Opportunity and Responsibility for Health
Wealth and income are highly predictive of health and longevity. Egalitarians who maintain that this “socioeconomic-status gradient” in health is unjust are challenged by the fact that a significant component of it is owed to the higher prevalence of certain kinds of voluntary risk-taking among members of lower socioeconomic groups. Some egalitarians have argued that these apparently free personal choices are not genuinely free, and that those who make them should not be held morally responsible for the resulting harms to their health. I argue to the contrary that such choices usually are fully free, and that those who make them are responsible for their consequences. This does not imply, however, that society cannot also be responsible for those consequences. It is responsible for them if they are statistically foreseeable and avoidable outcomes of unjust public institutions and policies. I show that many of the harms to health that contribute to the voluntary behavioral component of the SES health gradient satisfy that description. Society can therefore be morally responsible for those harms, even though the individuals who suffer them are also fully responsible for them.
KeywordsHealth Personal responsibility Social responsibility Equality of opportunity SES gradient in health
I am grateful to the Harvard Program in Ethics and Health for research support during an early stage of this project. For advice or comments on previous drafts I thank Hannah Byrnes-Enoch, Richard Volkman, and two anonymous reviewers for Journal of Ethics.
Compliance with Ethical Standards
Conflict of interest
The author declares that he has no conflict of interest.
- Anand, Sudhir, Fabienne Peter, and Amartya Sen (eds.). 2004. Public Health, Ethics, and Equity. Oxford: Oxford University Press.Google Scholar
- Arneson, R. 1990. Liberalism, Distributive Subjectivism and Equal Opportunity for Welfare. Philosophy & Public Affairs 19: 2.Google Scholar
- Barnett, W.S. 2008. Preschool Education and Its Lasting Effects: Research and Policy Implications. Boulder: Education and the Public Interest Center & Education Policy Research Unit.Google Scholar
- Blanden, Jo, Paul Gregg, and Stephen Machini. 2009. Intergenerational Mobility in Europe and North America. Sutton Trust Report.Google Scholar
- Bloom, David E., and David Canning. 2008. Population Health and Economic Growth. Commission on Growth and Development Working Paper; No. 24. Washington, DC: World Bank. http://documents.worldbank.org/curated/en/599491468151504321/Population-health-and-economic-growth.
- Bloom, David E., Michael Kuhn, and Klaus Prettner. 2018. “Health and Economic Growth.” Program on the Global Demography of Aging at Harvard University, Working Paper Series; PGDA Working Paper No. 153 http://www.hsph.harvard.edu/pgda/working/.
- Bratman, Michael. 2005. Planning, Agency, Autonomous Agency. In James Stacey Taylor, ed. Personal Autonomy, 33–37. Cambridge: Cambridge University Press.Google Scholar
- Brownell, K.D., et al. 2010. Personal Responsibility and Obesity: A Constructive Approach to a Controversial Issue. Health Affairs 3: 378–386.Google Scholar
- Cunha, F., et al. 2006. Interpreting the Evidence on Life Cycle Skill Formation. In Handbook of the Economics of Education, ed. E.A. Hanushek and F. Welch, 697–812. Amsterdam: North-Holland.Google Scholar
- Davey Smith, George (ed.). 2003. Health Inequalities: Lifecourse Approaches. Bristol: Polity Press.Google Scholar
- Eyal, N., S. Hurst, O. Norheim, and D. Wikler (eds.). 2013. Inequalities in Health: Concepts, Measure, and Ethics. Oxford: Oxford University Press.Google Scholar
- D’Agostino, Fred. 1996. Free Public Reason: Making It Up as We Go. New York: Oxford University Press.Google Scholar
- Daniels, Norman. 2008. Just Health: Meeting Health Needs Fairly. New York: Cambridge University Press.Google Scholar
- Daniels, Norman, Bruce Kennedy, and Ichiro Kawachi. 2004. Health and Inequality, or, Why Justice is Good for Our Health. In Anand et al.Google Scholar
- Durkheim, Emile. 1982. In The Rules of Sociological Method, ed. Steven Lukes. New York. The Free Press.Google Scholar
- Dworkin, Gerald. 1981. Taking Risks, Assessing Responsibility. Hastings Center Report 11: 5.Google Scholar
- Frankfurt, Harry. 1988b. Freedom of the Will and the Concept of a Person. Cambridge: Cambridge University Press.Google Scholar
- Frankfurt, Harry. 1988c. Identification and Wholeheartedness. Cambridge: Cambridge University Press.Google Scholar
- Gaus, Gerry. 2011. The Order of Public Reason. New York: Cambridge University Press.Google Scholar
- Goldenberg, R.L., et al. 1994. The Effect of Income on Use of Preventive Care: An Evaluation of Alternative Explanations. Journal of Health and Social Behavior 20: 397–406.Google Scholar
- Habermas, J. 1995. Reconciliation Through the Public Use of Reason: Remarks on John Rawls’s Political Liberalism. The Journal of Philosophy 92: 109–131.Google Scholar
- Hale, A.R., and A.I. Glendon. 1987. Individual Behaviour in the Control of Danger. New York: Elsevier.Google Scholar
- Heckman, James J. 2008b. The Case for Investing in Disadvantaged Young Children. In Big Ideas for Children, ed. First Focus. https://firstfocus.org/wp-content/uploads/2014/06/Big-Ideas-2008.pdf.
