Paper to be presented at the Conference

1. Why the notion of ‘responsibility for one's health' fails to direct priority setting in Swedish health care Paper to be presented at the Conference  "Priorities 2010. Priority Setting in Difficult Economic Times" Boston, MA, 24 April 2010 Dr. Werner Schirmer Department of Sociology Uppsala University Prof. Dimitris Michailakis Department of Social Work and Psychology Faculty of Health and Working Life University of Gävle/Sweden

2. 1 Introduction • Ethical Platform: Three Principles for priority-setting as proposed in 1995 • the human dignity principle • the principle of medical need and solidarity • the principle of cost-effectiveness • Evaluations from 2007 showed that these principles failed • they could neither provide guidance to physicians • nor did they contribute to save significant amounts of money • One potential solution suggested: • the notion of responsibility for one's health as a principle for prioritization

3. 1 Introduction • The aim of this paper: • Scrutinizing the responsibility principle • Theoretical framework: • Theory of society by German sociologist Niklas Luhmann

4. 2 Legitimacy If it was for effectiveness only, ascriptive social attributes (sex, age, class, ethnicity etc.) would be a suitable ordering principle for prioritization However, modern society considers them as illegitimate Acceptable candidates for prioritization criteria must comply with modern values such as equality and human dignity

5. 2 Legitimacy

6. 3 Prioritization paradox? The Ethical Platform considers the human dignity principle as unconditional and therefore superior other priority principles This approach seems to be based on a logical contradiction: unconditional equal value of human beings contradicts the very idea of prioritization Setting priorities means selecting someone instead of someone else, thus it means treating supposedly equals as unequals

7. 3 Prioritization paradox? Prioritization criteria have to derive their legitimacy in line with the human dignity principle while factually running counter to the idea of equal human value These criteria have to compete with human dignity – not in terms of legitimacy but of practicality What we, then, are looking for are reasonable exemptions from the human dignity principle

8. 3 Prioritization paradox?

9. 4 Finding reasonable exemptions from the human dignity principle • The criteria proposed in the Swedish debate on prioritization can be sorted into two major groups depending on whether their focus is on • ill/injured human bodies/minds needing treatment • or on a collectivity that has to pay or dispense • In other words, it is either medical rationality or welfare-political rationality that sets the frame for priority principles

10. 5 Cause of the problems from 1995 • Both the observational perspectives and the reference-problems of medicine and politics are incompatible • Medicine • The reference is the (ill/injured) human body/mind • Medical communication centres on diseases, organisms, treatments and healing • Politics • the reference is a collective (e.g. a national population) • Political communication centres on binding decisions and power • It depends on legitimacy and collective support • Therefore, the state is keen on satisfying moral needs such as equality, solidarity, fair allocation of taxes, and provision of services (security, education, infrastructure, or healthcare)

11. 5 Cause of the problems from 1995 Since modern society lacks an "Archimedean" standpoint that can objectively determine what is more important and what is less, medical needs are not per se more important than solidarity and vice versa Medical and welfare-political criteria cannot outrank each other Each can be legitimately rejected on the grounds of the other

12. 5 Cause of the problems from 1995

13. 6 Solution? The responsibility principle A report by The Swedish National Centre for Priority Setting from 2007 suggested reactivating the "responsibility principle" According to this principle, patients are held responsible for their illness if they conduct an unhealthy lifestyle (e.g. wrong diet, physical inactivity, abuse of narcotics) and those who fail to live up to these expectations can legitimately be down-prioritized

14. Unhealthy Lifestyle points out a scientifically established causal relation of people's lifestyle and their health condition Can be treated as an objective fact and allows hypothesis-like statements such as"physical inactivity makes cancer likely"

15. Responsibility for one's health Responsibility presupposes the attribution ofagency: has the patient a choice to act differently, and can thereby be held responsible, or is she just a victim of circumstances beyond her control, and thereby seen non-responsible? For instance expressed by the statement "being not physically active, it is your fault if you become ill with cancer"

17. Scrutinizing the responsibility principle The responsibility principle pretends to be a medical selection but it is a political one In a medical context, individuals are relevant as bodies/minds but not as agents The medical system can establish facts, but is has no conception of responsibility The moment of choice that enables the attribution of responsibility in the causal relation (lifestyle  health outcome) is added by the political system

18. Conclusion The deadlock from 1995 cannot be overcome simply by introducing a principle based on individual responsibility for one's health The connection of responsibility and lifestyle falsely assumes a subordination of medicine under politics Responsibility is a political notion building on the contingent attribution of agency due to current political interests, there is no corresponding concept in medicine (Un)healthy lifestyle assumes causal reasoning about objectively measureable facts and cannot be usurped by political logics Viable solutions have to take seriously that medicine and politics are each autonomous spheres with incompatible rationalities