Responsibility for Unhealthy Choices – a Limited Approach to
Personal Responsibility in Health
Andreas Albertsen, External Lecturer
Department of Political Science and Government, Aarhus University
aba@ps.au.dk
Abstract
Cappelen and Norheim has presented a novel approach regarding how we are to understand and
implement the idea of personal responsibility in health. It consists of two elements. The first
allows for co-payments for those diseases which are not life-threatening, costly or undermining
important capabilities, if these are causes or influenced by people’s own choices. The second
applies to all other diseases. Unhealthy choices should be taxed and treatment offered equally to
everyone without further cost. While an interesting approach it faces important difficulties. It is
not quite coherent, with important tensions existing between the two elements comprising it. It is
unable to address important questions of prioritization. This is apparent when discussing nonmonetary shortages such as the organ shortage, where levying a tax will not bring about the
resources needed to provide care for all. It is also incomplete in that it fails to give any guidance
or recommendation in relation to the public health measure which go beyond the provision of
healthcare. Finally the idea of taxing choices makes the approach different from the luck
egalitarian theories it cites as its inspiration in two different ways. One is that it comes closer to
the concept of all-luck egalitarianism, which provides redistribution between unlucky gamblers,
the other is that it risks holding people responsible for choices influenced by their social
circumstance, something which any luck egalitarian theory would seek to avoid.
Introduction
Much attention has been given to discussions over how we are to apply theories of
distributive justice to questions regarding distributions of health and provisions healthcare. 1
Norman Daniels, Just Health Care, Studies in Philosophy and Health Policy (Cambridge [Cambridgeshire] ; New
York: Cambridge University Press, 1985); Norman Daniels, Just Health : Meeting Health Needs Fairly (Cambridge;
New York: Cambridge University Press, 2008); Nir M Eyal, ed., Inequalities in Health: Concepts, Measures, and
1
1
Of special interest has been the debate over how to apply luck egalitarianism to such
discussions. 2 Roughly stated, luck egalitarianism expresses the idea that distributions are
just, if and only if, people’s relative positions reflect their exercises of responsibility. 3 The
interest in whether luck egalitarianism yields plausible conclusions in the context of health is
likely to be connected with the fact that it is an influential and much discussed theory over
distributive justice. 4 But it may also be because the theory connects with an idea influential in
much academic and political discussion, namely that we are allowed to give lower priority to
those who can be said to be responsible for their own medical needs. 5 Considering the
Ethics (Oxford: Oxford University Press, 2013); Jennifer Prah Ruger, Health and Social Justice (Oxford ; New York:
Oxford University Press, 2010); Shlomi Segall, Health, Luck, and Justice (Princeton, NJ: Princeton, 2010); Amartya
Sen, “Why Health Equity?,” Health Economics 11, no. 8 (December 2002): 659–66, doi:10.1002/hec.762; Sridhar
Venkatapuram, Health justice (Cambridge: Polity Press, 2011); Sridhar Venkatapuram and Michael Marmot,
“Epidemiology and Social Justice in Light of Social Determinants of Health Research,” Bioethics 23, no. 2
(February 2009): 79–89, doi:10.1111/j.1467-8519.2008.00714.x.
2 Author, “Author’s Publication,” n.d.; Julian Le Grand, “Individual Responsibility, Health, and Health Care,” in
Inequalities in Health: Concepts, Measures, and Ethics, ed. Nir Eyal et al., Population-Level Bioethics Series
(Oxford: Oxford University Press, 2013), 299–306; Shlomi Segall, “In Solidarity with the Imprudent: A Defense of
Luck Egalitarianism,” Social Theory and Practice 33, no. 2 (2007): 177–98; Segall, Health, Luck, and Justice; Kristin
Voigt, “Appeals to Individual Responsibility for Health,” Cambridge Quarterly of Healthcare Ethics 22, no. 02
(March 14, 2013): 146–58, doi:10.1017/S0963180112000527.
3 Kasper Lippert-Rasmussen, “Arneson on Equality of Opportunity for Welfare,” Journal of Political Philosophy 7,
no. 4 (1999): 478–87, doi:10.1111/1467-9760.00087.
