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Whoopie Pies, Supersized Fries: “Just” Snacking? “Just” Des(s)erts?1


The annual cost of healthcare in the United States reached $2.5 trillion in 2009 (about 17.6% of GDP) with projections to 2019 of about $4.5 trillion (about 20% of likely GDP).

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1. Maine and Lancaster, Pennsylvania, both want to claim to be the originator of the whoopie pie. The Maine legislature is seeking to make it the state dessert, hardly an affirmative vote for a greater degree of personal responsibility for health. Zezima K. Laying claim to a treat, and hearing, “not so fast.” New York Times 2011 Mar 12; available at (last accessed 3 Mar 2011).

2. Truffer CJ, Keehan S, Smith S, Cylus J, Sisko A, Poisal JA, et al. . Health spending projections through 2019: The recession’s impact continues. Health Affairs 2010;29:522–9.

3. Jemal A, Bray F, Center MM, Ferlay J, Ward E, Forman D. Global cancer statistics. CA: A Cancer Journal for Clinicians 2011;61; published online ahead of print and available at (last accessed 6 Feb 2011).

4. American Diabetes Association. Diabetes statistics: Data from the 2011 National Diabetes Fact Sheet; available at (last accessed 7 Feb 2011). Twenty-six million Americans have diabetes, and another 79 million Americans are prediabetic.

5. The egalitarians who are strong advocates of personal responsibility for health are luck egalitarians. Their essential claim is that responsibility must be an integral part of a morally defensible conception of healthcare justice. See Dworkin R. Sovereign Virtue: The Theory and Practice of Equality. Cambridge, MA: Harvard University Press; 2000, especially chapters 2 and 13.

6. Segall S. Health, Luck, and Justice. Princeton, NJ: Princeton University Press; 2010.

7. Arneson R. Luck egalitarianism and prioritarianism. Ethics 2000;110:339–49.

8. Stemplowska S. Making justice sensitive to responsibility. Political Studies 2009;57:237–59.

9. See, for example Meulen R. Increasing individual responsibility in Dutch health care: Is solidarity losing ground? Journal of Medicine and Philosophy 2008;33:262–79.

10. Schmidt H. Personal responsibility for health developments under the German healthcare reform. European Journal of Health Law 2007;14:241–50.

11. Bringedal B, Feiring E. On the relevance of personal responsibility in priority setting: A cross-sectional survey among Norwegian medical doctors. Journal of Medical Ethics 2011;37:357–61.

12. Fojo T, Grady C. How much is life worth? Cetuximab, non-small cell lung cancer, and the $440 billion question. Journal of the National Cancer Institute 2009;101:1044–8.

13. A recent story in the New York Times is perfectly illustrative of this point. See Alford H. My unhealthy diet? It got me this far. New York Times 2011 Feb 28; available at;pagewanted=print (accessed 3 Mar 2011).

14. McCarthy M. Genomics, type 2 diabetes, and obesity. New England Journal of Medicine 2010;363:2339–50, at 2347.

15. Ibid., at 2346. McCarthy cites in support of this conclusion Speliotes EK, Willer CJ, Berndt SI, Monda KL, Thorleifsson G, Jackson AU, et al. . Association analyses of 249,796 individuals reveal 18 new loci associated with body mass index. Nature Genetics 2010;42:949–60.

16. Ibid. McCarthy writes, “As yet, there are insufficient genetic data to support management decisions for common forms of type 2 diabetes and obesity” (at 2348). The reader is referred to Pearson ER. Pharmacogenetics in diabetes. Current Diabetes Reports 2009;9:172–81.

17. See note 14, McCarthy 2010.

18. Kanaka-Gantenbein C. Fetal origins of adult diabetes. Annals of the New York Academy of Sciences 2010;1205:99–105, at 99.

19. American Diabetes Association. Economic costs of diabetes in the U.S. in 2007. Diabetes Care 2008;32:596–615.

20. Boyle JP, Thompson TJ, Gregg EW, Barker LE, Williamson DF. Projection of the year 2050 burden of diabetes in the US adult population: Dynamic modelling of incidence, mortality, and pre-diabetes prevalence. Population Health Metrics 2010;8:29–41; available at (last accessed 3 Mar 2011).

21. Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, et al. . Forecasting the future of cardiovascular disease in the United States: A policy statement from the American Heart Association. Circulation 2011;123:933–44.

22. Kelley M. Limits on patient responsibility. Journal of Medicine and Philosophy 2005;30:189–206, at 199.

23. I argue in the following text that the physician in this case is being expected to implement a policy that is prima facie unjustly discriminatory.

24. See Harris J. Could we hold people responsible for their own adverse health? Journal of Contemporary Health Law and Policy 1995;12:147–53, at 150.

25. Apparently individuals who do multiple marathons and ultramarathons over the course of many years are likely to do serious damage to their hearts. To avoid premature death, such individuals would need a left ventricular assist device at $200,000 or an artificial heart at $300,000. See Reynolds G. When exercise is too much of a good thing. New York Times 2011 Mar 9, Well column.

26. This is what Rawls refers to as “rational autonomy,” that is, citizens think of themselves “as having the moral power to form, to revise, and rationally to pursue a conception of the good” (at 72). Rawls J. Political Liberalism. New York: Columbia University Press; 1993.

27. I and two colleagues have argued against casually accusing some parents of children with various genetic disorders of being irresponsible. Andre J, Fleck LM, Tomlinson T. On being genetically “irresponsible.” Kennedy Institute of Ethics Journal 2000;10(2):129–46.

28. See Fleck LM. Do future possible children have a just claim to a sufficiently healthy genome? In: Rhodes R, Battin M, Silvers A, eds. Medicine and Social Justice: Essays on the Distribution of Health Care. New York: Oxford University Press; 2002:446–57.

29. On using coercive social policies to bring about greater responsibility for personal health in citizens see Wikler D. Persuasion and coercion for health: Ethical issues in government efforts to change life-styles. Milbank Memorial Fund Quarterly 1978;56:303–38. Likewise, Elizabeth Anderson is concerned that such government efforts would effectively obliterate the line between the public and the private to the detriment of individuals. See Anderson E. What is the point of equality? Ethics 1999;109:287–337. But I reject the views of libertarians who endorse some form of consumer-directed healthcare as an approach to healthcare cost containment and personal responsibility. For a critical assessment of those views, see Axtell-Thompson LM. Consumer directed health care: Ethical limits to choice and responsibility. Journal of Medicine and Philosophy 2005;30:207–26.

30. For a detailed defense of rational democratic deliberation in making fair and just rationing decisions, see Fleck LM. Just Caring: Health Care Rationing and Democratic Deliberation. New York: Oxford University Press; 2009. See especially chapter 5.

31. See note 6, Segall 2010. See especially chapters 4 and 5.

32. Cappelen AW, Norheim OF. Responsibility, fairness and rationing in health care. Health Policy 2006;76:312–9.

33. Schmidt makes a related point. “It is not implausible to assume that a sizable proportion of those who are eligible for bonuses would have behaved in the way that ‘earned’ them the bonus anyway, simply because they follow a healthy way of living.” Schmidt H. Bonuses as incentives and rewards for health responsibility: A good thing? Journal of Medicine and Philosophy 2008;33:198–220.

34. Schmidt H, Voight K, Wikler D. Carrots, sticks, and health care reform—problems with wellness incentives. New England Journal of Medicine 2010;362:e3(1)–e3(3).

35. Stock S, Schmidt H, Buscher G, et al. . Financial incentives in the German Statutory Health Insurance: New questions, new findings. Health Policy 2010;96:51–6.

36. Others are also critical of using co-payments as a mechanism to incentivize healthier behavior. Cappelen AW, Norheim OF, Tungodden B. Genomics and equal opportunity ethics. Journal of Medical Ethics 2008;34:361–4.

37. Feiring E. Lifestyle, responsibility, and justice. Journal of Medical Ethics 2008;34:33–6, at 35.

I wish to offer a special word of thanks to the Brocher Foundation in Geneva, Switzerland, for their generous support during the writing of this essay.

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Cambridge Quarterly of Healthcare Ethics
  • ISSN: 0963-1801
  • EISSN: 1469-2147
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