We also believe that responsibility sometimes has a role to play even when those who are responsible will likely fall below the threshold of sufficiency. Both Solomon and Sunita have a claim to have their lives saved. Whereas responsibility can invalidate one’s claim to aid when one will be left only in moderate need, it can only ever weaken it when one will be left in severe need. Nonetheless, if only one can be saved, Sunita’s claim is greater. However, there are several further issues to consider, which the adoption of responsibility-sensitive sufficientarianism does not resolve.
Degrees of Need
The first of these issues is the relationship between medical need and responsibility below the threshold. One possible view (which seems to be Herlitz’s) is that there are two categories of responsibility (responsible / not responsible) and two categories of medical need in reference to the sufficiency threshold (severe / moderate). Herlitz’s view appears to be that those who are responsible for their own severe need should be prioritized over those who are not responsible but who have only moderate need; however, those who are responsible for severe need should take a lower priority compared with those who have a severe need and are not responsible.
But medical need comes in degrees. To take the example of pain, even if one agrees that there is something morally distinctive about severe pain, there can be more and less severe cases within this category. Similarly, among those individuals whose medical conditions prevent them from forming and pursuing their own conception of a good life, there are important variations in mental and physical capacity. There are also differences in risk. In Severe Priority, we described Solomon and Sunita as both facing a “significant risk” of death. But that is consistent with Solomon facing a much higher risk than Sunita.
One possibility is that those who are responsible for their severe need should always be a lower priority when competing with those who are not responsible for their severe need, no matter how great a gap there is between their positions.
As we note in section II, sufficientarians have disagreed about what the precise moral role of the threshold should be. However, many argue that when deciding among individuals who are below the threshold, we should engage in something like prioritarian reasoning, where benefits to the worst-off matter more. To recap, this would mean that if we had to confer a benefit of equal size, we should prefer to give it to the worse-off individual. However, in cases where the benefit we can offer to the worst-off is significantly smaller than that which we can offer to the better off, we may prefer the better-off.
This view lends itself to a parallel claim about responsibility. Consider again our case of Severe Priority. Even though both Solomon and Sunita are in severe need following their accident, the degree of need may nonetheless be relevant to whether and how to involve responsibility. For instance, imagine that Sunita faces 5 per cent of dying if not treated within the next month, whereas Solomon is in a critical condition, with a 90 per cent chance of dying if not treated immediately.
Although Solomon is responsible for his condition, recall that the responsibility-sensitive sufficientarian view is that his claim is weakened, not eliminated. It is plausible that, in an ordinary case where neither patient is responsible, the patient with significantly more severe need has a stronger claim to priority. This means that if there is a considerable difference in the severity of need in Solomon and Sunita’s case, it may still be right to prioritize Solomon. Although his claim to treatment is weakened by his responsibility, it was significantly greater to begin with. On the other hand, if Solomon and Sunita were in a comparable state, or if Solomon’s need was much less severe, it would be right to prioritize Sunita.
Compare this with the Moderate Priority case of George and Lynette. Since Lynette will not be left badly off, we view her claim as undermined by her responsibility. As such, so long as Lynette will not be left badly off, it is right to prioritize George’s care over hers, even if she is significantly worse off than he is.
Degrees of Control
We have noted that medical need comes in degrees and claimed that this is relevant for responsibility-sensitive sufficientarianism. According to some views, it is also true that responsibility comes in degrees. For instance, Coates and Swenson argue that one can be more or less responsible depending on how well one is able to recognize and respond to reasons for action, both capacities which can vary by degrees. As Coates and Swenson suggest, one’s capacities for reasons recognition and response can be significantly affected without being entirely debilitated to the point where one lacks responsibility altogether. They discuss a case where a person’s severe depression means that she fails to pick up a friend from the airport, even though it is true that she would have left her house in response to other reasons, such as a fire. That she is still somewhat reasons-responsive shows that she still has moral responsibility. Yet that she faces a significant barrier to responding to reasons should, according to Coates and Swenson (2013, 634), “mitigate her responsibility and blameworthiness.” Nelkin (2016) adds that one’s degree of responsibility can vary depending on how reasonable it is to expect a person to take the opportunities with which they are presented. And Tierney (2019) suggests that as well as being affected by how difficult a person finds a particular choice, the degree of responsibility they face depends on the quality of the reasons for which they act, an idea we develop in the following section.
