Lorenzo Del Savio

Are Responsibility-Sensitive Distributive Theories Suitable for Health Policy? 

The high prevalence and social cost of diseases that are due to unhealthy individual habits (e.g. bad diets, smoking, etc.) is fuelling a debate on whether people should be held responsible for their unhealthy choices and the practical guidelines for health care systems stemming from responsibility-sensitive distributive theories. There are concerns regarding the latter prescriptive theories because unhealthy habits are in most cases sharply stratified socially and systematically more common among the poor: as a consequence, any policy of responsibilization would fall disproportionally upon the disadvantaged. A common philosophical position consists in upholding distributive-sensitive theories and denying or discounting responsibility in case of social determination (e.g. Roemer 1998). For the case of health related behaviors, this was most recently argued for by Brown (2012), who relies on Pettit’s account of when people are “fit to be held responsible”. Starting from the same source, I argue instead that there is no reason to deny or discount the responsibility of disadvantaged people for their health-related behaviors. Sociological explanations of health behaviors do not question the capacity of the poor for autonomous agency sensu Pettit. Nevertheless, people should not be held responsible for their unhealthy behavior in health policy: while most individuals are fit to be attributed responsibility for their lifestyles, they generally do not have duties (i.e. substantive responsibility) regarding their own health that stem from distributive-sensitive “liberal egalitarian” public health (Cappelen and Norheim 2005, Buyx 2007). The latter reconstruction of public health is unfit to societies where the degree of investments for health correlates with socio-economic status (for broadly consequentialist reasons) and relies on an unacceptably moralizing view of human conduct. I conclude that the only sound arguments in favor of responsibility-oriented reforms (e.g. contribution to health costs, de-prioritization) might be reasons of efficiency, i.e. avoiding negative externalities and moral hazard dependent on universal coverage of health systems: it is however a non-trivial empirical issue whether any of these mechanisms are ever instantiated in the case of health behaviors.