that arise from acknowledging the difference between social and moral values. First, the best practices for implementing EDPs may differ depending on whether the approach is grounded in moral versus social values. Second, the goals of deliberation may differ when focused on moral versus social values. I conclude by offering some considerations for future research to support the use of EDPs in practice, including the need to assess how different approaches to appraisal (eg, more quantitative versus qualitative) impact perceptions of the value of deliberation itself.

People's perspectives about COVID-19 vaccination certificate: Findings from a representative Italian sample

In Italy, like in other countries, issues still exist regarding how to reach high vaccine coverage and several countries have considered policies to increase vaccine uptake. In the present study, we focused on people who have a favorable attitude towards vaccination. In March-April 2021, we asked a representative sample of Italian participants (N = 1,530) to assess to what extent they would support the adoption of a COVID-19 vaccination certificate, excluding unvaccinated people from participating in public and cultural events. Furthermore, as the vaccination coverage increases, severe forms of COVID-19 requiring hospitalization more likely involve unvaccinated individuals, who might be perceived as those who don't contribute to ending the pandemic and who constitute a significant health cost for society. We then asked participants to assess to what extent they would favor the idea of requiring people who refuse the vaccine to pay for their own medical expenses in case of hospitalization. We hypothesized that support for the adoption of the vaccination certificate would be predicted by the COVID-19 vaccination status (received, booked, high-, medium-, low-willingness to be vaccinated, or refused) and by the same factors that are known to affect the willingness to get vaccinated. These factors were also tested in a model aimed at investigating if a vaccinated person would favor a measure requiring the unvaccinated individuals to pay for medical expenses. Results confirmed that the support towards the vaccination certificate policy was strongly predicted by the vaccination status and by factors known to affect the willingness to get vaccinated. Interestingly (and surprisingly), a similar pattern was observed for the support of the policy about medical expenses. In conclusion, support for a COVID-19 vaccination certificate was high among the Italian population in the early phases of the vaccination rollout. The findings are discussed considering potential policies to tackle the pandemic.

Psychosis and psychedelics: Historical entanglements and contemporary contrasts

Experiences of psychedelics and psychosis were deeply entangled in scientific practices in the mid-20th century, from uses of psychedelic drugs that could model psychosis, to detailed phenomenological comparisons of endogenous and drug-induced madness. After the moral panic of the 1960s shut down psychedelic research, however, these two phenomena became disentangled. In the decades following, the science of psychosis transformed, shedding the language of psychoanalysis, and adopting the new scientific veneer of psychiatry. Today, as psychedelic science re-emerges, the research programs surrounding psychosis and psychedelics now stand in stark contrast. Here, I look closely at how these research programs respond to questions related to what is worth measuring, what is worth investigating, and how we ought to respond to these experiences. This comparison reveals radically different assumptions and values that guide each research paradigm and shape clinical practice. While psychedelic research often includes scales that seek to capture experiences of mysticism, meaningfulness, and ego dissolution, research related to psychosis focuses on the measurement of pathological symptoms and functioning. Research into psychosis primarily seeks universal and reductionist causal explanations and interventions, while psychedelic research embraces the importance of set and setting in shaping unique experiences. Responses to psychedelic crisis involve warmth, compassion, and support, while responses to psychotic experiences often involve restraint, seclusion, and weapons. I argue that these differences contain important lessons for psychiatry. However, as psychedelic research struggles to meet regulatory requirements and fit within the paradigm of evidence-based medicine, these differences may quickly dissolve.

Rare diseases in healthcare priority setting: should rarity matter?

Rare diseases pose a particular priority setting problem. The UK gives rare diseases special priority in healthcare priority setting. Effectively, the National Health Service is willing to pay much more to gain a quality-adjusted life-year related to a very rare disease than one related to a more common condition. But should rare diseases receive priority in the allocation of scarce healthcare resources? This article develops and evaluates four arguments in favour of such a priority. These pertain to public values, luck egalitarian distributive justice the epistemic difficulties of obtaining knowledge about rare diseases and the incentives created by a higher willingness to pay. The first is at odds with our knowledge regarding popular opinion. The three other arguments may provide a reason to fund rare diseases generously. However, they are either overinclusive because they would also justify funding for many non-rare diseases or underinclusive in the sense of justifying priority for only some rare diseases. The arguments thus fail to provide a justification that tracks rareness as such.

