The right perspective on responsibility for ill health

Lie and Sabik (2008), Schmidt et al. (2009), Schmidt (2009a, b). For references to the general discussion about the movement toward what is sometimes called “conditional welfare regimes” in Europe and North America, see Knight and Stemplowska (2011), n. 2.

For philosophers, see for example Rakowski (1991), Scruton (2000), Segall (2009), Walker (2010). For non-philosophers, see for example Williams (1992), SOU (1995, p. 5, 97f), Bråkenhielm (1990), Bowling (1996), Dolan et al. (1999). Many of these, however, would be hesitant to withhold recourses if there was enough for everyone (see for example Walker 2010 and SOU 1995:5) which makes it plausible that one reason for why it has grown large in recent years is the perceived lack of recourses.

Refer to Segall (2009) and Sharkey and Gillam (2010) for recent overviews of the debate. For a historical perspective, see Resier (1985).

Some argue that we have no reason to hold people responsible for their ill health even when they are responsible for it (Harris 1995; Wikler 2002). Even though this is an interesting question, I will not pursue it here.

There are at least three reasons often combined in the debate. Except for the argument I present above, there are reasons to believe that our actions do not cause ill health even when we suffer from “lifestyle-based” diseases, even when these actions cause ill health, and when such behaviors stem from addiction.

See for example Minkler (1999): 126–130, Daniels (2008): 156 and Buyx (2008): 872.

For a recent substantial and critical overview of the different arguments, see Haji (2009). There have been concerns over whether this experiment actually succeeds in showing that non-philosophers are incompatibilists under these conditions instead of fatalists, which pertains to the notion that whatever we do, the outcome remains the same. Other similar descriptions, which have contributed to these worries, have, however, revealed similar results (Nahmias et al. 2007, p. 227). I have also argued elsewhere that we, at least for now, do not have any decisive reasons to believe that fatalism causes people to think the way they do when confronted with these scenarios (Björnsson and Persson 2012 ).

The careful reader has probably noticed that I do not speak of “free will” anywhere. This is due to the fact that many philosophers today believe that we can, in a substantial sense, be responsible even if we do not have free will (e.g. Fischer and Ravizza 1998).

For example, during the evaluation of whether Bill (who killed his wife and children to be with his secretary) was responsible for his act, 72 % answered yes even though his action was determined by factors outside his control (Nichols and Knobe 2007, p. 670). This finding is also supported by other similar studies (Nahmias et al. 2007).

I say this even though I have argued for a compatibilist position elsewhere (Björnsson and Persson 2012). My argument for this position, however, is made on the grounds of the psychological model below.

However, refer to Duus-Otterström (2008) for a different view. I have argued elsewhere that this is erroneous (Persson 2008, 2009).

The model, then, is only meant to capture many people’s intuitions about these cases, not everyone’s. Furthermore, it is not a normative or social theory, it is simply a hypothesis about how and why we judge the way we do when confronted with certain cases.

For a more thorough explanation, see Björnsson and Persson (2012).

For a more substantial discussion about what they call reason-responsiveness, see Fischer and Ravizza (1998).

A large body of evidence supports EH. Together with Björnsson, I have argued that EH can account for the dynamics in the philosophical discussions on moral luck, heteronomy, and a wide variety of ordinary judgments of responsibility Björnsson and Persson (2012). We have also argued that EH can account for a range of perplexing and diverging intuitions among non-philosophers, as revealed by recent experimental philosophy (Björnsson and Persson forthcoming). Björnsson (2011) has also argued that EH can account for the different types of intuitions that we have about collective responsibility.

Since what we perceive as an explanation is relative to our underlying normative expectations, we might think that the explanation for why the house burned down is the omission to extinguish the fire even though they have not got paid. For example, we might think that people who are firemen always have an obligation to extinguish fires, even in these sorts of cases. If this is true, then we would still think that the explanation for why the house burned down lies in the firemen’s inaction. But those of us who believe that firemen, as everyone else, only are obliged to do their job when their employee fulfills their end, the explanation for why the house burned down is that the employer did not fulfill their end of the bargain.

That different explanatory perspectives have this sort of influence on our explanatory judgments is well known and has been discussed in relation to law (Hart and Honoré 1986) and epidemiology (Holland 2007). However, before Björnsson and Persson (2012), it has not been used in a systematic way to analyze either the responsibility debate in general or the debate concerning personal responsibility for health.

In the case of smoking, this might not be true because it is often argued that people are manipulated. I am going to set that aside and assume that they are not.

I am not going to discuss the matter of distributing organs because this topic is much more of a micro-level question.

Questions about autonomy are also on the rise in these contexts (Munthe 2008). I discuss the implications of these views under the next heading. But for the short term, if someone believes that autonomy has a greater value than the others discussed in this section, then the argument in favor of the policymaker taking a perspective in which they perceive people as excused, fails.

For a defense of utilitarianism, see Sidgwick (1907) or Tännsjö (1998). A wide range of different utilitarian theories are available, from rule utilitarianism to aim-based utilitarianism. Different values for the promotion of utilitarianism have also been discussed and defended.