4 Richard J. Arneson, “Luck Egalitarianism Interpreted and Defended,” Philosophical Topics 32, no. 1/2 (2004): 1–
20; Richard J. Arneson, “Luck Egalitarianism - A Primer,” in Responsibility and Distributive Justice, ed. Carl Knight
and Zofia Stemplowska (Oxford; New York: Oxford University Press, 2011), 24–50; Carl Knight, Luck
Egalitarianism (Edinburgh: Edinburgh University Press, 2009); Zofia Stemplowska, “Rescuing Luck
Egalitarianism,” Journal of Social Philosophy 44, no. 4 (December 2013): 402–19, doi:10.1111/josp.12039.
5 Gene Bishop and Amy C. Brodkey, “Personal Responsibility and Physician Responsibility — West Virginia’s
Medicaid Plan,” New England Journal of Medicine 355, no. 8 (August 24, 2006): 756–58,
doi:10.1056/NEJMp068170; Alexander Brown, “If We Value Individual Responsibility, Which Policies Should We
Favour?,” Journal of Applied Philosophy 22, no. 1 (March 2005): 23–44, doi:10.1111/j.1468-5930.2005.00290.x;
Alexander Brown, Personal Responsibility: Why It Matters, Think Now (London ; New York: Continuum, 2009);
Nir Eyal, “Denial of Treatment to Obese Patients—the Wrong Policy on Personal Responsibility for Health,”
International Journal of Health Policy and Management 1, no. 2 (2013): 107–10, doi:10.15171/ijhpm.2013.18;
Department of Health, “Choosing Health: Making Healthy Choices Easier,” 2004; O. Golan, “The Right to
Treatment for Self-Inflicted Conditions,” Journal of Medical Ethics 36, no. 11 (August 16, 2010): 683–86,
doi:10.1136/jme.2010.036525; Julian Le Grand, Equity and Choice an Essay in Economics and Applied Philosophy
(London ;;New York, NY, USA : HarperCollins Academic, 1991); Howard M. Leichter, “‘Evil Habits’ and ‘Personal
Choices’: Assigning Responsibility for Health in the 20th Century,” The Milbank Quarterly 81, no. 4 (January 1,
2003): 603–26; M. Minkler, “Personal Responsibility for Health? A Review of the Arguments and the Evidence at
Century’s End,” Health Education & Behavior 26, no. 1 (February 1, 1999): 121–41,
doi:10.1177/109019819902600110; M. Minkler, “Personal Responsibility for Health: Contexts and
Controversies,” in Promoting Healthy Behavior : How Much Freedom? Whose Responsibility?, ed. Daniel Callahan
(Washington, D.C.: Georgetown University Press, 2000); S J Reiser, “Responsibility for Personal Health: A
Historical Perspective,” The Journal of Medicine and Philosophy 10, no. 1 (February 1985): 7–17; Harald Schmidt,
“Bonuses as Incentives and Rewards for Health Responsibility: A Good Thing?,” Journal of Medicine and
Philosophy 33, no. 3 (June 1, 2008): 198–220, doi:10.1093/jmp/jhn007; Harald Schmidt, “Personal
Responsibility in the NHS Constitution and the Social Determinants of Health Approach: Competitive or
2
strengths and weaknesses of luck egalitarianism in this context has led many to the
conclusion, that the implications of the general theory in this context reflects badly on the
theory as such and thus, on attempts to make allocation of healthcare attentive to personal
responsibility. 6 This has prompted several interesting attempts to restate luck egalitarianism
in health, in a way which is able to provide answers to recurrent criticism. This article
critically engages with one specific way of dealing whit this critique, which has receive much
attention, namely the ‘liberal egalitarian approach proposed by Cappelen and Norheim. 7 This
article presents their approach and points to some difficulties and ambiguities within it.