If moral responsibility comes in degrees, this raises a further question for responsibility-sensitive sufficientarianism: should all people who are responsible for their ill health be treated alike (within the categories of the well-off and badly off)?
We can defend a scalar conception of responsibility but acknowledge that it is also a threshold concept. For instance, just as people’s reasons-responsive capacities can affect how responsible they are, at some point a person can be so unresponsive to reasons that it is inappropriate to hold them responsible at all. In our view, this is because an individual’s inability to respond to reasons effectively undermines their ability to rationally control their choices in a reasonable way—that is, their autonomy. However, a lack of autonomy is not the only way in which someone might fail to have a sufficient degree of control. As well as lacking sufficient internal capacities to exercise proper control, someone might also lack sufficient opportunities because of their external circumstances. An insufficient availability of good choices, or excessive burdens being attached to those options, also undermine an individual’s ability to sufficiently control their health. It is thus inappropriate to hold them substantively responsible for choices which damage their health.
An alternative view (e.g., Roemer 1993; Segall 2013, 179) is that responsibility can only be relevant to distributive decisions when people have equal opportunity to choose well. The fact that someone chooses a poor diet may look like an exercise of responsibility, and in a narrow sense it is. But this person's choices may be heavily influenced by having lived in constrained circumstances while growing up, which both influenced her tastes and deprived her of adequate nutritional education. In addition, she may currently lack adequate time, money, or energy to research, buy, and cook nutritious meals. So, while she does not exactly lack the relevant capacities (she could in theory eat better), she cannot be held substantively responsible because she has not had equal opportunities.
However, it is not clear why people must have equal, as opposed to merely sufficient, opportunities to make good choices. Consider again a person who eats in ways that do not provide them with adequate nutrition. We have seen already that one constraint may be time: Elaine, who must work two demanding jobs to get by, lacks the time to cook. But the problem is not that she has less time than, say, a billionaire, Elon, who hires a professional chef and nutritionist. Carl, who has a secure, well-paid job also does not have as much time as Elon does to ensure that his meals are adequately nutritious, and so Carl faces an inequality of sorts compared with Elon. Nonetheless, Carl does not suffer in the same way as Elaine, who has barely any time for personal care. While Carl has less time than some, he still has enough time to cook adequately nutritious food. He could thus be fairly held responsible for choosing not to do so.
One might worry that this approach will tolerate intuitively objectionable disparities. Rather than comparing someone in secure, well-paid employment with a millionaire, we might instead compare them with a person who has barely adequate time to prepare food. Similar points arise for other kinds of health-promoting opportunity. Significant health inequalities seem likely to emerge. Does our analysis imply, counter-intuitively, that these inequalities do not matter because everyone involved has sufficient opportunity to promote their health?
Our answer involves pushing back on precisely what “barely adequate” opportunity means in this context. On reading this phrase, one might naturally imagine a person who struggles greatly to maintain good health yet does manage to do so. After all, one might think, if they successfully achieve good health, they must have had an adequate opportunity, even if it is barely adequate.
We resist this interpretation. The idea of sufficient responsibility, while a threshold concept, is not equivalent to the point at which we may begin to hold people responsible in any sense. The problem with Elaine’s situation is not that she is so constrained as to be entirely free of responsibility but that her degree of responsibility is insufficient to warrant being penalized for her choices. The degree of control which she has over her situation is considerably constrained by other moral obligations, financial needs, and knowledge. She is more responsible for her diet than others are; she may also be sufficiently responsible for certain types of judgement.Footnote 5 Yet she is not sufficiently responsible to be held substantively responsible, in the form of penalties including the expression of blame, for health problems she may incur.
Moreover, the fact that a person achieves good health does not mean that they have adequate opportunity to do so, since this does not take into account what else that individual had to sacrifice. As we outline in section IV.3, there are often good moral, epistemic, and prudential reasons to sacrifice one’s health to some extent. That a person can find the time and money to cook nutritious food does not entail that one has adequate opportunity to do this, since doing so might involve unreasonable sacrifices elsewhere.