The multi-subject cooperation mechanism of home care for the disabled elderly in Beijing: a qualitative research

BACKGROUND

Currently, population aging has been an obstacle and the spotlight for all countries. Compared with developed countries, problems caused by China's aging population are more prominent. Beijing, as a typical example, is characterized by advanced age and high disability rate, making this capital city scramble to take control of this severe problem. The main types of care for the disabled elderly are classified as home care, institutional care, and community care. With the obvious shortage of senior care institutions, most disabled elderly people are prone to choose home care. This kind of elderly care model is in line with the traditional Chinese concept and it can save the social cost of the disabled elderly to the greatest extent. However, home care for the disabled elderly is facing bumps from the whole society, such as lack of professional medical care, social support and humanistic care, and the care resources provided by a single subject cannot meet the needs of the disabled elderly.

OBJECTIVE

Based on the demands of the disabled elderly and their families, this study aims to explore the current status of home care service, look for what kind of care is more suitable for the disabled elderly, and try to find an appropriate elderly care mechanism which could meet the diverse needs of the disabled elderly.

METHODS

A total of 118 disabled elderly people and their primary caregivers were selected from four districts of Beijing by using multi-stage stratified proportional sampling method. A one-to-one and semi-structured in-depth qualitative interview were conducted in the study to find out the health status of the disabled elderly, the relationship between the disabled elderly and their primary caregivers, and utilization of elderly care resources, etc. The views of the interviewees were analyzed through the thematic framework method. All the methods were carried out in accordance with relevant guidelines and regulations.

RESULTS

The results showed that the average age of 118 disabled elderly is 81.38 ± 9.82 years; 86 (72.9%) are severe disability; 105 (89.0%)are plagued by chronic diseases; the average duration of disability is 5.63 ± 5.25 years; most of disabled elderly have 2 children, but the primary caregiver are their own partner (42, 35.6%), and there is an uneven sharing of responsibilities among the disabled elderly's offspring in the process of home care. The disabled elderly enjoy medical care services, rehabilitation training, daily health care, psychological and other demands. However, the disabled elderly and their families in Beijing face a significant financial burden, as well as physical and psychological issues. The care services provided by the government, family doctors, family members and social organizations fall far short of satisfying the diverse care needs of the disabled elderly.

CONCLUSIONS

In order to effectively provide home care services for the disabled elderly, it is therefore necessary to establish a coordination mechanism of multiple subjects and give full play to the responsibilities of each subject. This study proposes a strengthening path for the common cooperation of multiple subjects, which taking specific responsibilities and participating in the home care for the disabled elderly: (1) The government should give full play to the top-level leading responsibilities and effectively implement people-oriented measures to the disabled elderly. (2) Family doctors strengthen their responsibilities as health gatekeepers and promote continuous health management of the disabled elderly. (3) Family members assume the main responsibility and provide a full range of basic care services. (4) Social forces promote supplementary responsibilities of public welfare and expand the connotation of personalized care services. (5) The disabled elderly should shoulder appropriate personal responsibility and actively cooperate with other subjects.

The role of patients in the governance of a sustainable healthcare system: A scoping review

Patients, healthcare providers and insurers need a governance framework to establish the ‘rules of use’ to deliver more responsible use of services. The objective of this review was to provide an overview of frameworks and analyze the definitions of patient accountability to identify themes and potential gaps in the literature. Fifteen bibliographic databases were searched until July 2021. This included: MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, Allied and Complementary Medicine Database, Web of Science, HealthSTAR, Scopus, ABI/INFORM Global, Cochrane Library, ERIC, International Bibliography of the Social Sciences, Sociological Abstracts, Worldwide Political Science Abstracts and International Political Science Abstracts. Searches were also completed in Google Scholar. Inclusion criteria included articles focused on accountability of patients, and exclusions included articles that were not available, not written in English, with missing information, and commentaries or editorials. In total, 85530 unique abstracts were identified, and 27 articles were included based on the inclusion criteria. The results showed that patient accountability is rarely used and poorly defined. Most studies focused on what patients should be held to account for and agreed that patients should be responsible for behaviours that may contribute to adverse health outcomes. Some studies promoted a punitive approach as a mechanism of enforcement. Most studies argued for positive incentives or written agreements and contracts. While many studies recognized the value of patient accountability frameworks, there was a concern that these frameworks could further exacerbate existing socioeconomic disparities and contribute to poor health-related behaviours and outcomes (e.g., stigmatizing marginalized groups). Shared models of accountability between patients and healthcare providers or patients and communities were preferred. Before committing to a patient accountability framework for improving patient health and sustaining a healthcare system, the concept must be acceptable and reasonable to patients, providers, and society as a whole.