Complementary?,” Health Economics, Policy and Law 4, no. 02 (March 9, 2009): 129,
doi:10.1017/S1744133109004976; Kerith Sharkey and Lynn Gillam, “Should Patients with Self-Inflicted Illness
Receive Lower Priority in Access to Healthcare Resources? Mapping out the Debate,” Journal of Medical Ethics 36,
no. 11 (November 2010): 661–65, doi:10.1136/jme.2009.032102; Lance K. Stell, “Responsibility for Health
Status,” in Medicine and Social Justice: Essays on the Distribution of Health Care, ed. Rosamond Rhodes, M. Pabst
Battin, and Anita Silvers (Oxford ; New York: Oxford University Press, 2002); Gustav Tinghőg, Per Carlsson, and
Carl H. Lyttkens, “Individual Responsibility for What? – A Conceptual Framework for Exploring the Suitability of
Private Financing in a Publicly Funded Health-Care System,” Health Economics, Policy and Law 5, no. 02 (2010):
201–23, doi:10.1017/S174413310999017X; Peter A. Ubel, Jonathan Baron, and David A. Asch, “Social
Acceptability, Personal Responsibility, and Prognosis in Public Judgments and Transplant Allocation,” Bioethics
13, no. 1 (January 1999): 57–68, doi:10.1111/1467-8519.00131; R M Veatch and P Steinfels, “If National Health
Insurance Is Enacted--Who Should Pay for Smokers’ Medical Care?,” The Hastings Center Report 4, no. 5
(November 1974): 8–10; Daniel Wikler, “Personal and Social Responsibility for Health,” in Public Health, Ethics,
and Equity, ed. Sudhir Anand, Fabienne Peter, and Amartya Sen (Oxford; New York: Oxford University Press,
2004), 109–35.
6 R. C. H. Brown, “Moral Responsibility for (un)healthy Behaviour,” Journal of Medical Ethics, January 11, 2013,
doi:10.1136/medethics-2012-100774; A M Buyx, “Personal Responsibility for Health as a Rationing Criterion:
Why We Don’t like It and Why Maybe We Should,” Journal of Medical Ethics 34, no. 12 (December 1, 2008): 871–
74, doi:10.1136/jme.2007.024059; A. Buyx and B. Prainsack, “Lifestyle-Related Diseases and Individual
Responsibility through the Prism of Solidarity,” Clinical Ethics 7, no. 2 (July 19, 2012): 79–85,
doi:10.1258/ce.2012.012008; Norman Daniels, “Individual and Social Responsibility for Health,” in Responsibility
and Distributive Justice, ed. Carl Knight and Zofia Stemplowska (Oxford; New York: Oxford University Press,
2011), 266–86; E Feiring, “Lifestyle, Responsibility and Justice,” Journal of Medical Ethics 34, no. 1 (January 1,
2008): 33–36, doi:10.1136/jme.2006.019067; Leonard M. Fleck, “Whoopie Pies, Supersized Fries,” Cambridge
Quarterly of Healthcare Ethics 21, no. 01 (December 13, 2011): 5–19, doi:10.1017/S0963180111000454; Daniel
M. Hausman, “Egalitarian Critiques of Health Inequalities,” in Inequalities in Health: Concepts, Measures, and
Ethics, ed. Nir Eyal et al., Population-Level Bioethics Series (Oxford: Oxford University Press, 2013), 95–112;
Lasse Nielsen, “Taking Health Needs Seriously: Against a Luck Egalitarian Approach to Justice in Health,”
Medicine, Health Care and Philosophy 16, no. 3 (August 2013): 407–16, doi:10.1007/s11019-012-9399-3; Lasse
Nielsen and David V. Axelsen, “Three Strikes Out: Objections to Shlomi Segall’s Luck Egalitarian Justice in Health,”
Ethical Perspectives 19, no. II (2012): 307–16; Venkatapuram, Health justice; Wikler, “Personal and Social
Responsibility for Health.”
7 Alexander W. Cappelen and Ole Frithjof Norheim, “Responsibility in Health Care: A Liberal Egalitarian
Approach,” Journal of Medical Ethics 31 (2005): 476–80, doi:10.1136/jme.2004.010421; Alexander W. Cappelen
and Ole Frithjof Norheim, “Responsibility, Fairness and Rationing in Health Care,” Health Policy 76, no. 3 (2006):
312–19, doi:10.1016/j.healthpol.2005.06.013.
