“Responsibility” is quite a common word in today’s daily life being commonly understood as accountability for one’s own actions. This is also its most ancient and general meaning, only formally defined in the contemporary age, by law, and therefore embracing a legal dimension that still prevails.
It was just recently that the word “responsibility” gained a more precise moral dimension in the two different philosophical approaches of Emmanuel Lévinas and Hans Jonas. By focusing directly on responsibility, these philosophers widened its conceptual horizon from the “did” (primarily legal) to the “ought to be done” (mainly moral). Both perspectives on responsibility enter the realm of bioethics, specifically considered either as environmental ethics (responsibility having more of a social nature and being less controversial) or biomedical ethics (responsibility having more of an individual nature and being more controversial). “Individual responsibility” is currently recognized, together with “autonomy,” as one of the principles of The Universal Declaration on Bioethics and Human Rights (UNESCO (2005) Universal Declaration on Bioethics and Human Rights. http://www.unesco.org/new/en/social-and-human-sciences/themes/bioethics/bioethics-and-human-rights/. Last date of access 22 Oct 2015).
This entry starts by presenting an etymological and conceptual definition of “responsibility,” within a historical and philosophical framework, and proceeds by discussing some different kinds of highly controversial situations arising today in the biomedical field and challenging the boundaries of individual responsibility.
KeywordsBarcelona Declaration Emanuel Lévinas Hans Jonas Legal responsibility Moral responsibility Social responsibility Universal Declaration on Bioethics and Human Rights
“Responsibility” is a word of Latin origin, re+spondere, which literally means to promise a thing in return for something else, to offer or present in return (Cicero 1942, § 101, I.48.212); in a more general signification, it means to answer, reply, or respond. Today, the common meaning of “responsibility” is to be “accountable for one’s own actions,” accountable or answerable for something within one’s initiative, power, control, or management.
The notion of “responsibility,” or the idea the noun expresses today, has a long history. Nevertheless, the word itself is fairly new: although it is possible to find it occasionally from the sixteenth century on (mainly as a trace of character or a quality and therefore presented as an adjective), it was only in the second half of the eighteenth century that it began to appear frequently, mainly (as a noun) in texts of legal and also often of a broad political nature. Indeed, from a historical perspective, “responsibility” firstly assumes a legal meaning, and it will be quite later, already in the second half of the twentieth century, that a more demanding moral meaning will also impose itself at the technical level and by public opinion.
On the Path of Responsibility
One can go back in history to the ancient Greek philosophy, for instance, to Plato (1932, X, 617e) and Aristotle (1983, III, 7, 1113b), and find, under the Greek word aítios, which translates literally to authorship or cause, the same meaning nowadays expressed by the word “responsibility,” that is a direct relation between the agent, as cause, and the outcome of his free action. The same idea prevails throughout the Middle Ages and modernity and is also expressed in contemporaneity by Kant, in his Groundwork for the Metaphysics of Morals (1785), under the word verantworten, that is, “to answer for.” This verb is at the root of the German noun Verantwortlichkeit, that is, “responsibility” (Kant 2002).
This thought of a direct cause between the agent and his/her action is implicitly present throughout the history of philosophy. Nevertheless, to be explicitly defined in the concept of responsibility and in the consequences it entails, it needed a previous systematic and well-developed reflection on liberty, which takes place in the eighteenth and nineteenth centuries, namely, with Kant and Stuart Mill who ground responsibility on liberty. Only liberty can establish a direct cause between the agent and his/her action, the agent and the outcome of his/her action; only liberty can make the agent responsible. Before Kant, under a heterologous moral law (in which the principle of action is exterior to man, such as nature or God), man could only choose between alternatives posed to him (free will); he, himself, could not be the author or the principle (cause) of an action which, in this case, under the agent initiative, would be undetermined (liberty).