"I Think I Have Enough for Now": Living with COVID-19 Antibodies in the Philippines

Drawing on face-to-face and virtual fieldwork in the Philippines, I document the emergence of antibody testing as a popular practice among Filipinos during the COVID-19 pandemic, helping them make decisions about vaccines and other life choices. Antibodies gave people a sense of agency and control amid a health crisis for which political and medical authorities failed to offer certainty and hope, particularly at a time of vaccine scarcity and viral surges. However, by diverting attention from the health care system to individual immune systems, antibodies also reinforced the individual "responsibilization" that has characterized the Philippine government's pandemic response.

On the person in personal health responsibility

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.

Responsibility and the recursion problem

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.

Viewpoints among experts and the public in the Netherlands on including a lifestyle criterion in the healthcare priority setting

Context

It remains unclear whether there would be societal support for a lifestyle criterion for the healthcare priority setting. This study examines the viewpoints of experts in healthcare and the public regarding support for a lifestyle‐related decision criterion, relative to support for the currently applied criteria, in the healthcare priority setting in the Netherlands.

Methods

We conducted a Q methodology study in samples of experts in healthcare (n = 37) and the public (n = 44). Participants (total sample N = 81) ranked 34 statements that reflected currently applied decision criteria as well as a lifestyle criterion for setting priorities in healthcare. The ranking data were subjected to principal component analysis, followed by oblimin rotation, to identify clusters of participants with similar viewpoints.

Findings

We identified four viewpoints. Participants with Viewpoint 1 believe that treatments that have been proven to be effective should be reimbursed. Those with Viewpoint 2 believe that life is precious and every effort should be made to save a life, even when treatment still results in a very poor state of health. Those with Viewpoint 3 accept government intervention in unhealthy lifestyles and believe that individual responsibility should be taken into account in reimbursement decisions. Participants with Viewpoint 4 attribute importance to the cost‐effectiveness of treatments; however, when priorities have to be set, treatment effects are considered most important. All viewpoints were supported by a mix of public and experts, but Viewpoint 1 was mostly supported by experts and the other viewpoints were mostly supported by members of the public.

Conclusions

This study identified four distinct viewpoints on the healthcare priority setting in the Netherlands, each supported by a mix of experts and members of the public. There seems to be some, but limited, support for a lifestyle criterion—in particular, among members of the public. Experts seem to favour the decision criteria that are currently applied. The diversity in views deserves attention when policymakers want to adhere to societal preferences and increase policy acceptance.

'Personal Health Surveillance': The Use of mHealth in Healthcare Responsibilisation

There is an ongoing increase in the use of mobile health (mHealth) 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.

Healthcare, Responsibility and Golden Opportunities

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.

'Listen and learn:' participant input in program planning for a low-income urban population at cardiovascular risk

Background

Poverty increases the risk of cardiac disease, while diminishing the resources available to mitigate that risk. Available prevention programs often require resources that low-income residents of urban areas do not possess, e.g. membership fees, resources to purchase healthy foods, and safe places for physical activity. The aim of this study is to obtain participant input in order to understand the health-related goals, barriers, and strengths as part of planning a program to reduce cardiovascular risk.

Methods

In a mixed methods study, we used written surveys and focus groups as part of planning an intervention specifically designed to meet the needs of lower income individuals. Based on prior research, we used Self-Determination Theory (SDT) and its core constructs of autonomy, competence, and relatedness as the theoretical framework for analysis. The study collected information on the perspectives of low-income urban residents on their risks of cardiovascular disease, their barriers to and supports for addressing health needs, and how they addressed barriers and utilized supports. Focus group transcripts were analyzed using standard qualitative methods including paired coding and development of themes from identified codes.