3
Cappelan and Norheim’s proposal
The authors assess their own proposal as responsibility-sensitive, but not vulnerable to
prominent concerns regarding responsibility-sensitive policies in health.8 Their approach
consists of two distinct institutional measures, each of which is needed to realize their luck
egalitarian, or as they prefer: liberal egalitarian, ambitions. 9 One element involves the
taxation of a distinct subset of risky choices, while the other element allows for out-of-pocketpayment on some diseases. Unfortunately the literature has done little to disentangle these
two elements, often discussing only the first. 10 The thought driving this article is that a more
comprehensive engagement with the authors’ position will help move the debate forward.
According to Cappelen and Norheim, the nature of a disease determines which
institutional measure we ought to introduce. They distinguish between two subsets of disease
and introduce two distinct policy measures applicable to those, both of which are seemingly
responsibility-sensitive but in a different fashion. Consider first the element in their approach
which has received the least attention. It applies to diseases for which all of the following
conditions are met:

Not life-threatening

Do not limit the use of political rights or exercise of fundamental capabilities

Cost of treatment low compared to income 11
Assume that some of the diseases fulfilling those criteria will have been brought about
completely or partly as a result of individual behaviour, while others result from factors
outside the person’s control. The authors argue that the optimal policy would be to charge
actual cost co-payment for those who get such diseases through their own negligence, with
the purpose of offering full cover to those who get such diseases for reasons outside their
Cappelen and Norheim, “Responsibility in Health Care,” 479; Cappelen and Norheim, “Responsibility, Fairness
and Rationing in Health Care,” 315.
9 Cappelen and Norheim, “Responsibility in Health Care,” 478; Cappelen and Norheim, “Responsibility, Fairness
and Rationing in Health Care,” 313.
10 Buyx, “Personal Responsibility for Health as a Rationing Criterion”; Feiring, “Lifestyle, Responsibility and
Justice”; Harald Schmidt, “Just Health Responsibility,” Journal of Medical Ethics 35, no. 1 (January 1, 2009): 21–26,
doi:10.1136/jme.2008.024315; Segall, Health, Luck, and Justice, 47; Nicole A Vincent, “What Do You Mean I
Should Take Responsibility for My Own Ill Health?,” Journal of Applied Ethics and Philosophy 1, no. 1 (2009): 39–
51.
11 Cappelen and Norheim, “Responsibility, Fairness and Rationing in Health Care,” 315.
8
4
control. 12 They illustrate their approach by comparing two groups with different diseases. In
one group all are sick for reasons unrelated to behaviour, in the other it’s a mix of selfinflicted illness and illness from circumstance. Under the assumption that we cannot tell who
is responsible in the second group, the authors would favour to charge more from this group
than the first. 13 This first element, which allows for introducing co-payments for diseases
which are not life-threatening, do not limit political capabilities and where the cost of treatment
is low in comparison to the patient’s income, does however not exhaust the role for personal
responsibility.
The authors explicitly address this subset of diseases because it avoids many
common objections to letting personal responsibility affect access to health. The purpose,
according to the authors is to whether it is possible to ‘define a limited but significant role for
individual responsibility.’ 14 In the same section they mention the approach they believe should
be used for all diseases which do not meet the criteria outlined above. This is an important
supplement because we can easily imagine diseases where individual choice may contribute
to people’s risk of acquiring a low level of health, but where one or more of the conditions
outlined above are not met. By definition, the first element of Cappelen and Norheims
approach is silent regarding how we are to deal with diseases which are life-threatening,
expensive to treat or diminish people’s political capabilities, but where individual choices
have contributed to the individual’s poor health. The second however, addresses such
questions and the authors maintain that there is room for responsibility-sensitive policies
even in those cases. They propose that in such instances we should not hold people
responsible for the consequences of their choices (the disease), but rather for the risky
choices they’ve made. As their institutional measure for doing this, they propose taxing
potentially unhealthy activities to raise money for treating those who fall ill as a consequence
of such choices. Each choice will be taxed the same, and no one suffering from such diseases
will be further charged for treatment. 15 According to the author’s this idea has a number of
advantages compared to introducing responsibility for consequences, co-payment, for this
group of diseases as well. The advantage of taxing choices and treating everyone for free is
Ibid., 316.
