Sunday, November 20, 2016

Public Health Strategies Part 2: Personal Responsibility

In an earlier post I mentioned a few different commonly proposed public health strategies, and how most of them fit quite nicely into the political spectrum characterised by an authoritarian-libertarian axis and a left-right axis.  In this post I’ll discuss the strategy of personal responsibility, which I thought fits nicely into the libertarian right quadrant.  This is because personal responsibility is a key value of the political right, and because personal responsibility is a strategy that maximises individual freedom and ultimately limits the influence of government and others

I discussed in previous posts that I doubt free will exists, and that I believe the absence of free will is not just an academic issue but that it has some very important implications.  One of these is that the absence of free will is a valid argument against morally blaming people for their health behaviours and health outcomes, as these are a product of their genes and environment.  Ultimately, we can’t choose our personality traits such as conscientiousness, the environment that we grow up in, and our genetic susceptibility to health and disease and so shouldn’t be blamed for that

However, there’s also the risk that this line of thinking goes too far in the other direction.  With the absence of free will, it can be tempting to play the victim and blame your genes, your upbringing and the obesogenic environment.  While this has an element of truth, this mindset is ultimately unproductive.  If your health is impairing your quality of life, what good would it do to ruminate in self-pity that your poor health (or other problem) isn’t your fault and not do anything about it.  While playing the victim may yield some sympathy in the short term, the problem won’t go away and will likely get worse until you take active steps to fix it.  In this respect, holding yourself and others personally responsible is more empowering than fatalism and self-pity

While you can’t change your genes, can’t change the past and have a limited ability to change the broader environment, you can change the way you engage with the broader environment and set up your own microenvironment to support good habits.  We all know the basics of what to do to improve our health (that whole foods are on average healthier than highly processed foods and that getting enough exercise and sleep are important) and no one has a gun to our heads forcing us to make the wrong choices.  Ultimately, your health is in your hands

The efficacy of personal responsibility as a public health strategy is difficult to assess.  Some people may argue that it’s the status quo and so is failing as a public health strategy.  However, I don’t think this is completely true

1) Taking personal responsibility for your health isn’t as incentivised as it could be.  Most Western countries have some degree of universal healthcare, health insurance, subsidised pharmaceutical drugs, and government funding into the basic sciences that can lead to drug development.  These policies and institutions mean that individuals and not completely financially responsible for the costs of poor health resulting from poor lifestyle choices, and the financial costs are instead shouldered by others to varying degrees in the form of more taxes, or from funding being taken away from other public services.  Under such conditions it would be expected that individuals would be less motivated to prevent and treat diet and lifestyle diseases themselves by improving their diet and lifestyle

2) Our society’s narrative on ageing and chronic disease is one that emphasises an inevitability of chronic disease and the role of bad luck, rather than personal responsibility.  I think some of this narrative is to protect against blaming and shaming when people are at their most vulnerable, but it has the unintended consequence of fostering a belief that humans are broken and creating a sense of hopelessness

So the potential of personal responsibility as a public health strategy is not likely to be realised in a society that has universal healthcare or health insurance, social norms against personal responsibility (a victimhood vs. dignity culture) and a pessimistic attitude towards ageing and chronic disease.  So the strategy of personal responsibility should be coupled with: (1) the addition of a mechanism in healthcare that incentivises people not getting lifestyle diseases/adopting good health choices (focus of the next post I have planned); and (2) a change in society’s narrative of chronic disease to one that empowers people 

The second point illustrates a weakness with personal responsibility as a public health strategy.  Which is that it requires that people either know or have readily available access to the knowledge that will allow them to make the healthy lifestyle choices that will dramatically reduce their risk of chronic disease or in other cases treat or reverse existing diseases.  Some of this knowledge is already widely known, but most people don’t know about even well supported interventions (such as very low calorie diets for type 2 diabetes and vitamin K2 for osteoporosis) and there will almost certainly be more options available that no one knows yet until more research is done

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