Results

Participants had health goals that aligned with accepted approaches to reducing their cardiovascular risks, however they lacked the resources to reach those goals. We found a lack of support for the three SDT core constructs. The barriers that participants reported suggested that these basic psychological needs were often thwarted by their environments.

Conclusions

Substantial disparities in both access to health-promoting resources and in support for autonomy, competence, and relatedness must be addressed in order to design an effective intervention for a low-income population at cardiac risk.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10423-6.

Prevention in the age of personal responsibility: epigenetic risk-predictive screening for female cancers as a case study

Epigenetic markers could potentially be used for risk assessment in risk-stratified population-based cancer screening programmes. Whereas current screening programmes generally aim to detect existing cancer, epigenetic markers could be used to provide risk estimates for not-yet-existing cancers. Epigenetic risk-predictive tests may thus allow for new opportunities for risk assessment for developing cancer in the future. Since epigenetic changes are presumed to be modifiable, preventive measures, such as lifestyle modification, could be used to reduce the risk of cancer. Moreover, epigenetic markers might be used to monitor the response to risk-reducing interventions. In this article, we address ethical concerns related to personal responsibility raised by epigenetic risk-predictive tests in cancer population screening. Will individuals increasingly be held responsible for their health, that is, will they be held accountable for bad health outcomes? Will they be blamed or subject to moral sanctions? We will illustrate these ethical concerns by means of a Europe-wide research programme that develops an epigenetic risk-predictive test for female cancers. Subsequently, we investigate when we can hold someone responsible for her actions. We argue that the standard conception of personal responsibility does not provide an appropriate framework to address these concerns. A different, prospective account of responsibility meets part of our concerns, that is, concerns about inequality of opportunities, but does not meet all our concerns about personal responsibility. We argue that even if someone is responsible on grounds of a negative and/or prospective account of responsibility, there may be moral and practical reasons to abstain from moral sanctions.

Responsibility, prudence and health promotion

This article considers the role of responsibility in public health promotion. Efforts to tackle non-communicable diseases which focus on changing individual behaviour and reducing risk factor exposure sometimes invoke individual responsibility for adopting healthy lifestyles. We provide a critical discussion of this tendency. First, we outline some key distinctions in the philosophical literature on responsibility, and indicate how responsibility is incorporated into health promotion policies in the UK. We argue that the use of some forms of responsibility in health promotion is inappropriate. We present an alternative approach to understanding how individuals can ‘take responsibility’ for their health, based on the concept of prudence (i.e. acting in one’s interests). In this discussion, we do not prescribe or proscribe specific health promotion policies. Rather, we encourage public health professionals to consider how underlying assumptions (in this case, relating to responsibility) can shape health promotion policy, and how alternative framings (such as a shift from encouraging individual responsibility to facilitating prudence) may justify different kinds of action, for instance, shaping environments to make healthy behaviours easier, rather than using education as a tool to encourage responsible behaviour.

'There is no such thing as getting sick justly or unjustly' - a qualitative study of clinicians' beliefs on the relevance of personal responsibility as a basis for health prioritisation

BACKGROUND

Concerns have been raised regarding the reasonableness of using personal health responsibility as a principle or criterion for setting priorities in healthcare. While this debate continues, little is known about clinicians' views on the role of patient responsibility in clinical contexts. This paper contributes to the knowledge on the empirical relevance of personal responsibility for priority setting at the clinical level.

METHODS

A qualitative study of Norwegian clinicians (n = 15) was designed, using semi-structured interviews with vignettes to elicit beliefs on the relevance of personal responsibility as a basis for health prioritisation. Sampling was undertaken purposefully. The interviews were conducted in three hospital trusts in South-Eastern Norway between May 2018 and February 2019 and were analysed with conceptually driven thematic analysis.

RESULTS

The findings suggest that clinicians endorsed a general principle of personal health responsibility but were reluctant to introduce personal health responsibility as a formal priority setting criterion. Five main objections were cited, relating to avoidability, causality, harshness, intrusiveness, and inequity. Still, both retrospective and prospective attributions of personal responsibility were perceived as relevant in specific clinical settings. The most prominent argument in favour of personal health responsibility was grounded in the idea that holding patients responsible for their conduct would contribute to the efficient use of healthcare resources. Other arguments included fairness to others, desert and autonomy, but such standpoints were controversial and held only marginal relevance.

