Accountability for an unhealthy lifestyle

The goal of public health is to “prevent disease, promote health, and prolong life among the population as a whole” (WHO). Limited resources oblige to prioritize between competing health technologies or patient populations [28].

Personal responsibility for self-inflicted health problems is being debated publicly [29]. It is argued that the right to life includes obligations of the person the life belongs to; hence suicide or euthanasia or self-mutilation are often forbidden by law, and so should life-threatening habits. However, a person may legally eat, smoke or drug him or herself to death.

Not only is health care expenditure mainly due to self-inflicted and preventable conditions, it has considerable hidden related social costs: adequate housing, transport, social assistance, dependents and caretakers. Social effort, empathy-promoted as a duty to care for the sick, the old and the disabled, is a long-standing tradition in our societies [30]. But does a persistently self-harming citizen merit society’s empathy?

Self-harm may be active, passive, sought or imposed. An example of imposed self-harm is child vaccination. An unvaccinated child is unprotected and may suffer and transmit diseases. Moral conflicts abound: is a physician legitimized to not see a patient if he or she will not change their self-harming behavior? [31]. Can parents be held responsible for imposing self-harm on their child? As mentioned, the debate not only needs to categorize self-harm, but also the deciding competence over lifestyle decisions.

Governments and health care authorities inform citizenry on health conditions resulting from lifestyle. Project HOPE is quantifying the considerable differences in life expectancy and disability years between healthy and unhealthy lifestyles [32]. However, lifestyle may be involuntary. Health problems resulting from the “lifestyle” of a child living in a heavily contaminated or insecure or famine area, as denounced by the International Labour Office (ILO) in the Global Estimates of Child Labour 2017 or the Maplecroft Child Labour Index 2019 [33, 34] are beyond their control.

There are many grey areas. Mental conditions reduce accountability. It can be argued that personal life choices and lifestyle are inherent results of a society model and that, by education, social instinct, or the need to fit in, a person may decide to embrace a “socially correct” but unhealthy lifestyle. Thus lifestyle choices are linked to education, income, race, gender and religion, and not necessarily free choices. Nevertheless, society needs citizens to be accountable for their actions. The consequence of an unhealthy lifestyle may be a reduction of rights to health care but only if the person did understand the hazards, had valid and accessible alternatives, and was not coerced.

A legally relevant lifestyle choice and corresponding responsibility has personal causal conditions, including behavioral characteristics, personal relationships, and personality [9]. When a person adopts a hypercaloric diet, becomes overweight and develops a severe cardiac condition, that person’s accountability for the ensuing cost of a heart transplant needs to be considered. Smoking, physical inactivity, heavy alcohol intake, and obesity are risks, measured with the EuroQol five-dimensional questionnaire (EQ-5D), confirming shorter life expectancy (up to 12.9 years), and substantially less Quality-Adjusted Life Expectancy (QALE) (up to 10.9 years).[35]. To determine accountability, a “responsibility grading system” could define consequences of lifestyle. However, whatever the grade of responsibility, the person’s need for health care persists, and limitations will conflict with human rights as commented above.

The WHO indicates that 60% of factors determining individual health and quality of life are correlated with lifestyle. Endogenous causal factors are elusive but relevant for a to-be-established accountability. Even when persons are not accountable, perceptions of blame are quite common [9, p.1167]. The impact of accountability on health care expenditure and human rights needs further study, but initial data are challenging. Two examples of actual conflicts:

– A voluntary unhealthy lifestyle relates to dementia, irrespective of genetic risk (hazard ratio 2.83, = 196,383) [36]. In 2015, 5-year dementia care averaged $287,038, compared to $175,136 for heart disease and $173,383 for cancer. Such financial consequences for patient and family cause problems. In the US, Medicare may pay dementia care up to 100 days. Private providers have similar limits. Universal health care systems provide incomplete care, affecting poorer populations [37] that are less susceptible to change of lifestyle [38]. Accountability for self-inflicted health problems would violate human rights here.

– An involuntary unhealthy lifestyle relates to the cost of being born. A NHS analysis found that infants, born to women exposed to high levels of air pollution in the week prior to delivery, were more likely to be admitted to a newborn intensive care unit (NICU) [39]. In the US, NICU costs up to $10,000 per day per child and comprehensive providers do not cover all expenses. NICU and related expenses could exceed $2 million (sic) as evidenced by some published cases [40]. Involuntary unhealthy lifestyle may annul human rights.

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