In fact, one can even take a step back in the reconstruction of the favorable conditions for the definition of “responsibility” by discovering the need for self-consciousness preceding the exercise of liberty. It is only within the trilogy “conscience,” “liberty,” and “responsibility” that this latter one can be structured and defined: the subject has to be aware of himself/herself as an agent (self-consciousness) and to have the power to act freely (liberty), to also be able to answer for his/her actions (responsibility), and, therefore, to become responsible. A state of self-conscience and the exercise of liberty are requirements sine qua non to one’s acknowledgment of responsibility.
This trilogy was only soundly established by Western philosophy in the eighteenth century, and, at that time, philosophy stayed deeply committed to the complex and major issue of liberty, while the law focused mainly on the sequence “conscience,” “liberty,” and “responsibility.” It was in this context that the law originally defined the concept of “responsibility,” preserving the philosophical tradition and developing it in the realm of a political thought: in the debates about the separation of powers, about representative government, and about movements of political independence that dominated liberal thought at that time.
In a very broad way, there are some main features that legal “responsibility” always expresses and that define it: an obligation, established by law, to answer for a “done act,” caused by the person in question (who is to blame), and to repair any injury it may have caused (imposing penalty measures or sanctions). These features are well translated by the word “accountability” – still the most common meaning for the notion of “responsibility,” and often used synonymously.
From a legal perspective, “responsibility” was always viewed as a consequence of liberty, and the same was true for a philosophical perspective until very recently: for instance, even within existentialism, a philosophy that spread in Europe in the first half of the twentieth century and until the sixties, “conscience” and “liberty” were major concepts, and “responsibility,” although as essential as irrefutable, was always regarded as subordinated to or depending on liberty, that is, a consequence of liberty. This linkage between responsibility and liberty turned the conceptualization of the first possible; at the same time, the subsidiary role of “responsibility” toward liberty dictated its quite narrow definition (that the law preserved), only later widened by philosophy.
This most recent conceptualization of “responsibility” becomes possible due to two simultaneous and convergent aspects: a perspective of a different dynamic between “conscience,” “liberty,” and “responsibility” no longer necessarily viewed as a sequence but also as a triangulation, through which each reality is enhanced by the relation held with the others and the rupture of the subsidiarity from “responsibility” to “liberty,” allowing a direct and privileged look into “responsibility” itself. The relation with conscience is then reinforced, and responsibility widens its concept from what was done, the “did,” to what “ought to be done,” presenting itself as a duty firstly addressed to the individual’s moral conscience. Noncompliance might entail personal remorse and social disapproval but not necessarily a legal action.
Briefly, we can systematize the history of the concept “responsibility” in three different periods. In the first, from ancient philosophy to the Contemporary Age, the notion was recurrent and well known, but the concept was absent. In the second, from the eighteenth century on, the concept of liberty is defined, and responsibility is presented as its unavoidable consequence, also defined within this sequence which dictates its legal dominant dimension. Finally, a third moment is inaugurated by philosophy in the second half of the twentieth century, characterized by a direct attention to responsibility, which is no longer viewed in just a subsidiary role but in itself. This new perspective on responsibility allowed overcoming the narrowness of the legal definition and value responsibility from merely a consequence from liberty (even when unwanted) to a duty on itself as well, thus grounding its moral dimension.
Legal responsibility refers to the “did,” expressing an obligation established by law and demanding repair, that is, foreseeing sanctions and imposing punishments; moral responsibility refers to the “did” but also to “to be done,” expressing a duty valuable in itself, that addresses the individual conscience and might be followed by the feeling of guilt and of remorse but does not necessarily entail a punishment.
Contemporary Approaches to Moral Responsibility
Responsibility is a privileged theme in contemporary philosophy for various reasons, mainly: at the political-legal level, the great development of the liberty movement, through the institutionalization of the Universal Declaration of Human Rights (1948), and the conquest of civil rights by minorities around the world motivated reflection upon other realms of individual and social life, namely, responsibility; within philosophical thought, the acknowledgment that liberty can never be absolute leads to the recognition that the agent is not only an individual but also a member of a community toward which he/she has obligations and should be committed to.
