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The Ethics of Making Patients Responsible

  • SVEN OVE HANSSON
Abstract:

In their daily clinical work, healthcare professionals generally apply what seems to be a double standard for the responsibility of patients. On the one hand, patients are encouraged to take responsibility for lifestyle changes that can improve their chances of good health. On the other hand, when patients fail to follow such recommendations, they are not held responsible for the failure. This seeming inconsistency is explained in terms of the distinction between task responsibility and blame responsibility. The double standard for responsibility is shown to be epistemologically rational, ethically commendable, and therapeutically advantageous. However, this non-blaming approach to patient responsibility is threatened by proposals to assign lower priority in healthcare to patients who are themselves responsible for their disease. Such responsibility-based priority setting requires that physicians assign blame responsibility to their patients, a practice that would run into conflict with the ethical foundations of the patient–physician relationship. Therefore, such proposals should be rejected.

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Notes

1. Dworkin, G. Voluntary health risks and public policy: Taking risks, assessing responsibility. Hastings Centre Report 1981;11:2631.

2. Goodin, RE. Apportioning responsibilities. Law and Philosophy 1987;6:167–85.

3. Kelley made a similar remark in terms of the related distinction between forward- and backward-looking responsibility. See: Kelley, M. Limits on patient responsibility. Journal of Medicine and Philosophy 2005;30:189206.

4. Among 100 patients, there will be 60 who can stop smoking and also do so, 30 who can quit but do not do so, and 10 who are unable to quit. Therefore, 30 of the 40 who did not quit (75 percent) would have been able to do so.

5. Locke EA, Latham GP. A Theory of Goal Setting and Task Performance. Englewood Cliffs, NJ: Prentice Hall; 1990; Nelissen R, de Vet E, Zeelenberg M. Anticipated emotions and effort allocation in weight goal striving. British Journal of Health Psychology 2011;16(1):201–12.

6. Eisenberg, ME, Neumark-Sztainer, D, Story, M. Associations of weight-based teasing and emotional well-being among adolescents. Archives of Pediatrics and Adolescent Medicine 2003;157(8):733–8; Puhl, RM, Moss-Racusin, CA, Schwartz, MB. Internalization of weight bias: Implications for binge eating and emotional well-being. Obesity 2007;15(1):1923; Neumark-Sztainer, D, Falkner, N, Story, M, Perry, C, Hannan, PJ, Mulert, S. Weight-teasing among adolescents: Correlations with weight status and disordered eating behaviors. International Journal of Obesity 2002;26:123–31; Adler, NE, Stewart, J. Reducing obesity: motivating action while not blaming the victim. Milbank Quarterly 2009;87:4970.

7. Banja J. Obesity, responsibility and empathy. Case Manager 2004;15:43–6. Quotation at 43.

8. Pierce, JW, Wardle, K. Cause and effect beliefs and self-esteem of overweight children. Journal of Child Psychology and Psychiatry 1997;38(6):645–50.

9. Chapple A, Ziebland S, McPherson A. Stigma, shame, and blame experienced by patients with lung cancer: Qualitative study BMJ 2004;328(7454):1470; compare Hamann HA, Ostroff JS, Marks EG, Gerber DE, Schiller JH, Craddock Lee SJ. Stigma among patients with lung cancer: A patient-reported measurement model. Psycho-Oncology 2014;23(1):81–92.

10. Phelan SM, Griffin JM, Jackson GL, Zafar SY, Hellerstedt W, Stahre M, et al. Stigma, perceived blame, self-blame, and depressive symptoms in men with colorectal cancer. Psycho-Oncology 2013;22(1):65–73; Else-Quest NM, LoConte NK, Schiller JH, Hyde JS. Perceived stigma, self-blame, and adjustment among lung, breast and prostate cancer patients. Psychology and Health 2009;24(8):949–64.

11. Guttman, N, Ressler, WH. On being responsible: Ethical issues in appeals to personal responsibility in health campaigns. Journal of Health Communication: International Perspectives 2001;6:117–36.

12. See note 10, Else-Quest et al 2009, at 960.

13. Sharkey K, Gillam L. Should patients with self-inflicted illness receive lower priority in access to healthcare resources? Mapping out the debate. Journal of Medical Ethics 2010;36(11):661–5.

14. Stegeman I, Willems DL, Dekker E, Bossuyt PM. Individual responsibility, solidarity and differentiation in healthcare. Journal of Medical Ethics 2014;40(11):770–3; Andersen MM, Nielsen MEJ. Luck egalitarianism, universal health care, and non-responsibility-based reasons for responsibilization. Res Publica 2015;21:1–16.

15. Thornton V. Who gets the liver transplant? The use of responsibility as the tie breaker. Journal of Medical Ethics 2009;35(12):739–42; Leong J, Im GY. Evaluation and selection of the patient with alcoholic liver disease for liver transplant. Clinics in Liver Disease 2012;16:851–63; Donckier V, Lucidi V, Gustot T, Moreno C. Ethical considerations regarding early liver transplantation in patients with severe alcoholic hepatitis not responding to medical therapy. Journal of Hepatology 2014;60:866–71.

16. Johri, M, Ubel, PA. Setting organ allocation priorities: Should we care what the public cares about? Liver Transplantation 2003;9:878–80; Waller, BN. Responsibility and health. Cambridge Quarterly of Healthcare Ethics 2005;14:177–88. See also note 15, Thornton 2009.

17. Ho, D. When good organs go to bad people. Bioethics 2008;22(2):7783.

18. See note 16, Waller 2005.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
  • URL: /core/journals/cambridge-quarterly-of-healthcare-ethics
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