CONCLUSIONS

Our study provides important novel insights into the clinicians' beliefs about personal health responsibility improving the empirical knowledge concerning its fairness and potential applications to healthcare prioritisation. These findings suggest that although personal health responsibility would be difficult to implement as a steering criterion within the main priority setting framework, there might be clinical contexts where it could figure in prioritisation practices. Additional research on personal health responsibility would benefit from considering the multiple clinical encounters that shape doctor-patient relationships and that create the information basis for eligibility and prioritisation for treatment.

Taking responsibility for the tooth: A semiotic and thematic analysis of oral health and disease in the TV show 'Embarrassing Bodies'

Oral health and dentistry are seldom the subject of medical reality TV. This study investigates whether the dental segments within the British medical reality show, 'Embarrassing Bodies', may contribute to the anthropological understanding of oral health and social status, through semiotic and thematic analysis. This methodology involves close examination of both the visual and narrative themes within the programme. The show presents mouths afflicted by oral disease as traumascapes, the framing of which provides voyeuristic appeal. The portrayal of dental disease as negatively affecting human flourishing through shame and the inhibition of intimacy was common across the analysed cases. The key themes of intimacy and social distance; discipline, blame and personal responsibility; carnography; disciplining gaze and authority; and redemption and rebirth were identified through analysis. The cases also present a strong correlation between a lack of personal responsibility and the development of dental disease within the wider context of social class, with the dentist as a disciplining authority, enforcing professional and societal norms.

Responsibility in healthcare across time and agents

It is unclear whether someone's responsibility for developing a disease or maintaining his or her health should affect what healthcare he or she receives. While this dispute continues, we suggest that, if responsibility is to play a role in healthcare, the concept must be rethought in order to reflect the sense in which many health-related behaviours occur repeatedly over time and are the product of more than one agent. Most philosophical accounts of responsibility are synchronic and individualistic; we indicate here what paying more attention to the diachronic and dyadic aspects of responsibility might involve and what implications this could have for assessments of responsibility for health-related behaviour.

Concepts of health in long-term home care: An empirical-ethical exploration

BACKGROUND

Concepts of health have been widely discussed in the philosophy and ethics of medicine. Parallel to these theoretical debates, numerous empirical research projects have focused on subjective concepts of health and shown their significance for individuals and society at various levels. Only a few studies have so far investigated the concepts of health of non-professionals and professionals involved in long-term home care and discussed these empirical perspectives regarding moral responsibilities.

OBJECTIVES

To identify the subjective concepts of the health of non-professionals (care recipients, informal caregivers) and professionals (registered nurses) involved in long-term home care and to discuss them against the background of existing normative guidelines addressing non-professionals and professionals' responsibilities and rights concerning health.

RESEARCH DESIGN

A qualitative design was chosen to explore subjective concepts of health. Data were collected by semi-structured interviews; content analysis was applied according to Mayring.

PARTICIPANTS AND RESEARCH CONTEXT

Twenty-eight interviews were conducted with non-professionals and professionals in long-term home care arrangements in Northern Germany.

ETHICAL CONSIDERATIONS

Ethics approval was obtained from the Institutional Review Board at the University Medicine Greifswald (BB123/16).

FINDINGS

Non-professionals and professionals consider health as a capability that enables them to participate in social activities and live their own lives according to their preferences. The former regard health particularly as a feeling and an attitude, the latter as the absence of disease with a focus on mental and emotional well-being. Both groups highlight the unsurpassable value of health and the personal responsibility for it.

DISCUSSION

Normative guidelines applicable to practice in long-term home care discuss responsibilities and rights unevenly and raise several problems regarding non-professionals and professionals' subjective concepts of health.

CONCLUSION

Individuals' concepts of health are relevant for the subsequent interpretation of rights and responsibilities and should, thus, be reflected upon to address health-related needs effectively.

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

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.

Solidarity and Responsibility in Health Care

Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health.

Being Healthy, Being Sick, Being Responsible: Attitudes towards Responsibility for Health in a Public Healthcare System

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 (LHL)’s 2015 Health Survey (N = 2689), 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 (including information, health incentives, prevention and regulations). 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.