Besides, the expression “ethics of responsibility” only becomes famous in the beginning of the twentieth century, with the social philosopher Max Weber and especially with his work The Profession and Vocation of Politics (Weber 1919). Here, the author establishes a sharp distinction between an “ethics of conviction,” under which the agent chooses the means and ends of his/her actions autonomously (deontological ethics), and an “ethics of responsibility,” under which the agent recognizes himself/herself responsible for the predictable consequences of his/her actions (consequentialist ethics). An ethics of responsibility, which should also help attain the desired consequences in our empirical world, is then presented as the only ethics capable of facing the challenges in a shared world.
In contemporaneity, there are at least two leading philosophers who developed the concept of responsibility beyond its common borders and who ought to be referred: Emmanuel Lévinas and Hans Jonas. Both give priority to “responsibility” in their work and broaden its range from a traditional narrow legal meaning – the outcome of a free agent’s deeds, that is, a responsibility that derives from liberty – to a renewed wide moral meaning – man’s obligation to act according to the other’s needs and/or the self’s power, that is, a responsibility that comes before liberty. The moral concept of responsibility is, therefore, the widest and the most demanding.
Lévinas’ Responsibility: A Response to Human Vulnerability
Emmanuel Lévinas (1906–1995) is a Jewish French philosopher, strongly influenced by the Second World War and the Nazi genocide of the Jews and others. Steered by his cultural and religious roots and lived experience, as well as taking distance from his teacher Martin Heidegger, Lévinas strongly criticizes ontology for leading to the violence of man over humanity throughout the centuries. This traditional dominance of ontology in Western philosophy developed through the self-proclaimed sovereignty of the individual, as if he/she were at the beginning of existence or the origin of significance, an authoritarian attitude over the other.
In Totality and Infinitude : An Essay on Exteriority (Lévinas 1961), the philosopher, developing the phenomenological method, proposes a move beyond ontology, before the self-affirmation of the human being, to reach a primitive stage where human relationships begin, where the other arrives first and where subjectivity constitutes itself within this relationship with the other. This is the stage of ethics, considered first philosophy, defined as a nonviolent relationship.
The original human experience is the face-to-face encounter with the other, who claims the existence of the self, and of the self who arrives later. The other – a “you,” (the neighbor, the brother) and a “he-ness” (the infinitude, God) – presents itself as nudity and expressiveness: nudity, because it is naked from all personal ornaments and cultural forms, being significant without context and expressiveness of the other’s presence, as “epiphany” of the infinite, of the vulnerability of the other in its absolute exposure. The self, before the other who makes him/her to be from its vertical superiority, is subject to the other (in the etymological meaning of the word) and is subordinated and submissive to the other; the self, before the other who inquires him/her from its horizontal vulnerability, is the response to the other.
It is within this relationship that the self constitutes himself/herself through its response to the other’s call, to the other’s vulnerability, as responsibility in the etymological and literal meaning of the word. Vulnerability, or exposure to be wounded, harmed, hurt, and injured, is a universal feature of human beings which grounds ethics as a nonviolent relationship, as responsibility from the self to the other, which is also a gift of himself/herself to the other, totally free, absolutely disinterested, and expecting nothing in return. Responsibility is the ethical response to vulnerability.
For Lévinas, the other comes indeed before the self; hence, relation is prior to subjectivity, ethics precedes ontology, and responsibility, the response to the other, is previous to liberty, to any one’s free decision about himself/herself. Subjectivity is responsibility.
Responsibility is thus indeclinable, because it cannot be refused, and interchangeable, because the subject cannot replace himself/herself, under the risk of losing his/her own identity. Responsibility is also total and infinite as a proportional response to the other, a brother in fraternal humanity, and to the other, the infinite whose trace is in the other’s face. Responsibility is therefore not reciprocal: it is not the self’s response to a compromise with the other, but the way subjectivity is before the other. Responsibility is then also total because it goes beyond what the self does, as the self’s response to the other’s need. In sum, within Levinasian philosophy, moral responsibility acquires a unique and outstanding statute and dimension.
