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Personal and Social Responsibility for Health

  • Daniel Wikler


Everyone wants to be healthy, but many of us decline to act in healthy ways. What bearing, if any, should these choices have on the ethics of clinical practice and health policy? Should risk-takers have the same claim on scarce resources, such as organs for transplant, as those whose plight is due to no choices of their own? And is there any reason not to impose fees and taxes on risk-takers, be they smokers or mountain climbers, to defray the added expense of the care they may need? In health resource allocation aimed at reducing the burden of disease, should we regard certain burdens as individual responsibilities: for example, dealing with stigma, or caretaking for family members?

Socioeconomic status (SES) and health expectancy are strongly linked. To the extent that this results from risk-taking by the poor, is reduction of SES-linked health inequalities a morally important social goal? International public health aims at improving health on a population level. The World Health Organization has been criticized for failing to distinguish genuine health risks from personal lifestyle choices, as when it speaks of a tobacco-related “epidemic” as if cigarette use were a contagious disease like malaria. Should personal responsibility for health be taken into account in setting the agenda for global public health, and in measuring progress by countries in improving health. This paper addresses applications of the notions of personal and social responsibility for health. It also looks at the vulnerability of the notion of personal responsibility for health to intentional manipulation by self-interested parties in health policy debates.



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1 Lalonde, MarkA New Perspective on the Health of Canadians: A Working Document 1974 OttawaReport of the Government of Canada); and Surgeon General of the United States Healthy People: Report on Health Promotion and Disease Prevention 1979 Washington, D.C.Government Printing Office).

2 Knechtle, Stuart et al. Liver Transplantation for Alcoholic Liver Disease Surgery 1992 112 no. 4694703; Sherman, DavidWilliams, RogerLiver Transplantation for Alcoholic Liver Disease Journal of Hepatology 1995 23 no. 4474–79; and Ubel, Peter ABaron, JonathanAsch, DavidSocial Responsibility, Personal Responsibility, and Prognosis in Public Judgments about Transplant Allocation Bioethics 1999 13 no. 15768.

3 Scruton, Roger The Risks of Being Risk-Free Wall Street Journal Europe January 7, 2000; and Scruton, RogerWHO, WHAT, and WHY: Trans-National Government, Legitimacy, and the World Health Organization 2000Occasional Paper No. 113London, Institute of Economic Affairs). In 2002 the Guardian revealed that Scruton was on the payroll of a multinational tobacco company, which hired him to place pro-smoking articles in British newspapers and magazines.

4 Scruton, , “The Risks of Being Risk-Free.”

5 Ibid

6 Roemer has gone the furthest in addressing the assignment of responsibility for health from a luck-egalitarian perspective. His elegant proposal, which avoids the harsher implications of other theories that combine equality and responsibility, is discussed along with other philosophical considerations in Roemer, John E A Pragmatic Theory of Responsibility for the Egalitarian Planner Philosophy & Public Affairs 1993 22 no. 2146–66; and Roemer, John EEquality and Responsibility Boston Review 1995 20 no. 2.

7 Boyer, PaulNissenbaum, StephenSalem Possessed: The Social Origins of Witchcraft 1974 CambridgeHarvard University Press 11 ff.

8 Lynch, J WKaplan, G ASalonen, J TWhy Do Poor People Behave Poorly? Variation in Adult Health Behaviors and Characteristics by Stages of the Socioeconomic Lifecourse Social Science and Medicine 1997 44 no. 6809–19.

9 Ubel, Baron, Asch, Social Responsibility, Personal Responsibility, and Prognosis in Public Judgments about Transplant Allocation

10 Marchand, SarahWikler, DanielPowah, Julia Tao Lai Equality and the Distribution of Health in Cross-Cultural Perspectives on the (Impossibility of Global Bioethics 2002 DordrechtKluwer Academic Publishers); Marchand, SarahWikler, DanielLandesman, BruceClass, Health, and Justice Milbank Quarterly 1998 76 no. 3449–67; see also Daniels, NormanKennedy, BruceKawachi, IchiroIs Inequality Bad for Our Health 2000 BostonBeacon Press).

11 MacDonald, HeatherThe Burden of Bad Ideas: How Modern Intellectuals Misshape Our Society 2000 ChicagoIvan R. Dee); and Satel, SallyPC, M.D.: How Political Correctness is Corrupting Medicine 2000 New YorkBasic Books).

12 Lantz, P MHouse, J SLepkowski, J MWilliams, D R et al. Socioeconomic Factors, Health Behaviors, and Mortality: Results from a Nationally Representative Prospective Study of U.S. Adults Journal of the American Medical Association 1998 279 no. 31703–708.

13 Scanlon, ThomasMcMurrin, Sterling M The Significance of Choice in The Tanner Lectures on Human Values 1988 vol. 8 Salt Lake CityUniversity of Utah Press).

14 Crawford, RobertReverby, SusanRosner, David Individual Responsibility and Health Politics in the 1970s in Health Care in America: Essays in Social History 1977 PhiladelphiaTemple University Press); and Crawford, RobertYou Are Dangerous to Your Health: The Ideology and Politics of Victim Blaming International Journal of Health Services 1977 7 no. 4663–80. See also Wikler, DanielStalker, DouglasGlymour, Clark Holistic Medicine: Concepts of Personal Responsibility for Healthin Examining Holistic Medicine 1985 Buffalo, N.Y.Prometheus Press).

* The author offers thanks to Sarah Marchand, Robert Beaglehole, Dan Brock, and Fabienne Peter for valuable criticism. For a longer version of this essay, see Daniel Wikler, “Social and Personal Responsibility for Health,” in Sudhir Anand, Fabienne Peter, and Amartya Sen, eds., Health, Ethics, Equity (Oxford: Clarendon Press, forthcoming).

Personal and Social Responsibility for Health

  • Daniel Wikler


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