Healthcare, Responsibility, and Golden Opportunities

Written by Gabriel De Marco

This blog post is based on a co-authored paper (w. Tom Douglas and Julian Savulescu) recently published in Ethical Theory and Moral Practice.

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; e.g. whether a lifetime smoker is responsible for developing his lung cancer, or whether someone is responsible for heart disease on the basis of having an unhealthy diet. Policies that take responsibility for the unhealthy lifestyle or its outcomes into account—responsibility-sensitive policies, or RSPs, for short—have been a matter of debate for some time.

Some argue that implementing such a policy can result in a fairer distribution of health-related goods, especially when there is a serious scarcity in these goods. If there is a scarcity in lungs available for transplants, it may be better if non-smokers who need one have a better chance at getting one. In cases where we have tough choices to make, using responsibility as a deciding factor may be better than making a choice arbitrarily.

Others argue that we should not implement RSPs, and the objections are varied. One family of concerns relates to our responsibility for health-related behaviors (and their outcomes) themselves. When it comes to being responsible for something, it’s usually thought that one both needs to have control over it, and one needs be aware of, or could reasonably be expected to be aware of, the relevant features of one’s behavior. If I have no control over whether I end up developing Alzheimer’s, then I can’t reasonably be said to be responsible for developing. Likewise, before it was widely known that smoking causes cancer, smokers were likely not responsible for getting it, even if it was a result of their smoking.

Some object to RSPs by appealing to one, or both, of these two conditions: we do not have enough control over our health-related behavior to be responsible for it (or its outcomes), and/or we do not know enough about the potential health-related consequences of our behavior to be responsible for it (or its outcomes). Sometimes, people make a slightly different point: even if we sometimes meet these conditions, those in charge of making healthcare decisions are typically not in a position to know whether a particular patient does meet them for her health-related behavior (or its outcomes). Both forms of objection make an appeal to common obstacles to the exercise of responsible agency. If one is in an environment that does not provide many opportunities for a healthy diet, for instance, one may not have much control over whether their diet is healthy. Even if one does, however, health-care officials may not be in a position to know whether one is in such an environment. But this is just one possible obstacle, and given how many such obstacles there are, many may fail to have the relevant control and/or awareness. And, healthcare officials may rarely be justified in believing that a particular individual has not faced such obstacles. Knowing how a theory of responsibility applies to a particular individual is a difficult and complicated matter.

In a recent paper, co-authored with Tom Douglas and Julian Savulescu, we present a framework for a policy of Golden Opportunities (GOs), which builds on previous work by Savulescu and co–authors. On such a policy, individuals with unhealthy lifestyles (of a certain sort) would be offered an opportunity to change that lifestyle for a healthier one. Such an opportunity would involve substantial support for making the change, thereby removing various (though not all) potential obstacles to making the change. Further, when making the offer, the individual would be made aware of the relevant features of their decision, both in terms of the sort of help that will be offered in making the change, and the risks they incur by not making the change, as well as the potential consequences in how the healthcare system will take into account their responsibility, should they choose not to change.

Consider a brief example. On a GO policy, we could offer a smoker the opportunity to quit smoking, by providing options between different cessation products (e.g., vaping, nicotine gum, etc.), either at a discount or for free. The change could be further supported by access to professional and peer support. Further, the smoker could be informed of the potential health risks of continued smoking, the potential benefits of quitting, etc. If the offer constitutes a good enough opportunity, it is a GO; by removing various obstacles to making the change, it can provide the smoker with an opportunity to make a fuller exercise of his agency when deciding whether to accept or reject the offer.

The nature of the opportunity offered, as well as the standard used to measure whether an individual adhered to it, will have to take a variety of factors into account. For instance, it will have to take into account various obstacles the individual might face, like those that are the result of socioeconomic status, whether the unhealthy lifestyle involves an addictive desire, and if so, whether the opportunity involved involves a replacement of the addictive substance (e.g., vaping) or whether it involves something more difficult (e.g., abstinence from the substance).

We argue that a GO policy, used as a component of an RSP, can address some of the problems that RSPs typically face. By providing patients with opportunities that involve substantial support, designed to help patients surmount obstacles to making the change to a healthier lifestyle, it can help individuals exercise their agency more fully. By involving the healthcare system in the provision of these opportunities, it can provide some pushback to the claim that members of the healthcare system do not have the sort of knowledge about patient responsibility required for such a policy to be justified.

There are, however, two important points to make.

First, although a policy of GOs, implemented as a component of RSPs, may be able to address some concerns with the use of RSPs, it is not a panacea. Others have objected to RSPs by taking different lines than the ones we consider. For example, RSPs that don’t make use of GOs face the concern that delving into patients’ pasts would be too intrusive, or that it would be too impractical. GOs avoid this by creating a system on which we wouldn’t delve deeply into a patient’s past; yet they do not avoid gathering information on the patient. After all, we need some information to know whether the patient adheres to the offer. Or, one might also worry that using responsibility as a factor that influences decisions would end up driving a wedge between patients and doctors, and give an incentive for patients to be less open with information that could be used against them, or perhaps to even avoid visiting a physician altogether. One might also worry that using responsibility as one of our deciding factors may sometimes result in treatment that is overly harsh; not treating a patient that is seen as responsible for their health is too disproportionate of a response.

This leads to the second point. We already have reason to provide individuals with GOs. Many individuals do face significant obstacles to making a change to a healthier lifestyle, and many such obstacles are not of their own doing in any important sense, but rather a result of how our societies are structured, or just plain old bad luck (e.g., in genetic pre-dispositions). Insofar as we want to empower individuals to make choices that are informed, and to have more control over their lifestyles, we have reason to present patients with GOs. Thus, even if one thinks that RSPs are irredeemable, one might still be in favor of a policy of GOs that is divorced form such a policy.