The impact of Lévinas’ new and formally radical concept of responsibility in bioethics has been indirect and mainly achieved through his crucial concept of “vulnerability”: in an authentic relationship, the other presents himself/herself totally exposed (the patient, the human subjects of scientific experimentation), and responsibility is the only ethical response to this extreme vulnerability (responsibility is correlated to vulnerability). Lévinas’ philosophy has inspired theoretical approaches to bioethics as well as writings on clinical and research ethics, mainly through vulnerability as a universal human characteristic and through the recognition of the other’s vulnerability as foundation of morality, demanding a moral response, different according to different authors – care, solicitude, etc. – but always fulfilling responsibility.
Jonas’ Responsibility: A Response to Human Power
Hans Jonas (1903–1993) is a philosopher whose work has widely overcome the restricted circle of philosophy and extended its influence to other domains of knowledge and practice, such as environmental sciences and sociology. Jonas also influenced bioethics in a direct and very significant way at two different levels – environmental and biomedical – in both of which through his reconceptualization of “responsibility” and its assumption as an ethical principle, in The Principle Responsibility . In Search of an Ethics for the Technological Age (1979).
The philosopher starts by focusing his attention on human action, and specifically on technical action, that had always been dismissed from all ethical scrutiny. In fact, since Aristotle’s distinction between “praxis” – or immanent action, which outcome is interior to the agent (Homo sapiens), for instance, he who acts charitably is charitable – and “techné,” or technical action, technical production, which result is the fabrication of a product, an object, exterior to the agent (Homo faber), only the first was recognized as susceptible to moral evaluation. But, in the current technological age, under the growing belief that scientific progress always leads to a greater good and that it has the capacity of self-regulation, this technical production has evolved from a useful mean for human ends, to an end in itself. Even more concerning, the essence of human action has evolved, and the so-called technical production has gained an unprecedentedly strong power, acting no longer just on the surface of things, externally, but also intrinsically, in the natural world and in life itself.
This new human power endangers the ecosystem’s balance and the survival of man as we know him/her. Jonas is referring, for example, to the wild exploitation of nonrenewable natural resources and its damaging impact on the integrity of our planet, manifest, for example, by climate change; at the human level, he is referring to human experimentation and mostly to genetic engineering aiming at human enhancement. This new and overwhelming power recently conquered by man threatens all perishable existence – man, animals, plants, and ecosystems – which can therefore cease to exist. The fear for the living, the knowledge that the best interest of the living is to continue to live, impels men to act in order to preserve life and its intrinsic integrity. It is power that imposes duty, and duty is already an answer, a response to guarantee the preservation of the world’s life and of man on earth.
Responsibility no longer reports just to praxis but also to tecnhé, nor does it confine just to human relationships, at the intersubjective level, but also embraces all living beings and ecosystems, at the environmental level. Hence, responsibility no longer refers just to the “did” but also to the “ought to be done,” to protect and preserve the perishable, nor does it respond just to the present but also to the future, acknowledging that today’s actions can have a huge impact in tomorrow’s world; therefore, responsibility is not only directed toward those who surround us but also to future generations to whom we have the duty to deliver heritage as we received it from our ancestors. And it is this concept of responsibility that Jonas establishes as a principle, that is, a moral obligation.
Hans Jonas widened the concept of responsibility more than everybody else, and it is this reconceptualization of responsibility that influences bioethics directly, although raising different reactions according to the recommended moral action of the particular fields it applies to: when the Jonasian responsibility applies to the environment and compels man to protect all forms of life and their habitats, it is considered pioneering and revolutionary; when it applies to human life and it compels to protect human beings, particularly the most vulnerable, such as the embryo, it is criticized as old-fashioned and conservative, disregardful of women’s rights. Nevertheless, the principle responsibility is the same and coherently applied to both domains: all forms of life want to prevail in their existence, and those who have power also have the duty and the responsibility to protect and preserve them.
In this context, it is understandable that Jonasian responsibility has developed a most significant influence and earned a huge impact in environmental bioethics, especially under today’s common designation of the precautionary principle: responsibility entails that when one cannot correctly evaluate the consequences of one’s action, he/she should refrain from acting.