Against Moral Responsibilisation of Health: Prudential Responsibility and Health Promotion

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 (in general) 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 (in general) 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 (all-things-considered) 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.

Taking Responsibility for Responsibility

Governments, physicians, media and academics have all called for individuals to bear responsibility for their own health. In this article, I argue that requiring those with adverse health outcomes to bear responsibility for these outcomes is a bad basis for policy. The available evidence strongly suggests that the capacities for responsible choice, and the circumstances in which these capacities are exercised, are distributed alongside the kinds of goods we usually talk about in discussing distributive justice, and this distribution significantly explains why people make bad health choices. These facts suggest that we cannot justifiably hold them responsible for these choices. We do better to hold responsible those who determine the ways in which capacities and circumstances are distributed: they are indirectly responsible for these adverse health outcomes and possess the capacities and resources to take responsibility for these facts.

Placebos as a Source of Agency: Evidence and Implications

Bioethical discussions surrounding the use of placebos in clinical practice have long revolved around the moral permissibility of deceiving a patient if it is likely to benefit them. While these discussions have been insightful and productive, they reinforce the notion that placebo effects can only be induced through deception. This paper challenges this notion, looking beyond the paradigmatic clinical encounter involving deceptive placebos and towards many other routes that bring about placebo effects. After briefly describing the bioethical terrain surrounding the deceptive use of placebos in clinical practice, section 1 offers an examination of the various mechanisms known to contribute to placebo effects: classical conditioning, expectations, affective pathways, open-label placebo treatments, and additional factors that do not fall easily into a single category. The following section explores how each of these routes can be harnessed to bring about clinical benefits without the use of deception. This provides grounding for reconceiving of the placebo effect as a clinical tool that is not always in conflict with patient autonomy and can even be seen as a source of agency. In the final section, implications of the shift away from seeing placebos as necessarily deceptive are discussed. These include the necessity of looking beyond the clinical encounter and mainstream medicine as the primary sites of placebo responses, how important acknowledging the limits of placebo effects will be when we do so, as well as the difficulties of disentangling agency, responsibility, and blame within medicine.

[Liver transplants and organ allocation in Brazil: from Rawls to utilitarianism]

The process of liver donations and transplants in Brazil reveals major inequalities between regions and states of the country, ranging from uptake of the organs to their transplantation. In 2006, the MELD score (Model for End-stage Liver Disease), inspired by the U.S. model and based on the principle of need, was introduced in Brazil for liver transplant allocation. However, Brazil's inequalities have partially undermined the initiative's success. Other countries have already benefited from growing discussion on the benefits of models that seek to harmonize utilitarianism and need. The current article reviews the relevant literature with a special focus on the Brazilian reality.

Self-responsibility, rationing and treatment decision making - managing moral narratives alongside fiscal reality in the obesity surgery clinic

Background

Addressing the prevalence of severe obesity and its concomitant morbidities is widely acknowledged as one of the most pressing global health priorities. Nevertheless, a paucity of effective interventions and universal pressure on health‐care budgets means that access to obesity treatments is often limited. Although health‐care rationing can be conceived as a socially constructed process, little is known about how decisions emerge within the context of face‐to‐face doctor–patient interactions.

Methods

In this study, we used in‐depth interviews and clinic observations to investigate clinicians’ (n = 11) and patients’ (n = 22) experiences of the rationing of obesity surgery and to examine how broader cultural assumptions around personal responsibility for health emerged in the context of clinical interactions.

Results

Patients and clinicians worked within similar frameworks when it came to self‐responsibility for health and the appropriateness of providing publicly‐funded weight loss surgery. Issues around personal accountability dominated consultations, and patients were expected to provide narratives of the development of their obesity and to account for the failure of previous interventions. Clinicians faced the added pressure of having to prioritise a limited number of patients for surgery, which was predominantly managed through mandating pre‐referral weight loss targets.

Discussion

Although clinicians sought to maintain an empathic attitude towards individual patients, in practice they were conflicted by their responsibility to ration health‐care resources and tended to rely on entrenched models of behaviour change to allocate treatment. As a result, the content of consultations was mostly focused on issues of personal responsibility, reflecting wider stigmatized attitudes towards extreme obesity.