The problem of resource allocation is a global concern with varying methods being adopted; from rationing, to queuing systems, to withholding certain treatment and restricting procedures for older people, all countries set limits. Setting limits is a general prerequisite of justice and use of resources need to be controlled so that it reflects both the individual and social values at risk. Some proponents of personal responsibility believe that this is one method in which resources can be allocated. However, is justice achieved by holding individuals responsible for their individual choices in the context of health care?
In writing this essay, it is important to gain an understanding of the personal responsibility argument. There are arguments both in support and opposition of such health care policies, however, I will attempt to demonstrate that the Rawlsian Liberal Egalitarian theory supports the argument that the worse off should be reflected in health care resource prioritization. Other moral arguments will be briefly considered in response to the question. Furthermore, a definition of distributive justice is outlined. Whilst I recognize the value in health promotion and the positive role this can play in society I fundamentally believe that holding individuals responsible for their choices in the context of health care is a controversial issue and that personal responsibility deserves, but a minor role in health care policies.
Medico moral decision making is directed by four philosophical principles 1) respect for autonomy, 2) beneficence, 3) malificence and 4) justice. This essay will consider the fourth of these principles, that of justice. The principle of justice is intended amongst other things to venerate and to do justice to people. The principle of justice in health care is further subcategorized by the term distributive justice. Distributive justice is illustrated by Aristotle’s principle of proportionality, which continues to be a key element of contemporary theories of justice; ‘equals should be treated equally, unequal’s equally in proportion to the relevant equality’. Procedural justice is about what decision making processes should be followed.
In understanding what justice means and how the process of decision making is followed, it is perhaps important to evaluate whether or not justice can be achieved in a health care policy that supports personal responsibility, as this would need to reflect both the individual and societal values. Furthermore, how do we define justice? Is it just to give the resource to anyone who has a need without discrimination?
Political philosophy has a long history of concern for the ‘worse off’ and for John Rawls A Theory of Justice is his attempt to solve the problem of distributive justice. Rawls asserts that his theory is deontological (certain actions are right or wrong, regardless of the consequences of those actions) as it has a strong emphasis on the principles of social contract, rather than on the utilitarian approach. The utilitarian approach seeks to maximize the overall benefits to a population, this in stark contrast to the egalitarian principles which are concerned with how benefits are allocated to particular individuals. It should be reflected on however, which approach is good or bad or another way of taking into account, which approach is more just?
Rawlsian society begins in the following way, that you imagine yourself in an original position behind a ‘veil of ignorance’. The veil means you are ignorant of your sex, race, natural abilities and social status. The intuition which Rawl’s captures is that which connects fairness to ignorance, which is a Kantian interpretation. If I don’t know which of the five slices of cake that I am cutting and I am going to end with them, then it follows that I should cut the pieces into equal slices. The theoretical claim substantiated by the ‘veil of ignorance’, is that when individuals make decisions about justice distribution, people should be regarded as both free and equal. There is a clear skepticism from Rawls as to whether people deserve to be born into privilege or if they were talented or untalented and his theory is a way of trying to redress the imbalance; some people have a lot and others very little. Put in Rawlsian terms, the distribution of such attributes are ‘arbitrary from a moral point of view.’
Rawls’s Difference Principle necessitates that society’s social and economic institutes are ordered in such a way that they maximize the prospects of the worse off representative group. Rawls recognizes that institutions affect our lives and in relation to the subject of resource allocation and personal responsibility, Rawl’s theory helps to design fairer institutions, which in turn would positively influence the life chances for the ‘least advantaged’ in society, through the obligations of social justice. Daniels believes that Rawls’s principles have wide ranging relevance relating to questions of distribution of funds for healthcare. Daniel’s further commentary states that Rawls principle of fair equality of opportunity is too broad to make exact decisions relating to resource allocation. Giving complete priority to the worse off would be hard to accept, principally if that meant not addressing the health needs of individuals who had symptoms, but the symptoms were less severe. There is consensus that concern for worse off should be reflected in healthcare resource prioritization. However, who are the worse off? And for what reasons should the worse off receive priority for healthcare resources? In a general theory of distributive justice that gives some precedence to the worse off, it is worst overall wellbeing that is most significant. Daniels’s theory of justice is centered on the loss of function caused by a disease and how this loss leads to reducing people’s opportunity, his theory is created with the aim of elevating such individuals to the normal range for the society in which they belong. Vitally, his theory does not seek to give precedence to the worse off when a greater loss of function and opportunity can be returned for better-off persons than can realized for others who are worse off. Harris fervently asserts that “a principle of justice worth its salt” does not lessen claims to resources because of who they are. It is perhaps possible how to identify who is worse off in society, however, how resources of therefore allocated needs further exploration.
The concept of personal responsibility was introduced into public health arena in the seventies where public health promotion revolved around individuals taking greater responsibility for their own health and wellbeing. Most current health promotion is related to individual lifestyle choices, which encourages the public to exercise regularly, stop smoking and increase fruit and vegetable consumption, the object of this is to reduce the risk factors for disease, which contributes to the mortality rate in high-income countries. Legislation came into force in 2007 which made it illegal for people to smoke in enclosed working places in England. Later described as ‘the most important piece of legislation in a generation’ and has further lead to a significant reduction in smoking and the resultant health related diseases. The ability to choose how one lives their life is what makes us individual, the result of such choices, however, will have an impact on a person’s health and their need for medical intervention in the future. Can society, however, justify treating individuals ‘differently’ if they fail to fulfill their duty to themselves?
Arguments which support personal responsibility are generally associated with the idea that lifestyle choices are as important in achieving positive health outcomes as costly medical interventions are in securing good health. This is predated by Immanuel Kant’s moral philosophy in Groundwork of the Metaphysics of Morals, which endeavors to define the ethical duties of rational beings.
As a rational being, Kant asserted, we have a duty to maintain our life and to nurture our talents. Health enables an individual to attain these two obligations: for that reason a rational being is obligated to safeguard his or her own health. As rational beings there is a moral obligation upon individuals to take some personal responsibility for the maintenance and preservation of one’s health. If healthcare is considered as a duty to maintain our life and to develop our talents as far as we are able, what moral responsibility does society have in order to protect these values?
The first opposing argument against the inclusion of responsibility is called the ‘humanitarian objection’. According to this argument, we have an responsibility to help people who are in real need, regardless of the reason that they have found themselves in a particular situation, provided that helping is feasible and would not impose adverse sacrifices on those who provide the aid. The example being a woman who is a long-term smoker, who at the age of 65 develops coronary heart disease, as a result of her lifestyle behavior she now suffers from angina pectoris and consequently is at risk of a myocardial infarction (MI). The cardiologist makes further diagnostic tests and tells her she requires coronary angioplasty and stent insertion. Many people believe that it would be unfair to withhold the procedure from her because the disease could be said to be self-imposed. The humanitarian concern would be greater if we assume that the individual has already suffered an MI and is now in considerable pain and at risk of dying. Furthermore, if this individual was not treated this would breach the commitments of the NHS constitution.
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