Nevertheless, the Jonasian responsibility has also influenced biomedical bioethics, especially in two different aspects. The first and most direct one is the consideration of the human genome as a heritage of humanity, proclaimed by The Universal Declaration on the Human Genome and Human Rights, in 1997 (UNESCO 1997). The philosopher, expressing responsibility toward future generations, had long advocated for the preservation of man as he/she is against any attempts of genetic engineering to alter its genome. The second influence, indirect, to which Lévinas has also contributed, is the valorization of responsibility toward the perishable, or the vulnerable, in bioethics. Hence, the introduction of the principle responsibility in the Universal Declaration on Bioethics and Human Rights, in 2005, Article 5 (“Autonomy and individual responsibility”), although under a different definition than the Jonasian one; the Jonasian concept of responsibility toward the vulnerable is introduced in Article 8 (“Respect for human vulnerability and personal integrity”).
(Bio)ethical Controversies in Individual Responsibility
The debate on moral obligations and legal limits of individual responsibility has been constant in bioethics, although often diluted in the discussion of other issues, and mostly under a legal perspective. Only recently was the concept of individual moral responsibility discussed per se in bioethics.
From a Legal to a Moral Perspective
Considered in its legal dimension, as accountability, and within the Anglo-Saxon context, responsibility is a part of bioethics since its origins.
Going back in time, to the birth of bioethics, in the United States, we confirm that it was primordially shaped by law and specifically by court decisions. The Anglo-Saxon legal system, of a jurisprudential nature (case-law based or common law system), contrarily to what happens in Europe (statutory law system), establishes new doctrines out of very particular court decisions. When, throughout the twentieth century, new situations, forged by biotechnological developments, were brought to court, the judge’s rule became paradigmatic for future analogous cases: for example, the sequence Schloendorff v. Society of New York Hospitals (1914), Salgo v. Leland Stanford Jr. University Board of Trustees (1957), Natanson v. Kline (1960), and Canterbury v. Spence (1972) established the doctrine of informed consent in what concerns the need for consent, to disclose information, and sufficient information for an informed consent – which is a legal requirement for invasive therapeutics and methods of diagnosis but mostly a moral obligation for the clinical encounter.
In these situations in which it is the (bio)law that establishes the (bio)ethical rule, responsibility is mainly attributed by the self to the other: those who suffer someone else’s action require legal responsibility from those who did not comply with their obligations toward them.
In continental Europe, as well as in other countries legally ruled by statutory law system, ethical reflection and debate are prior to legal regulations: the law tends to legally establish ethical consensus. This situation favors the establishment of moral responsibility, prior to and broader than legal responsibility. Moral responsibility does not only address the other as a legal requirement but also the self as a moral obligation. Under this perspective, the broad concept of responsibility built by contemporary philosophy, which focuses on the responsibility that belongs to each person, is also included. This can represent a shift on the perception of individual responsibility.
Individual Responsibility as a (bio)Ethical Principle
The specific notion of moral responsibility was only formally introduced in bioethics quite late.
The first major text of bioethics that refers to responsibility, in its moral dimension rather than as legal accountability, is the Barcelona Declaration, in 1998, a European project to define the basic ethical principles in bioethics and biolaw. Responsibility, together with solidarity and justice, is then presented as the framework for the promotion of the four basic principles – autonomy, integrity, dignity, and vulnerability – within a culture of care. These four designated principles are said to be important characterizing features of the terrain, or common ground, for a European bioethical debate. But they are not considered sufficient to guarantee an ethics of care that Europeans are said to share: “care for others and care for the quality of the global environment.” Therefore, “‘autonomy’ (networked with integrity, dignity, and vulnerability) should be placed in the context of care for others – a context that already presupposes an ethics of solidarity, responsibility and justice (fairness)” (Rendtorff and Kemp 2000, pp. 394–395). In turn, responsibility is presented as “responsibility for” and “responsibility to” others, thus revealing its moral dimension and showing that responsibility belongs, indeed, to each person – individual responsibility – and that the others matter.