Ibid.
14 Ibid., 315.
15 Cappelen and Norheim, “Responsibility in Health Care,” 4792006; Cappelen and Norheim, “Responsibility,
Fairness and Rationing in Health Care,” 315.
12
13
5
that it does not let people die from their diseases, suffer severe economic hardship or allow
illness to diminish people’s fundamental capabilities. All diseases in this category have, by
definition, the potential to do exactly that, but Cappelen and Norheim’s proposal ensures that
this does not transpire.
They offer another reason, related to luck, for introducing a tax on those choices.
They argue that there is an unfairness in people being unequally well off after having made
the same choices from a starting point of equality of opportunities. The unfairness, they
submit, arises because the difference between the persons is due to luck. 16 Such differences in
luck could express ‘different degrees of luck (for example, that the parachute did not open), or
different genetic dispositions (for example, a disposition to develop cancer or cardiovascular
diseases)’ 17 The liberal egalitarian commitments to eliminate differences in luck, they
maintain, would lead us to the view that differences stemming from similar choices should be
subject to redistribution. 18 In that regard they suggest that if the outcome of people’s choices
were not affected by luck, that is free from influence from other factors, then holding people
responsible for their choices and holding people responsible for their circumstances would
amount to the same thing. 19 The discussion in the literature is not always attentive to the two
distinct elements of the responsibility sensitive proposal from Cappelen and Norheim. One
element applying to a certain set of diseases, while the other applies to another. This article
unfolds these elements and critically evaluates them, both separately and examined in
relation to each other. Three criticisms will be raised in that regard. The first pertains to the
coherence of the two elements, the next to the completeness of their framework understood
as its ability to deal with important issues. The third evaluates the luck egalitarian credentials
of the proposal.
Coherence
One important thing to discuss is whether the two elements proposed by Cappelen and
Norheim can be incorporated into a coherent framework. We can imagine a group of diseases
all of which are related to people’s choices. Some of these diseases are expensive to threat
Cappelen and Norheim, “Responsibility in Health Care,” 479.
Ibid., 477.
18 Ibid., 479.
19 Ibid., 478–479.
16
17
6
(compared to income), life-threatening or undermine political capabilities, others however, do
not. On the face of it, it seems quite simple to evaluate which kind of diseases are subject to
one institutional measure, and which are subject to the other. Along with the reasoning
presented above, we could suggest that regarding the diseases with the mentioned
consequences a tax is to be levied on the choice which could result in those diseases.
But in their reasoning for holding people responsible for their choices through
taxes the authors’ suggest a justification for this scheme which complicates matters. They
write that only in instances where people’s health outcome ‘depends solely on the individual’s
choices and not on any other factors that this principle implies that individuals should be held
responsible for the consequences of their actions.´ 20Thus, one reason to introduce a tax on
unhealthy choices is that the severe health outcomes arise out of a complex relationship
between choices and luck. This gives rise to a tension, because the authors then seems to
suggest both that how to decide between responsibility for consequences and responsibility
for choices depends on the nature of the consequences and the degree to which people are
responsible. But these considerations may come into conflict.
To see how consider a person suffering from a disease which is related to his
unhealthy choices, but does not give rise to the serious consequences listed by Cappelen and
Norheim. Intuitively, based on the initial description of the authors’ position, we would belief
that what matters is the nature of the consequences. As they are, by assumption, not very
severe in this case, co-payment seems the appropriate institutional measure to evoke. But
could such a person not also claim that he is in the stated sense unlucky that his behaviour
leads to a disease? Based on the authors’ own description, this is clearly the case. While the
two elements of tax and co-payment in their approach are presented as if they can
complement each other, this is seemingly not the case, the authors’ framework lack a ways of
deciding which element to prefer when their stated reasons for choosing between them come
into conflict. Without such a way of deciding between the two institutional measures we lack
the coherence of an applicable framework.