Secondly, however, we suggest that even while a sufficientarian approach requires a threshold concept of control, this is compatible with one’s degree of control also making some difference. Crucially, what one’s degree of control makes a difference to is how reasonable it is for you to make particular choices. We regard both Elon and Carl as having adequate time to eat nutritiously; it may nonetheless be true that Carl is more likely than Elon to face situations where it is reasonable for him to sacrifice his health and thus avoid substantive responsibility for resulting health problems. The same is not true for those who fail to have sufficient control, since the idea of sufficient control is that one must be above the threshold to be held substantively responsible. Two people who fail to have sufficient control may have different degrees of control, but this does not mean they should be treated differently from a substantive perspective.
It is difficult to be precise about the level at which one has sufficient control so as to be legitimately held substantively responsible. Nonetheless, we can establish some apparently clear cases. Again, compare the case of the working parent with one of our original cases, Severe Priority. Let us fill in some more details and stipulate that Solomon is fully aware of the dangers of drinking and decides to take the risk simply because he is happy to take chances with his future welfare in order to increase his satisfaction in the present. Clearly, Solomon had ample opportunity to make the right decision, both in terms of internal capacities and external means. As such, it is reasonable to hold him substantively responsible for his decision. Nonetheless, given the dangers of holding a person responsible when they lack sufficient opportunity, the range of cases to which responsibility can be applied as a distributive criterion are, as we discuss in more detail further on, limited to those where patients have refused a clear and accessible opportunity of support to change an unhealthy habit.
However, the fact that the degree of control a person can exercise affects their degree of responsibility and hence the appropriateness of holding them substantively responsible in healthcare does raise a further issue for our initial cases. While we have hypothetically filled in the details of Solomon’s decision to make it clear that he is sufficiently responsible, in the real world this information is unlikely to be readily available. As such, even if it is theoretically permissible to hold people substantively responsible in cases like Moderate Priority and Severe Priority , we should exercise a considerable degree of caution in such cases and a greater degree of caution when patients are at risk of becoming badly off—that is, of falling below the sufficiency threshold.
It may be, then, that in practice, responsibility should play a role only where we can have reasonable belief that patients have sufficient control over their behaviour. One way to ensure this is to look to cases of repeated irresponsibility. Consider an ideal instance of exercising health-related responsibility, where a fully autonomous patient is deliberately and carefully offered a reasonable chance to change behaviour that is causing, exacerbating, or threatening a health burden (Savulescu 2018). Now imagine that a person is repeatedly offered such opportunities and repeatedly fails to take them and so must repeatedly be the subject of costly interventions. Such an individual shows such disregard for the burdens that their care places on others that at some point we can allow their failure to exercise the responsibility of which they are capable to influence their claim to further care. What’s more, the establishment of a pattern of behaviour allows for a reasonable judgement about whether a patient has sufficient control over their behaviour.
It is worth noting that this argument does not require that we abandon the repeatedly imprudent altogether. Rather, it may be that responsibility’s role is in moving people from a first-choice treatment to a less attractive treatment or a longer waiting time. For instance, someone who responds to successive liver transplants by continuing the drinking habit that gave them cirrhosis in the first place may no longer qualify for future transplants, have to wait longer, or only qualify as a candidate if there are no other suitable candidates. But they will still qualify for palliative care. Alternatively, repeated irresponsibility may mark a point at which additional conditions may be legitimately placed on care, such as counselling for alcohol abuse or even taking Naltrexone or Disulfiram, both of which are used as part of treatment for alcoholism. The key point is that a responsibility-sensitive sufficientarian view need not commit us to treat this patient as we would someone who incurred multiple health problems in ways that were not due to the exercise of her responsibility.
A third issue concerns the quality of the reasons for which a person acts. We have already mentioned Tierney’s view that the degree of responsibility a person is subject to depends in part on the quality of their reasons. Tierney mentions two ways in which the quality of a person’s reasons can vary. Reasons can have different moral qualities. For instance, failing to keep to an appointment because you are comforting a friend is less serious than failing to keep an appointment because your favourite film is on TV. Reasons can also have different epistemic qualities. Failing to pick up a friend because you dreamt their flight was cancelled is worse than failing to do so because of misleading information on the airline’s website.