Later, in 2005, and having the Barcelona Declaration in mind, The Universal Declaration on Bioethics and Human Rights (UNESCO 2005) introduced responsibility as a principle and a fundamental human right, a moral obligation, under the categorization of “social responsibility.” This is said to promote health and social development worldwide – a purpose to be shared by all sectors of society (Article 14).
“Individual responsibility” is also explicitly mentioned, together with autonomy, in Article 5, “Autonomy and individual responsibility,” which reads as follows: “The autonomy of persons to make decisions, while taking responsibility for those decisions and respecting the autonomy of others, is to be respected. For persons who are not capable of exercising autonomy, special measures are to be taken to protect their rights and interests.” This principle establishes responsibility: once more as subsidiary of autonomy/liberty, which corresponds to a narrow meaning of the concept, and, for the first time, as a condition or requirement to respect autonomy, which indicates the valorization of moral responsibility. Furthermore, it is worth noting that this association of responsibility to autonomy represents an important development on the bioethical doctrine of autonomy and also an explicit contribution of the European perspective to bioethics.
Nevertheless, individual moral responsibility remains restricted to the “did” and not yet embracing what “ought to be done.”
Outlining (bio)Ethical Individual Responsibility
After the WMA Declaration of Lisbon on the Rights of the Patient (WMA 1981) and reaffirming the dominant logic that every right gives rise to a corresponding duty, several organizations drew up a set of duties of the patient. These have not been unanimously and formally established so far, signaling the controversy that involves individual responsibility on health promotion. Nevertheless, there is today a clear understanding that patients also have duties or responsibilities to fulfill not only toward health-care professionals – they should be truthful, contributing to the best diagnosis and therapeutics, and they should be respectful, contributing to a trustful relationship – but also toward themselves in what concerns one’s own health protection.
In the same line of reasoning, but at a broader realm, communities and states also started to develop several health education programs for their citizens in order to achieve a higher quality level of public and individual health, as well as to optimize human, technical, and financial resources allocated to healthcare (health rationalization). The democratization of knowledge and dissemination of science, together with the strengthening of individual autonomy and the spread of information and communication technology, among other factors, facilitated the access to health education and likewise responsibility toward the community’s and one self’s health protection and preservation. Individual responsibility on health promotion has to be considered in this context and can be systematically presented at three different levels, which entail successively deeper ethical controversies.
The first level to consider is that of individual responsibility toward public health, which has been growing stronger and expanding to new fields. This responsibility consists of the individual (negative) obligation to avoid causing disease or aggravating harmful conditions or illnesses of public health, which is particularly pertinent regarding infectious or communicable diseases.
The current doctrine is that when an individual’s health condition represents a significant risk (not only to himself/herself but also) to the community, he/she must comply with the medical requirements adequate to the clinical situation, which can include temporary confinement. The Ebola epidemic which, in 2014 and 2015, spread across several African countries and into other continents is a good example, so it is the more common example of a mental disorder originating threats of death, serious injury, or sexual violence to others. In both situations, if the patient does not want or cannot assume individual responsibility of his/her health, he/she will be legally confined until no longer constituting a danger for the others and for himself/herself.
Nevertheless, unlike what happens in the aforementioned examples, this individual moral responsibility to do no harm is not always considered strong enough to have a correspondent legal responsibility. In this context, the most paradigmatic case is surely HIV infection: although a deadly infectious disease during the first decades of its outbreak, there was an absolute respect for individual privacy (complying with the patient’s wishes) to the detriment of public health (even when other’s health was at stake). Another example of a very serious lack of individual responsibility with potential severe impact on public health is the multidrug-resistant tuberculosis patient unwilling to be properly treated, such as homeless patients who have been an ongoing challenge to public health efforts to control tuberculosis.
In all the given examples, there is an indelible individual moral responsibility; if it were consensually recognized, it would be translated into a legal responsibility. This, however, does not always happen, as was just demonstrated.
