Personal responsibility for health is a tricky issue. In addition to complicated philosophical problems, one of the major difficulties is that talk about personal responsibility appears deeply embedded in a polarized discourse between the political left and the right. The notion of personal responsibility is generally abhorred by the left. Generations of conservatives have made it their mantra, from the Georgian upper classes in England who viewed the gin-addicted masses as suffering from a purely self-inflicted problem to Thatcherite policy-makers who happily implemented libertarian ideas on health and employment from cozy Whitehall armchairs.
But the usual left-right divide on personal responsibility oversimplifies the problem. In 1977, John H. Knowles, an outspoken critic of the American health care system, left no doubt about his take on the matter when he wrote in an article in Daedalus that “The cost of sloth, gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, and not an individual, responsibility. This is justified as individual freedom – but one man’s freedom is another man’s shackle in taxes and insurance premiums. I believe the idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health – a public duty if you will. The individual then has the ‘right’ to expect help with information, accessible services of good quality, and minimal financial barriers.” But Knowles doesn’t really fit the standard left-right pattern: he was a moderate Republican interested both in greater emphasis on personal responsibility for health and in universal health care for all Americans.
Currently, personal responsibility for health is debated in the United States mainly in the context of West Virginia’s Medicaid Membership Agreement and the Florida Medicaid Reform Plan. To some extent the contemporary debate mirrors the left-right ambiguity found in Knowles: the policies in Democrat-controlled West Virginia have been particularly controversial because they focus on compliance and provide penalties for noncompliance. Republican-controlled Florida, by contrast, concentrates more on providing incentives to encourage Medicaid recipients to engage in certain wellness activities.
In an obvious way, there is something quite wrong with the West Virginia initiative. Many of those who are fortunate enough not to have to rely on Medicaid (or similar plans) would have problems with complying with the Membership Agreement requirements: most people miss medical appointments once in a while, forget to take their medicines, could drink, eat or smoke less, and tend to drop out of exercising regimens. So why should Medicaid recipients, who are already among the most vulnerable people, be required to live up to expectations that even more privileged people would fail to meet?
A different but related way of thinking about personal responsibility is to consider policies that do not focus on the vulnerable, but instead require or encourage everyone to maintain certain standards. Recent developments in the United Kingdom and Germany, two countries whose universal health care coverage is sometimes viewed with envy by U.S. residents, help illustrate the range of ways in which measures that promote personal responsibility can be incorporated into a health care system, including Knowles’s vision of integrating universal personal responsibility with universal health care.
The new U.K. Prime Minister Gordon Brown is well aware of the real and symbolic value of Britain’s National Health Service, which is widely held to “provide treatment for all, free at the point of need.” More or less on the day Brown announced his intention to succeed Tony Blair as leader of the Labour Party, he stressed that his vision for Britain included “fairness and opportunity for all,” and for the NHS to become “the envy of the world,” One aspect of current English health policy that is unlikely to be envied around the world is guidance providing that hip and knee replacements should not be performed unless patients have a body mass index below 30 – in some sense an indirect appeal to take personal responsibility by not getting obese in the first place or by losing weight before requesting surgery. This policy was first implemented by a Suffolk Primary Care Trust (PCT) in 2005 and, according to a recent survey, has been adopted within 18 months by just under 10% of England’s PCTs. (PCTs control 80 per cent of the NHS total budget.) Four PCTs also refuse to perform any joint surgery on smokers, with North Staffordshire, the strictest, stipulating that in order to qualify for any routine operation, patients must have a BMI of below 30 and not have smoked for three months. The policies apply universally to all NHS patients living in the PCT catchment area.
The PCTs that have been promoting these measures are in severe financial difficulties, and the justifications provided for the measures usually emphasize equally the goals of maximizing clinical effectiveness for the patient and avoiding opportunity costs incurred through providing treatment that may be (largely) ineffective, or not effective for long enough. Questions remain, of course, about the extent to which these policies will actually save costs in the long run. Also, it would be wrong to see these examples as representative of the general take on personal responsibility for health in the current NHS. But they are indicative of two important points: First, in no subtle ways, it is put to some patients that the financial pressures on the NHS are such that the buck ultimately stops with them. Second, the policy has been implemented in the absence of any structured debate about the responsibilities that patients might have in relation to making the most equitable use of necessarily limited health care resources in a system that seeks to provide universal coverage.
In this context, a noteworthy recent Discussion Paper launched by the British Medical Association (BMA) expresses considerable concern about the long-term sustainability of the NHS in England. It seeks to encourage open discussion about rationing and priority setting issues, and also calls for more transparency and clarity about the respective roles of the government, the NHS, and patients. The Discussion Paper sets out a number of recommendations “which could deliver better services to patients while safeguarding the core values of the NHS.” The first of these calls for a formal Constitution for the NHS that would include “a charter explaining what the public can expect and what is expected of them.” Sounds like West Virginia’s Medicaid Membership Agreement? Well, that may not be that far off. Although the BMA’s paper does not comment in more detail on what the charter might include, it refers to the Scottish NHS’s guidance The NHS and You as an example. The Scottish document offers several specific provisions under headings such as: “Look After Yourself, Keep Your Appointments, Follow Advice and Treatment, and Use Health Services Appropriately.”