Completeness
The above section discussed whether the framework has the coherence its authors portray it
20
Ibid.
7
with. This leads to another important discussion, which has to do with whether the
framework is complete. Completeness here is to be understood as questions regarding,
whether there are important cases to which the framework does not provide any guidance,
apart from those of the kind discussed in the previous section. This section raises two issues,
for which the approach seemingly provides inadequate answers. One relates to important
distributive questions inside the healthcare system, the other to the health policies which go
beyond this. Consider first the important questions of prioritizing healthcare resources, which
arises due to the shortage of organs. If we have a population of people needing a liver
transplant, we could say that those among them who need a liver for reasons related to their
past consumption of alcohol are suffering from a disease which has severe consequences. 21
The solution suggested by Cappelen and Norheim’s approach would be to tax the
consumption of alcohol and treat everyone who needs a new liver for free, utilizing the funds
collected through the tax. But such a solution is incomplete in an important way. While liver
transplants are costly the most important resource in this context is not of a monetary kind. 22
The primary shortage is organs. This means that raising extra funds through taxes does not
make it possible to treat everyone. The approach proposed by Cappelen and Norheim is thus
silent on an important issue, namely that related to shortages of organs.
In recent epidemiological discussion, much attention has been given to the
concept of social determinants in health.23 The idea is that people’s health and the choices
they make to stay healthy is vastly influenced by the places they live, working conditions and
socio-economic position. As this literature has been quite influential, much normative
literature has tried to incorporate such concerns into their frameworks.24 Often the
suggestion is that these findings push us towards considering public health measures, or
broader measures to mitigate the influence of social determinants on people’s health. But the
approach suggested by Cappelen and Norheim is surprisingly silent on these matters. They
don’t have any tools available to incorporate the thought that our health might be unfairly
Vibha Varma, Kerry Webb, and Darius F Mirza, “Liver Transplantation for Alcoholic Liver Disease,” World
Journal of Gastroenterology 16, no. 35 (2010): 4377–93, doi:10.3748/wjg.v16.i35.4377.
22 in the US for a single transplantation is around $300,000 Tom Koch, Scarce Goods: Justice, Fairness, and Organ
Transplantation (Westport, Conn: Praeger, 2002), 7.
23 M. G Marmot and Richard G Wilkinson, Social Determinants of Health (Oxford; New York: Oxford University
Press, 2006).
24 Daniels, Just Health; Segall, Health, Luck, and Justice; Venkatapuram and Marmot, “Epidemiology and Social
Justice in Light of Social Determinants of Health Research.”
21
8
influenced by social circumstances, at least not beyond providing treatment when we do fall
ill. In addition to that, they even seem to allow for levying a tax on choices which could be very
influenced by the social conditions in which they are made and the opportunities available to
those who are making them. The latter point will also be stressed in the final section.
Removing Luck and embracing responsibility
The third point to be taken up here, is the extent to which the examined approach reflects the
luck egalitarian or liberal egalitarian values. Especially the credentials in that regard of their
proposal of taxation of unhealthy choices. This section argues that it overstates the extent to
which this reflects the luck egalitarian literature, that it involves too narrow a view on the
way in which we can hold people responsible and finally that
One thing to note is that the authors overstate how much in line with liberal
egalitarianism and luck egalitarianism their position is. This is especially clear with regard to
the idea of holding people responsible for their choices. The authors quote Cohen and
proceeds as if this idea is clearly in line with his thoughts. They furthermore submit that it is a
common ‘misinterpretation…that these theories argue that individuals should be held
responsible for the consequences of their choices.’ 25 Most luck egalitarians would find this a
puzzling statement. Most, if not all, luck egalitarians does indeed allow for situations, where
people are asked to bear the consequences of choices for which they are responsible. 26 If
some buy stocks and earns a profit, while others lose money on their investments the goods
and burdens flowing from these transactions are not some which luck egalitarianism
considers unjust. It would not seem a more likely luck egalitarian scheme to charge each stock
an extra premium and use this to compensate those, who fare badly at the stock exchange.