In our view, whether a person’s responsibility should be allowed to impact their condition depends on whether the risk that they take is reasonable. The moral and epistemic qualities of reasons that Tierney raises form two of the three planks that comprise the reasonableness of a risk. The third plank is the prudential quality of a person’s reasons.
An individual’s health is of clear prudential value to them. Health is both constitutively and instrumentally good for you; illness is constitutively and instrumentally bad for you. However, the pursuit of health has opportunity costs: always choosing what will improve your health may reduce your ability to enjoy other things that are good for you. Since health is not the only component of well-being, it is often prudentially reasonable to choose the less healthy of several options when that will improve your well-being overall.
This basic idea can help to explain the common view that it is unfair to penalize people for certain types of choices. For instance, it is unreasonable to penalize someone for eating unhealthily when almost all of their realizable food options are unhealthy. If fresh food is not readily available, accessing it may require an expenditure of time or money that individuals do not have. The decision to eat unhealthily in such a context is therefore prudentially entirely reasonable and thus not one for which anyone could be reasonably penalized.
Similar considerations apply to the moral and epistemic qualities of one’s reasons. A person’s actions might be unreasonable not only because the value of his goal does not prudentially justify the level of risk he puts himself under but also because it does not morally justify the level of risk he puts others under. Solomon and Lynette’s decisions are morally neutral in themselves. But people can sometimes have excellent moral reasons for sacrificing their health. A person who chooses to feed her children rather than herself makes a choice that harms her health. But the quality of her reasons (her wish to care for her children) shows that this is a morally reasonable risk to take.
A person’s pursuit of a worthy goal might be epistemically unreasonably reckless because they have formed relevant beliefs (e.g., about the worthiness of the goal or the efficacy of their chosen means) in epistemically unjustified ways. Solomon could not, for instance, appeal to a belief, even if it were sincere, that significant alcohol consumption would not affect him as it does other people. Given the evidence he has, including warnings from a medical professional, this is not a reasonable belief to hold. Compare this to a person who smoked before it was widely known that smoking caused lung cancer; their belief that they were doing something harmless—perhaps even healthy—is epistemically reasonable.
Attaching penalties to risk without making these distinctions is itself risky. It risks constraining the kinds of good at which people aim in their lives (Savulescu 2002). Taking risks can lead to harm, but it can also lead to much greater good than a life lived entirely cautiously. It is therefore a disadvantage of a healthcare policy if it punishes people for taking reasonable risks. Responsibility-sensitive sufficientarians should therefore, all else being equal, prioritize those who end up badly off due to reasonable risks over those who end up badly off due to unreasonable risks.
The application of the idea of reasonableness to responsibility and justice is not new. The most developed example is Shlomi Segall’s (2009, 20) claim that we should simply define “brute luck” as, roughly, outcomes that “it would have been unreasonable to expect an agent to avoid.” Our notion of reasonable risk is close but different to Segall’s. As Segall says, his own view “shifts the focus of attention from the individual to the society,” because it “asks not whether the individual has acted in a reasonable way, but rather whether it is unreasonable for society to expect the individual to avoid a certain course of action.” Our interest remains in the question of whether the individual has acted with a sufficient degree of reasonableness by showing sufficient care for the quality of the reasons for which they act.
Consider a non-health-related example of Segall’s (2009, 23–24): in his view, it would not be unreasonable for society to expect me to refrain from giving half my money to charity, even though I might do so for morally excellent reasons.Footnote 6 Since his is an egalitarian rather than a sufficientarian view, he suggests that a focus on the quality of an agent’s reasons would generate the absurd conclusion that we should compensate them for their voluntary loss of salary. A focus on what it is reasonable for society to expect does not.
Since ours is a sufficientarian view, it does not have the absurd conclusion that concerns Segall. To translate the example to one relevant to health, if the loss of half my salary resulted in slightly worse health (because I had to, say, give up my personal dietician and trainer), that is of only very weak sufficientarian concern. So even if the purported moral reasonableness of this decision means that it does not qualify as something for which I am responsible, all that would mean is that I should not be discriminated against when competing with other patients with similar, minor reductions in health.