Citizens enjoy broad rights to promote their own values, and health care systems respect this autonomy by granting patients substantial control over decisions regarding medical treatments.

Increased emphasis on informed consent and informed refusal of treatment highlight the clear role of the patient as the ultimate decision maker.^1,2 This autonomy extends beyond the clinical context of informed consent and informed refusal to encompass a wide variety of health-related behaviors; people choose their diet, select which of their medicines to take, elect to continue or quit smoking, and make a multitude of other decisions that have significant impact on their health.

If we recognize personal autonomy in making decisions about health behaviors, we should also hold people responsible for the consequences.

Just as some patients lack the ca­pacity to make treatment decisions, however, several factors can limit the autonomy and responsibility people bear for their health-related behaviors. The best approach, therefore, will assess decision-making capacity, hold people with capacity accountable for their individual health behaviors, and provide an environment that supports and encourages decisions that are health promoting instead of defeating.

Autonomy requires respect for individual treatment decisions, but it must be based on an understanding of the expected benefits, risks, and costs of treatment and on the payer’s willingness to accept responsibility for those costs. The problems with health care utilization and increased costs might also come from the fact that patients and providers are often shielded from the cost of care by the third-party payer system.³

To determine which treatments are worth the costs, both patients and physicians must understand treatment outcomes and costs – and perhaps physicians should involve patients in the cost/value tradeoffs of medical decisions.⁴ If patients share in some part of the cost, they may be prepared to forgo some treatments when the cost/value balance is no longer favorable.

Even with increased awareness of health care costs, patients cannot be expected to bear sole responsibility for their individual health. Their choices are not made in isolation; they are a product of their environment, culture, education, and economic means. Socioeconomic disparities, in particular, highlight limits on an individual’s health behaviors. A review of several studies demonstrates the significant health disparities associated with limited access to produce and other nutritious foods in minority neighborhoods, compared with white neighborhoods.⁵

Another difficulty in assigning personal responsibility is the relationship between behavior and illness. It may seem easy to link diabetes to poor diet or lung cancer to smoking, but in reality many chronic and expensive conditions such as diabetes, cancer, and heart disease are multifactorial; factors beyond an individual’s choices contribute to the development and severity of disease.

The West Virginia Medicaid program offers a two-tiered benefit package for patients qualifying for Medicaid services. The enhanced plan provides expanded prescription coverage, wellness programs, mental health services, and specialty services but is available only to patients who are compliant with medical recommendations, keep appointments, and make healthy lifestyle choices.³

However, limiting access to benefits because of patient behaviors may further increase the disparities already noted. These disincentives do not take into account religious, cultural, or socioeconomic factors.⁶ Patients may not comply with treatment recommendations because of financial or educational barriers, and limiting access to benefits without fully understanding the reasons for patients’ behaviors is not beneficent, nor does it promote justice in health care. In addition, this kind of program may jeopardize honesty in the physician-patient relationship, as patients may be reluctant to admit difficulties in adherence to a plan for fear of losing health benefits.⁶

Implementation of incentive programs must be evidence-based and work to avoid the potential for increased discrimination against vulnerable populations.

The Affordable Care Act (ACA) of 2010 attempts to assign a level of patient responsibility through the individual mandate to purchase health insurance.^7,8 It strives toward a more equal distribution of health care by providing health insurance for many Americans who lack coverage under the current system. Premised on a belief that better access to preventive care results in overall lower health care costs, it works to address, at least in part, the concerns of cost containment by requiring all individuals to carry some form of health insurance.⁸

The ACA may not be the most appropriate compromise, and it may not withstand political pressure or judicial review. But without some kind of health care reform, health care may well become a commodity that none of us can afford.

There must be an acceptance of shared responsibility both for individual health and our national health care system. We must continue to encourage positive health behaviors among our patients, with a wider appreciation for the perspective of justice, as we work together toward defining the new gold standard in compassionate and appropriate care, recognizing duties to act for the benefit of our patients and to serve as responsible stewards of the health care resources entrusted to us.

References

1. Rodwin, Marc A. Patient accountability and quality of care: Lessons from medical consumerism and the patients’ rights, women’s health and disability rights movements. Am. J. Law Med. 1994; 20(1-2):147-67.
2. Buyx AM. Personal responsibility for health as a rationing criterion: Why we don’t like it and why maybe we should. J. Med. Ethics 2008;34:871-4.
3. Steinbrook, Robert. Imposing personal responsibility for health. N. Engl. J. Med. 2006;355:753-6.
4. Morreim, Haavi E. Redefining quality by reassigning responsibility. Am. J. Law Med. 1994;20(1-2):79-104.
5. Larson N, Story MT, Nelson MC. Neighborhood environments: Disparities in access to healthy foods in the U.S. Am. J. Prev. Med. 2009;36(1):74-81.
6. American College of Physicians. Ethical Considerations for the Use of Patient Incentives to Promote Personal Responsibility for Health: West Virginia Medicaid and Beyond. Philadelphia: American College of Physicians; 2010: Position Paper (www.acponline.org/running_practice/ethics/issues/policy/personal_incentives.pdf). Accessed 10 March 2012.
7. Gostin, Lawrence. The National Individual Health Insurance Mandate: Ethics and the Constitution. Hastings Center Report 2010;40(5):8-9.
8. Blake, Valarie. American Medical Association Policy – The Individual Mandate and Individual Responsibility. Virtual Mentor: American Medical Association Journal of Ethics. November 2011;13(11):799-802.

Dr. Bolton is an attending physician for the Advocate Christ Medical Center Emergency Medicine Residency and a member of the ACEP Ethics Committee. Dr. Walters is an emergency medicine resident physician at Christiana Care Health System and a member of the ACEP Ethics Committee.