Instead of being a straightforward application of luck egalitarianism to health,
the cost-sharing scheme proposed by Cappelen and Norheim seems to have much in common
with the idea of all luck egalitarianism. The main disagreement between traditional luck
egalitarians and all luck egalitarians is whether inequalities stemming from option luck
Cappelen and Norheim, “Responsibility in Health Care,” 478.
Richard J. Arneson, “Equality and Equal Opportunity for Welfare,” Philosophical Studies 56, no. 1 (1989): 84; G.
A. Cohen, “On the Currency of Egalitarian Justice,” Ethics 99, no. 4 (1989): 917; Knight, Luck Egalitarianism; John
Roemer, “Equality and Responsibility,” Boston Review 20, no. 2 (1995),
http://bostonreview.net/BR20.2/roemer.html; Eric Rakowski, Equal Justice (Oxford: Clarendon, 1993).
25
26
9
gambles should be redistributed.27 When arguing that we should redistribute between people
who run such risks with their health, the authors seems much closer to the arguments of all
luck egalitarians than to those of traditional luck egalitarianism.28 This is not as such
problematic, but shows that rather than provide an account of what luck egalitarianism in
health means they provide one which accepts a not uncontroversial adjustment of luck
egalitarianism.
Moving beyond their depiction of luck egalitarianism, consider how the authors
describe the range of opportunities available for holding people responsible. The authors
maintain, as one important policy measure, that if one holds people responsible for the
consequences of their choices rather than their choices, this would imply in the context of
healthcare ‘that individuals should be refused treatment (or collectively financed treatment).’29
This is a quite limited range of options for holding people responsible, ignoring alternative
such as responsibility-weighted waiting lists. But the whole idea of holding people responsible
through taxing their every choice is in a more fundamental way suspect as a responsibilitysensitive measure. Following from the already presented idea of social determinants, holding
people responsible for their choices carry an important risk. If this is done without an attempt
of incorporating the context in which these choices are made, thus healthcare is provided with
little attention to influences of our health lying outside the traditional healthcare system.
It is thus an open question whether taxing every risky or potential unhealthy
choice people make with their health is actually a responsibility sensitive policy. It is choice
sensitive for sure, but as already argued many would say that we are not responsible for all
our choices. If this is the case the proposal ends up taxing people for choices which they are
not responsible for. The importance of this concern is highlighted by what we know regarding
how people’s social circumstances affect the choice they’ve made. This topic warrants further
attention. For one might ask how well equipped the proposed theory is in dealing with such
broader issues. While the authors mention them as a concern they seem not initially able to
Nicholas Barry, “Reassessing Luck Egalitarianism,” The Journal of Politics 70, no. 1 (January 7, 2008): 136–50,
doi:10.1017/S0022381607080103; Lippert-Rasmussen, “Arneson on Equality of Opportunity for Welfare”; Carl
Knight, “Egalitarian Justice and Expected Value,” Ethical Theory and Moral Practice 16, no. 5 (February 21, 2013):
1061–73, doi:10.1007/s10677-013-9415-6.
27
29
Cappelen and Norheim, “Responsibility in Health Care,” 478.
10
deal with them. This is interesting, not least because it would mean that the theory fails in
what its authors considers its most important achievement, namely to ‘eliminate the effect of
factors outside the control of the agent.’30
Conclusion
After evaluating the strengths and weakness of the approach argued for by Cappelen and
Norheim several remarks can be made. Their framework is less coherent than we could hope
for, because there are important and unaddressed tensions between the two policy measures
they propose. Furthermore the framework is at best silent on important matters such as
prioritization beyond monetary scarcity and public health policies which go beyond the
healthcare system. Finally the responsibility-sensitive credentials of their theory where
questioned. This is reasonably to do partly because their approach risk holding people
responsible for choices they are not responsible for, and furthermore because it relies on a
not uncontroversial interpretation of luck egalitarianism, more related to the all-luck
egalitarian position than the traditional source of luck egalitarianism which they cite as their
inspiration.
30
Ibid., 479.
11