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As we come to understand the multiple determinants of health, the list of agents whose actions have a role in its maintenance and restoration grows long-ranging from international organizations to states, communities, employers, insurers, and the health professions. The ethics of health policy consists in part in determining the appropriate role for each: who is responsible for health? This essay addresses the responsibility of individuals for their own health.
At the population level, it is increasingly clear that individual choices-"healthy lifestyles"-are at least as significant in achieving good health outcomes as costly medical interventions, and that providing information and encouragement is an essential function of health systems. But what should happen when an individual fails to take advantage of these resources? Placing responsibility on the individual could mean holding people accountable for what they do and do not do to remain healthy-an idea with far-reaching implications for health policy. While acknowledging its appeal, this essay argues that personal responsibility for health deserves but a peripheral role in health policy.
EVOLUTION OF THE CONCEPT
The initial significance of the notion of personal responsibility for health as expressed in reports and policy statements of several governments in the 1970s was to call the attention of both physicians and the public to the importance of lifestyles in maintaining health.1 By giving individuals the information they needed, they could protect themselves by adopting healthy habits rather than counting on their doctors to restore health once it was gone. The sense of "responsibility" in this message was that of a duty to oneself, or perhaps that of the reciprocal obligations of partners in the patient-doctor team.
It did not take long, however, for some observers to infer a duty to other parties; for one person's illness imposes financial and other burdens on those who must provide care. The notion of personal responsibility for health thus could be extended to include an obligation to avoid placing these burdens, either by staying healthy or by shouldering the costs of care through supplementary insurance or taxes. Failure to assume this responsibility might have consequences for the individual, such as lower priority for treatment. Debates over whether smokers and alcoholics should be candidates for lung and liver transplants, respectively, sometimes invoked these themes.2
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