What is fair? Responsibility and solidarity in health care
An insurance is purchased in order to cover oneself when taking a risk. In the case of health insurance, the risk taking behavior is the living itself. Health insurance is therefore “thought to protect against medically undesirable consequences of unavoidable hazards, either those presented by nature or those imposed by the toxic environment”. (Wikler, 1987, p. 19) From this ‘luck-egalitarian approach’ most people are prepared to be solidary with the unavoidable, less solidary with the avoidable. Recent polls on our attitude towards non-communicable diseases healthcare suggest that we have become less solidary with people struggling with ‘avoidable diseases’.
Often, their criterion is the avoidability of the disease and the responsibility of the individual, but what exactly is our criterion for judging whether an individual has done enough to protect his health? It is about far more than bad habits (not avoiding), it is about personal contribution. Although at first hand ‘avoidable illness’ sounds unison, but when examining it, things become more blurry: which diseases actually are avoidable and whose choices are really free? To be free is also a question of ‘are the terms of the choice’ fair? If the available alternatives to a healthy choice are less attractive than they can/should be, maybe the terms of the unhealthy choice is unfair. e.g. working in a coal mine: you know it is risky, but sometimes, there is no alternative.
Risk behavior on the other hand such as climbing a mountain may be the result of a deliberate and autonomous choice, while almost no one complains about the costs of mountain climbing to society, contrary to the consequences of eating or smoking. The kinds of behavior which are most commonly singled out in the debate of personal responsibility for health such as eating or drinking habits, are often in a very gray zone. Who for instance is able to distinguish have done something (eating) or not having done enough something else (reduce stress, jogging)?
Dealing with this grey zone, then the question is: what is fair? How and when does responsibility meet fairness? In the end, the future of social health insurance will be about these questions: do we accept the grey zones or opt for a ‘feed-the-meter society’ in which one pays for every failure to maximize contributions to the public good? As Wikler (Wikler, 1987) has demonstrated, the claim that those whose unhealthy lifestyles are placing an unfair burden on others requires, then, a substantive theory of the public and the private; and this theory is unlikely to distinguish unhealthy lifestyles from a host of other habits and actions which we ordinarily permit people to engage in without penalty.