- Hurley, Susan. 2007. The ‘What’ and the ‘How’ of Distributive Justice and Health. In Egalitarianism: New Essays on the Nature and Value of Equality, ed. Nils Holtug and Kasper Lippert-Rasmussen, 308–334. Oxford: Oxford University Press.Google Scholar
- Karoly, Lynn A., M. Rebecca Kilburn, and Jill S. Cannon. 2005. Early Childhood Interventions: Proven Results, Future Promise. Rand Corporation Monograph Series.Google Scholar
- Kirkpatrick, R.M., M. McGue, and W.G. Iacono. 2015. Replication of a Gene-Environment Interaction Via Multimodel Inference: Additive-Genetic Variance in Adolescents’ General Cognitive Ability Increases with Family-of-Origin Socioeconomic Status. Behavioral Genetics 45: 200–214.CrossRefGoogle Scholar
- Kuh, D., et al. 1997. Social Pathways Between Childhood and Adult Health. In A Life Course Approach to Chronic Disease Epidemiology, ed. D. Kuh and Y. Ben-Shlomo, 169–198. Oxford: Oxford University Press.Google Scholar
- Laflamme, Lucie, Stephanie Burrows, and Marie Hasselberg. 2009. Socioeconomic Differences in Injury Risks: A Review of Findings and a Discussion of Potential Countermeasures. Copenhagen: World Health Organization.Google Scholar
- Marmot, M., and R.G. Wilkinson (eds.). 1999. Social Determinants of Health. Oxford: Oxford University Press.Google Scholar
- Masters, R. 1997. Brain Biochemistry and Social Status: The Neurotoxicity Hypothesis. In Intelligence, Political Inequality, and Public Policy, ed. Elliott White, 141–183. New York: Prager.Google Scholar
- McNeill, A. et al. 2017. Tobacco Packaging Design for Reducing Tobacco Use. Cochrane Database of Systematic Reviews 4. https://doi.org/10.1002/14651858.cd011244.pub2.
- National Highway Traffic Safety Administration. 2016. Traffic Safety Facts: Seat Belt Use in 2015—Overall Results. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration. http://www-nrd.nhtsa.dot.gov/Pubs/812243.pdf.
- Nisbett, R.E. 2009. Intelligence and How to Get It: Why Schools and Cultures Count. New York: Norton.Google Scholar
- Owen, M.J. 2006. Genes and Behavior: Nature-Nurture Interplay Explained. Oxford: Blackwell Publishers.Google Scholar
- Pereboom, Derk. 2003. Living Without Free Will. Cambridge: Cambridge University Press.Google Scholar
- Rakowski, Eric. 1991. Equal Justice. Oxford: Oxford University Press.Google Scholar
- Rawls, John. 1993. Political Liberalism. New York: Columbia University Press.Google Scholar
- Rawls, John. 1999. A Theory of Justice, Rev ed. Cambridge, MA: Harvard University Press.Google Scholar
- Roemer, John. 1993. A Pragmatic Theory of Responsibility for the Egalitarian Planner. Philosophy & Public Affairs 22: 142–166.Google Scholar
- Roemer, John. 1995. Equality and Responsibility. Boston Review 20. http://www.bostonreview.net/BR20.2/roemer.html.
- Roemer, John. 1998. Equality of Opportunity. Cambridge, MA: Harvard University Press.Google Scholar
- Scanlon, Thomas. 1995. Comments on Roemer. Boston Review 20. http://bostonreview.net/archives/BR20.2/Scanlon.html.
- Scientific American Editorial Board. 2012. For a Healthier Country, Overhaul Farm Subsidies. https://www.scientificamerican.com/article/fresh-fruit-hold-the-insulin/.
- Sen, Amartya. 2004. Why Health Equity. In Anand et al.Google Scholar
- Susser, M., W. Watson, and K. Hopper. 1985. Sociology in Medicine. Oxford: Oxford University Press.Google Scholar
- Whitehead, Margaret. 1990. The Concepts and Principles of Equity in Health. Washington, DC: World Health Organization Regional Office for Europe.Google Scholar
- Wilkinson, Richard G. 1996. Unhealthy Societies: The Afflictions of Inequality. London: Routledge.Google Scholar
- Wilkinson, Richard, and Michael Marmot (eds.). 2003. Social Determinants of Health: The Solid Facts. Geneva: World Health Organization.Google Scholar
- World Health Organization. 2016. Plain Packaging of Tobacco Products: Evidence, Design, and Implementation. http://apps.who.int/iris/bitstream/10665/207478/1/9789241565226_eng.pdf.