Some healthcare systems are said to be grounded in solidarity because healthcare is funded as a form of mutual support. This article argues that health care systems that are grounded in solidarity have the right to penalise some users who are responsible for their poor health. This derives from the fact that solidary systems involve both rights and obligations and, in some cases, those who avoidably incur health burdens violate obligations of solidarity. Penalties warranted include direct patient contribution to costs, (...) and lower priority treatment, but not typically full exclusion from the healthcare system. We also note two important restrictions on this argument. First, failures of solidary obligations can only be assumed under conditions that are conducive to sufficiently autonomous choice, which occur when patients are given ‘Golden Opportunities’ to improve their health. Second, because poor health does not occur in a social vacuum, an insistence on solidarity as part of healthcare is legitimate only if all members of society are held to similar standards of solidarity. We cannot insist upon, and penalise failures of, solidarity only for those who are unwell, and who cannot afford to evade the terms of public health. (shrink)

A considerable literature has emerged around the idea of using ‘personal responsibility’ as an allocation criterion in healthcare distribution, where a person's being suitably responsible for their health needs may justify additional conditions on receiving healthcare, and perhaps even limiting access entirely, sometimes known as ‘responsibilisation’. This discussion focuses most prominently, but not exclusively, on ‘luck egalitarianism’, the view that deviations from equality are justified only by suitably free choices. A superficially separate issue in distributive justice concerns the two–way relationship (...) between health and other social goods: deficits in health typically undermine one's abilities to secure advantage in other areas, which in turn often have further negative effects on health. This paper outlines the degree to which this latter relationship between health and other social goods exacerbates an existing problem for proponents of responsibilisation (the ‘harshness objection’) in ways that standard responses to this objection cannot address. Placing significant conditions on healthcare access because of a person's prior responsibility risks trapping them in, or worsening, negative cycles where poor health and associated lack of opportunity reinforce one another, making further poor yet ultimately responsible choices more likely. It ends by considering three possible solutions to this problem. (shrink)

The objective of this article is to explore people’s attitudes toward responsibility in the allocation of public health care resources. Special attention is paid to conceptualizations of responsibility involving blame and sanctions. A representative sample of the Norwegian population was asked about various responsibility mechanisms that have been proposed in the theoretical literature on health care and personal responsibility, from denial of treatment to a tax on unhealthy consumer goods. Survey experiments were employed to study treatment effects, such as whether (...) fairness considerations affect attitudes about responsibility. We find that, overall, a substantial minority of the respondents find it fair to let the health care system sanction people—in one way or another—for voluntary behaviors that increase the risk of becoming ill. Quite surprisingly, we find that people are more prone to report that they should themselves be held responsible for unhealthy lifestyles than others. (shrink)