Utilitarianism and cost-effectiveness are, of course, not one and the same thing. Strictly speaking, if utilitarianism is true, I believe determining the course of action would be impossible to accomplish in practice (Gren 2004). My use of “utilitarianism” is instead similar to how people often use it in contexts wherein priority setting and other similar questions are discussed.

See Roberts (2006, p. 56) for a similar view.

See for example Crawford (1977) and Wilkinson (2005).

Fierlbeck (1996) explains his results in the same way. Conservatives are less interested in preventive work because they believe that people are responsible for their ill health.

Less preventive work may, of course, lead to greater happiness than can alternatives given that health is not all that matters and different types of infringements on people’s autonomy may diminish well-being even though better health is achieved (cf. Mill 1869). However, taking an abstract perspective that disallows these types of considerations has not been discussed.

I am not claiming here, of course, that they know about the psychological model presented in this paper. Instead, I believe that at least some of the people who were employed in the project had an intuitive feeling about how to approach encouraging the judgment of ordinary people as blameless. I think this made them even more adamant about adopting a clear stance on motivational structures having no role in explaining why one group fared better than another.

Cf. Björnsson and Persson (2012).

Parfit (1991, 1997), Temkin (1993). There are also different kinds of “threshold views,” or “sufficiency views,” which state that when people have reached a certain threshold, further improvements are not required on account of justice. For a classic defense, see Frankfurt (1971) and for a recent overview and critique, refer to Casal (2007).

We can distribute health as well as health care. For a discussion, see Daniels (2008, pp. 29–102) or Segall (2009).

An opportunity-based egalitarian should opt for the same perspective. Many such egalitarians, such as Norman Daniels (2008), often argue that good health is special compared with other beneficial attributes because it is instrumental in affording us opportunities to realize our life goals (pp. 29–79). Suffering from ill health deprives us of the opportunities available to others who are healthy, which is unfair from the opportunity-based egalitarian view. Given that my empirical arguments are sound, perceiving people as responsible for ill health may lead to a low motivation to help those with poor health and eradicate the social determinants of ill health. This situation naturally provides purely opportunity-based egalitarians a strong argument against adopting such a perspective. The same line of reasoning, as I said at the end of the former paragraph, can be applied to the other egalitarian views as well.

Beauchamp and Childress (2008). It might be argued, of course, that we should use the same ethical considerations on both levels. I am not going to discuss this here, however, since it would take us too far afield.

Numerous studies have been made on the negative attitudes that many doctors hold toward people who suffer from lifestyle-based diseases, such as obesity. I discuss this in the next paragraph.

Strictly speaking, Alfred Mele is not defending a sufficient condition, but only a necessary condition for autonomy. It should also be noted that there is and has been a huge discussion about what autonomy is and how it should be defended [e.g. Kant (1785), Mill (1869), Korsgaard (1996), Scanlon (1998)].

This is, of course, an oversimplification on my part. For a discussion about how different types of perspectives on autonomy may be used to justify varied treatment approaches, see Sandman and Munthe (2009).

Kuokkanen and Leino-Kilpi (2000). A recent study revealed, for instance, that when patients feel that they are treated with respect (a phenomenon presumably more common when patients are considered accountable), they feel more able to go back to work (Lynöe et al. 2011).

In debates, people often distinguish between paternalism, shared decision making, and informed choice (Charles et al. 1997). Paternalistic decision making is the classic authoritarian approach in which a doctor basically decides what should be done. Informed choice is at the other end of the spectrum, in which a doctor withdraws from the decision-making process and only provides a patient with information about his/her condition and different ways to treat it. Shared decision making is a situation wherein a patient is involved in the decision-making process but the doctor does not completely withdraw from it by only giving information. Both parties are involved, discussing what decision the patient should make.

For a review, see for example Rodriguez-Osorio (2008).

One problem with taking the concrete perspective, however, is that doctors might view obesity, for instance, as not a disease and therefore does not require involvement (Hansson et al. 2011). I believe that this problem can be solved through specificity. Being obese in itself is not a kind of illness; rather, the consequences that stem from it, such as heart disease and diabetes, are. For a different opinion, see WHO (2000).

For a discussion about blaming patients, see for example Martin (2001).

I would like to hint at a problem that may be worth looking into. According to recent studies, helping people with their lifestyle-based diseases can be stressful for health care personnel given that they often do not see any behavioral changes among patients (Jallinoja et al. 2007). This type of stress can have negative effects on the health of personnel, which is important in its own right. However, (and perhaps more important), when these health care providers are emphasized, they are more likely to hold stereotypes about patients, which can generate negative results [for a classical monograph in this area, see Michael Lipsky’s Street-level Bureaucracy; Dilemmas of the Individual in Public Services (1980)]. I do not pursue the matter further here because it would lend more speculativeness to the other ideas that I have discussed in this section. More research is needed to definitively discuss the subject.

This is actually compatible with EH; see Björnsson and Persson (2012).