At this stage, it seems that that we have come full circle to John H. Knowles’ credo that “the idea of a ‘right’ to health should be replaced by the idea of an individual moral obligation to preserve one’s own health.” Admittedly, though, the BMA’s proposal is looking to the future, and the document is silent on whether the called-for Charter should merely formulate aspirational ideals or take a more binding form. It remains to be seen what will become of the project, and much, of course, depends on the political context. In this regard, it was perhaps mere coincidence that Gordon Brown highlighted the priority he would give to the NHS a day after stating that “[the UK needs] a constitution that is clear about the rights and responsibilities of being a citizen in Britain today.”
Speculation aside, Germany can illustrate how an explicit recognition of health care rights and responsibilities is realized without being embedded in entrenched left-right debates. Germany continues to pride itself of its Social Welfare State tradition and practices. At the same time, personal responsibility for health is enshrined in the law in Book V of the Sozialgesetzbuch – SGB (Social Security Code), which codifies the German statutory health insurance scheme since 1988. Its prominent Article 1 is entitled Solidarity and Personal Responsibility, and states that citizens have “co-responsibility” for their health, and should therefore “lead a health-conscious lifestyle, take part in appropriately timed preventative measures [and] play an active role in treatment and rehabilitation, [in order to] avoid sickness and disability, and overcome the respective consequences.”
A wide range of legal and more policy-based provisions put this general guidance into practice. For example, many statutory sickness funds help people maintain their health by subsidizing health promotion or exercise courses. In rewarding compliance, and penalizing noncompliance, different levels of co-payments are required from insured persons for dental care, depending on how regularly check-ups are attended (reductions for adults require annual appointments, and under 18-year-olds need to see their dentist twice yearly to qualify). All major sickness funds also offer lower insurance contributions, financial bonuses, or bonuses in kind (such as sports equipment) to those who provide evidence of health maintenance efforts or take part in age-related health promotion and screening measures (such as mammography, colon cancer screening, and prenatal care programs). More controversially, recent reforms mean that insured persons may no longer claim free treatment for complications arising from certain “lifestyle choices” such as cosmetic surgery, tattoos, piercings or other “non-medically indicated” measures. Chronically ill and cancer patients must also now abide by more stringent compliance requirements or face higher copayments (Those who comply with certain disease-related screening and preventative measures will have to pay a maximum of 1% of their gross annual income in co-payments for services and medicines, but the cap has been raised to 2% for those who show insufficient compliance.)
The main point of these anecdotal examples from three different countries is this: conceptually, there is a spectrum of ways in which personal responsibility for health can feature in health care policy and practice. At the most problematic end of the spectrum is a Kafkaesque scenario where already vulnerable people are denied important treatment on grounds that they are solely responsible for their poor health, although in fact significant factors that contributed to it are beyond their control. At the other end of the spectrum, personal responsibility for health may feature in the form of noncoercive incentives to maintain good health, which is likely to benefit both the individuals concerned and the health care system as a whole. In practice, one important consideration for appeals to health responsibility is the background structure of the health care system in which it is to be implemented: a system that provides universal coverage has a certain fairness-advantage over a system that doesn’t. And the more one moves away from the incentive-focused end of the spectrum to the disincentive/penalty end, the higher the risk of increasing unfairness and potential “victim-blaming.”
This helps explain why many are alarmed by approaches along the lines of the West Virginia Medicaid Membership Agreement. However, it would be shortsighted to associate any appeal to personal responsibility for health with libertarian or rightwing ideologies. As the example of Germany shows, in principle, personal responsibility and solidarity may form important constituents in a framework that can plausibly be understood along Social Contract lines, which is not necessarily incompatible with a left-leaning political orientation. The benefit of approaching personal responsibility from a nonpartisan point of view is that it allows us to focus more importantly on issues arising from specific types of appeals to personal responsibility, and the ways in which these are to be realized.
Look, for example, at the issue of keeping appointments, which features prominently in the West Virginia agreement as well as in the Scottish charter on patient responsibilities referred to in the BMA’s Discussion Paper. According to a survey by Developing Patient Partnerships, English patients missed 11 million appointments with GPs in 2006 and just over 5 million appointments with practice nurses. Appeals to patients to take more seriously their responsibilities by cancelling appointments in time, and thereby enabling the health service better to plan and deliver care (and other patients to benefit from it) surely must be a worthy goal, irrespective of whether you find yourself on the left or on the right. How exactly patients might be motivated to take responsibility, whether through information leaflets, more persuasive appeals, charges for missed appointments or other penalties is of course another matter. Likewise, legitimate questions arise over the extent to which it is fair to emphasize personal responsibility in other areas, especially in relation to peoples’ personal health risk behavior (or “lifestyle”). But these questions are unlikely to be resolved by reference to dogmatic left-right positions. Nor would it be appropriate to leave the issue to policy-makers alone, as there is a risk of an ever increasing patchwork of ad hoc polices justified principally on cost-containment grounds. To make progress in policy and theoretical debates, it is time systematically to analyze in what sense personal responsibility for health can be a meaningful and reasonable concept.
Harald Schmidt is Assistant Director of the Nuffield Council on Bioethics, London. The views expressed here are his own and may not be attributed to the Council.