Personal responsibility is, of course, not a binary construct. When we say unhealthy behavior — overeating, smoking, excessive alcohol use — is not your fault, we may rob people of the initiative to change it. When we say that same behavior is all your fault, we fail to recognize a more complex reality: Health is a product of genes, environment, work, education, family, medical care and many other factors.
Although it seems we should encourage personal responsibility, punishing the opposite may be heavy-handed and even counterproductive. Breaking down every factor that leads patients to develop cancer or heart disease or Alzheimer’s — and penalizing or rewarding them based on the share they could in theory control — seems a herculean and morally suspect task.
Personal responsibility is an attractive goal with deep roots in American culture. But if it’s too aggressively pursued, it may conflict with another worthy ideal: In a nation as wealthy as the United States, sick humans deserve health care — even if they can’t pay, and even if they’ve made some bad choices.
One eye opening experience was when I was climbing (really, walking up) a mountain in Nara, Japan. I kept passing the same guy. He was not quite my height but easily 30KG (about 66 pounds) lighter than me. Crazy hair, wispy beard, and a tan that identified him easily as a laborer.
I would pass him at the end of various legs of the journey. He would be at a waystation, puffing on a cigarette and drinking a Coke while munching down on some junk food. He would effortlessly pass me on each leg with a large bundle strapped to him, not seeming to break a sweat.
I don’t smoke. I don’t drink soda. And I don’t eat junk food.
But no one will convince me the fellow I crossed paths with so many times wasn’t healthier than me.
That health is a tapestry of “genes, environment, work, education, family, medical care, and many other factors” seems right to me.
In another anecdotal example, someone I know with similar habits to my own went on his “grind”, which basically means sudden excercise and dietary change largely focused on removing carbohydrates from his intake. He worked hard on his “grind” for several weeks to achieve a substantial weight loss. He admits the unlikelihood he will be able to maintain his current weight, and he was miserable while working toward it.
So when we talk about personal responsibility with health care, how do these two edge cases fit?
There needs to be an intelligent, nuanced, and scientifically-based discussion on how best to address Western (especially American) health in the immediate, short, and long terms. The current approaches seem inadequate.