Environmental Factor, March 2008, National Institute of Environmental Health Sciences
Bioethicist Addresses Issues of Responsibility for Health
By Eddy Ball
NIEHS Bioethicist David Resnik, J.D., Ph.D., presented his latest contribution to the on-going discourse about health policy and spending priorities in the United States with his January 31 talk in Rodbell Auditorium. In his presentation on "Responsibility for Health: Personal, Social, and Environmental," Resnik explored the strengths and weaknesses of opposing arguments about who is responsible for health. He also argued that government could improve its efforts in health promotion and prevention of disease by addressing environmental and regulatory issues and realigning spending priorities.
According to Resnik, the conflict between ways of looking at responsibility for health has increased because of advances in medicine and public health that have changed the kinds of disease that threaten health and well being in industrialized nations. Today, six of the top ten causes of disease and illness can be traced to lifestyle choices, such as smoking, unhealthy eating and substance abuse, which together are estimated to cost Americans $188 billion per year. According to Resnik, these kinds of lifestyle-related diseases raise important bottom-line questions that impact society as a whole: "Who's responsible for these diseases? Who should have to pay?"
Unlike the infectious diseases of the past, diseases caused by lifestyle choices can be seen as the responsibility of the individuals who are "making a personal choice" to harm themselves, rather than as a collective burden all should share. People with a strong "libertarian" orientation justify assigning the responsibility of health to individuals by arguments of utility, fairness, autonomy and the individual's moral responsibility. Resnik summarized the libertarian argument, "If you make people pay for their lifestyle choices, then they are going to change their behavior."
Advocates with a more "socialist" perspective counter with arguments that question the fairness and effectiveness of shaming and other punitive strategies, such as taxes and higher insurance costs, to discourage people from making life-style choices linked to preventable disease. These people disagree with what they consider an overly simplistic definition of free will and point to genetic and social factors that influence addictions, obesity and sexual behavior. As Resnik noted, "The problem with [the libertarian] argument is figuring out [just] how responsible someone is."
The extreme libertarian position on personal responsibility, Resnik continued, also runs opposite to society's perception of medicine as humanitarian and compassionate rather than judgmental and punitive. He gave several examples, including a drunk driver in a single vehicle accident and an alcoholic who needs a liver transplant. The drunk driver and the alcoholic have made negative lifestyle choices, to be sure, but, Resnik asked, "Should doctors withhold treatment because an individual made a personal choice that endangered his life?... Should doctors be assessing the moral character of their patients?... It doesn't seem that's what medicine is about at all."
Resnik's analysis of the arguments over social responsibility have led him to favor a balance between personal and social responsibility and re-direction of health spending. "Some social responses [such as health education and well being programs] can encourage personal responsibility," he explained. "And only government has the resources and motivation that are necessary for some situations." According to Resnik, much of what government can do, such as controlling pollution, regulating food and drug safety, and sanitation, will help everyone, as opposed to the few who benefit from technological advances in patient care.
By re-aligning spending to channel more resources into health promotion, prevention and regulation, Resnik concluded, government can get more benefit from the health dollar. We need to ask ourselves the big question, Resnik argued: "How much health is the $2.1 trillion [spent annually on health care] actually getting us?"