The second level to consider is that of individual responsibility toward (legally) dependent persons, such as children or elderly persons, that is, persons unable to take decisions about their own safety and well-being and who are cared for by another person, a guardian. This responsibility consists of the individual (negative and positive) obligation to avoid causing disease or aggravating harmful conditions or illnesses to the dependents and to actively contribute to promote the dependents’ health. This level of individual responsibility appears to be quite consensual, but practice suggests otherwise. Putting aside the traditional case of the Jehovah’s Witness when their children need a life-saving blood transfusion, which is today consensually resolved by a temporary withdrawal of parental rights, there are many other complex situations in which consensus is unlikely to be reached anytime soon.
In this context, one of the most complex examples is the unhealthy behavior of a pregnant woman (not only toward herself but also) toward the unborn child. It is scientifically proved that when a pregnant woman takes illegal drugs, drinks alcohol, or smokes, she can cause abnormal fetal development and future health problems to the child. She is morally responsible for the child’s well-being, but the difficulty of establishing adequate measures to legally implement moral responsibility has kept decisions concerning the healthy fetal development to the mother’s discretion. It is worth noting that in the situation of surrogacy, the contracting parents have been legally imposing a healthy lifestyle to the surrogate mother of their child.
Another interesting situation in this context is the parent’s responsibility toward their obese child. The number of obese children has been growing in the Western world, and it is common knowledge that obesity can lead to a number of severe and potentially life-threatening conditions, such as type 2 diabetes, coronary heart diseases, some types of cancer (breast cancer or bowel cancer), strokes, depression, etc. Parents who fail their responsibilities toward their children are very seldom charged as abusive or negligent; most of the time, there is no legal consequence, again, due to the difficulty of establishing adequate legal measures to implement the indelible individual moral responsibility.
The third level to consider is that of individual responsibility toward one’s own health, which remains deeply controversial under a moral perspective, implicitly acknowledged in some specialties of clinical practice, and totally excluded from legal judgment. This responsibility consists of the individual (negative and positive) obligation to avoid causing disease or aggravating harmful conditions or illnesses to oneself, which is particularly pertinent in behavior or environment-related diseases and healthy lifestyles.
In this context the ethical principle of autonomy has ruled alone: each person yields freedom to take decisions concerning his/her own health or life, whenever these do not affect someone else’s or public health. Notwithstanding, an absolute autonomy can be challenged by the principle of social justice mostly when those who take decisions concerning their own health status do not take charge of the entailing financial burden, as what happens in a welfare state. The issue is very controversial because it would have to presuppose a rigorous and objective distinction between genetic, environmental, and behavioral factors in a person’s health condition and would imply an individual responsibility over one’s own health whenever influenced by one’s own free will. This data cannot be completely and accurately identified in all its complex reciprocal interactions.
Nevertheless, there are specific areas of clinical care where patients are, at least indirectly, considered responsible for their own health condition, namely, in what concerns the enrollment for transplantation: an alcoholic cannot be considered for a liver transplantation nor a smoker for heart/lung transplantation. The main argument in these situations is always the lack of guarantees that the received organ shall be well cared for. If the person overcomes the addiction, he/she is not be penalized by former deeds. An extreme example can also be put forward such as a terrorist who assassinates and injures several persons and, being injured himself, is also treated at the hospital at the same time as his/her victims.
The general rule is, thus, that individual moral responsibility for one owns health, although clearly recognized – also through the set of the patient’s duties – has no legal correspondence due to the lack of the most elementary consensus in that regard.
The reluctance in imposing an individual legal responsibility on one owns’ health is understandable for it seems impossible within the framework of autonomy and even of social justice. Therefore, individual moral responsibility toward one’s own and public health must be enhanced through health education.
This entry showed that moral conceptualization of “responsibility,” by contemporary philosophy, broadened it to an unparalleled domain, no longer restricted to the “did” but also embracing the “to be done.”
This concept of individual moral responsibility is implied in ethical evaluations applied to clinical care. Nevertheless, it remains highly controversial in what concerns its legal implementation. Individual legal responsibility can and is implemented and reinforced; individual moral responsibility depends of the person’s autonomy and on the efficiency of health education.
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