Bringedal B, Feiring E (2011) On the relevance of personal responsibility in priority setting: a cross-sectional survey among Norwegian doctors. J Med Ethics 37:357-361 Habitual health-related behavior poses a challenge to accountability. On the one hand, it seems absurd to claim that individuals are not responsible for the routine, everyday behaviors they engage in over and over long periods of time. On the other hand, many people have trouble controlling these behaviors. This leads people to engage in behaviors they know could be harmful, often even if they want to change those behaviors.31 32 One could sympathize with both the views of those who argue that humans are naturally responsible for their behavior and those who argue that the apparent lack of control certainly indicates otherwise. Brown RC (2013) Moral responsibility for (un)healthy behaviour. J Med Ethics 39:695-698 As discussed elsewhere, the less than ideal circumstances represented by health contexts make them difficult instances, first, for assessing accountability and, second, for implementing accountability practices such as “accountability”.62 Other factors – beyond the satisfaction of epistemic and control conditions (and their diachronic and dyadic aspects) – must be taken into account. determine how responsibility for certain actions can and should be. translated into accountability practices, such as prioritizing some people for treatment over others.
Directly discussing responsibility, Levy54 recently called on philosophers to recognize their mistake of focusing (almost) exclusively on the individual (limited by skin) as a place of agency, and recognizing that agency – and responsibility – is invariably “socialized.” While we agree with much of what Levy says, we think it`s wrong to throw completely overboard the idea that the individual is confined by the skin – the physical distinction between our body and the outside world often has a completely unambiguous meaning. In addition, we believe that there are relevant differences between influences on a person that arise in the context of a particular relationship; those that come from agents foreign to the individual; and those that emerge from the natural environment. Ability and relationships are important in the context of influence and responsibility. This has been explored in the context of health in relation to the important role families play in making decisions about treatment and ongoing care. [Verkerk et al., 2015; Lindemann et al. forthcoming]. We can judge to what extent the epistemic and control conditions for our smoker are reached in a diachronic way. If he or she is reliably informed about the likely effects of smoking and smokes a cigarette at every opportunity, he or she is aware of the possible harms of his or her behavior, then he or she will also encounter demanding epistemic and diachronic conditions. However, if his ability to control his behavior fluctuates, and he can only temporarily abstain from smoking, he fulfills the condition of control of responsibility only if the diachronic disease is weakened. We believe that this debate has limited applicability. We suggest that discussions of responsibility in the context of health behaviour need to pay more attention to the diachronic and dyadic aspects of responsibility. These reflect how a person`s responsibility for their health is exercised over time and can be shared among members of small groups.
To simplify, let`s just consider the partner or a relative (spouse, common-law partner, etc.). Therefore, we call this aspect dyadic. Although existing discussions of accountability sometimes focus on these temporal and interpersonal aspects of responsibility, they rarely receive explicit attention in discussions of the practical application of accountability (e.g. in health care). An exception is the interest in describing reports on collective and social responsibility, particularly in the context of collective action issues, and some recent contributions arguing for a “socialization” of responsibility.33 34 Depending on one`s position on the continuity of identity, this aspect of diachronic responsibility may be modeled differently. It could be argued that P t and P t + n are identical, with little or no weakening of identity or responsibility over time. Alternatively, one could model P t and P t + n as non-identical, perhaps completely different, agents. In this case, P t can only be liable for the actions of P t + n to the extent that one agent can be responsible for influencing the behavior of another.
If the latter option is chosen, diachronic responsibility may depend on a representation of dyadic responsibility – responsibility distributed among agents – which we present in the next section. If it is plausible to think that cognitive systems such as memory and identity can be distributed among agents in important ways, then so can responsibility. Moreover, because of the profound effects of social life and close relationships, individuals are not necessarily the most useful or frugal unit of analysis associated with health behaviours. We begin by describing some of the ways in which accountability is used in health policy and practice to illustrate the penetration of this concept and the improbability of banning it altogether. We then discuss how the current use of responsibility does not sufficiently take into account how actors` responsibility for actions can be judged at different times, and how responsibility for actions can be distributed among different actors. We describe how accountability can be both diachronic and dyadic, particularly in the context of health-related behaviour, and discuss how considering these dimensions might have implications for health care. Dyadic responsibility selects where one agent plays an important constitutive role in the responsibility of another agent for the actions he undertakes. It focuses on the duties and duties between those who are closely related to each other, and how this should be reflected in their commitments, how they influence each other`s behavior. Ultimately, dyadic responsibility will affect how responsibility for results is shared among agents.
This could have interesting implications in light of debates on health responsibility. First, it provides an opportunity to maintain some space for responsible practices that play a role in discussions about health-related behaviors that emphasize the importance of social and environmental impact on behavior (and tend to downplay the role of the purely individual agency). Dyadic or collective responsibility is compatible with situations where an individual`s behavior is strongly influenced by other actors. To the extent that this is often the case (i.e. individuals often exist in close relationships with others, with each agent`s behavior affecting the other`s behavior), dyadic responsibility can be an important type of responsibility that is missing in current discussions, and to the extent that it is, naming dyadic responsibility can be a first step in developing strategies. to take advantage of this phenomenon. This could include adapting accountability practices to appropriately address dyadic responsibility or finding ways to support dyadic responsibility (e.g., targeted healthy eating interventions for dyads). ↵ii Some may find it attractive to characterize the “act” of smoking as the behavior repeated over time, rather than (as we did) as many different action cases. The individuation of actions is quite complex, and we do not believe it makes a significant difference in our presentation here if the action is repeated or includes all repetitions, as it seems in both approaches that responsibility must be judged diachronically. We are not trying to decide between these debates here, but we note that some of these arguments provide compelling reasons for both and against a role in responsible health practices.
Instead, we move on to discussing how traditional concepts of responsibility are ill-suited to guide action in areas of health care where it is often considered important, particularly in the context of “lifestyle-related diseases.” This informal term generally refers to chronic diseases associated with exposure to behavioral risk factors such as smoking, alcohol consumption, lack of exercise, and poor diet. Chronic diseases associated with these risk factors contribute significantly to global mortality and health expenditure, and are a priority area for public health systems.30 We therefore argue that if responsible health care practices are to play a role, a revision of the concept may be necessary so that it can be meaningfully applied in these contexts. ↵iii See also Levy`s informative account of how it may turn out that the autonomy of unwitting addicts is undermined over time due to fluctuations in preferences.65 There is no place here to discuss how responsibility and autonomy are linked, but it seems that significantly compromised autonomy could be a reason to relieve someone of responsibility. Hart HL (1949) The attribution of responsibility and rights. Proc Aristot Soc 44:171-194 We argue that approaches to thinking about health stewardship could usefully be improved if two key factors were sufficiently recognized. First, health behaviours are often the product of multiple decisions and actions over time, and second, the extent to which a particular person`s health behaviour is the product of both their own actions and the (dyadic) actions of others.