Personal responsibility for health

404 Pages·2014·2.65 MB·English

Personal responsibility for
health: meaning, extent and
consequences.

A thesis submitted to the University of Manchester
for the degree of

PhD in Bioethics and Medical
Jurisprudence

in the Faculty of Humanities

2014

Paul Snelling

School of Law
Page 2
Contents

Page
Abstract………………………………………………………………………. 7
Declaration and Copyright statement………………………………………… 8
Acknowledgements………………………………………………………….. 9

PART 1: INTRODUCTION
Chapter Introduction…………………………………………………… 11
1 .
Research questions…………………………………..…… 21
Structure of the thesis………………………………….…. 24
Part I Introductory material………………….… 24
Part II Published papers………………..……….. 27
Part III Conclusion……………………….…….... 31
A note on personal background……………………..……. 31

Chapter Background …………………………………………………… 33
2
Personal responsibility for health: a brief
history…………………………………………………..… 34
The definition and value of health……………………….. 41
Group cause and effect…………………………………… 45
Individual control and choice…………………………….. 46
Patient’s duties …………………………………………... 49
Codes and declarations: the NHS constitution…………… 55
Conclusion……………………………………………….. 59

Chapter Legal context…………………………………………………... 61
3
Legal and moral responsibility…………………………… 62
Autonomy, legal paternalism and criminalisation………... 68
Legal regulation short of criminalisation…………………. 74
The Rampton smokers: A judicial and policy challenge to
Mill………………………………………………………... 78
Lawful consequences of smoking: denying treatment……. 91
Conclusion………………………………………………... 95

Chapter Philosophical Approaches…………………………………….. 97
4
Analytical approach………………………………………. 98
Normative approach: bioethics and public discussion..….. 100
Public discussion (1): moral expertise………..… 101
Public discussion (2): arguments………..……… 103
Rationality as the basis of the philosophical approach…… 105
Deductive arguments: moral theory……………………… 109
Philosophical approach: broad dual level utili tarianism…. 112
Empirical justification…………………………... 113
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Normative justification………………………….. 115
How and what to calculate……………………… 117
Act or rule............................................................. 118
R.M.Hare’s dual level account………………… 120
Inductive arguments: case studies and analogies………… 123
Conclusion……………………………………………….. 128

PART II: PUBLISHED PAPERS
Chapter Saying Something interesting about responsibility for
5 health…………………………………………………………… 131

Abstract…………………………………………………... 131
Introduction………………………………………………. 132
Two concepts, many conceptions………………………… 133
Work required of the concept…………………………….. 135
Concept analysis (1): responsibility in use…….. 135
Concept analysis (2): responsibility as social
function…………………………………………. 139
The philosophical Literature……………………………... 143
Causation………………………………………... 143
Other forms of responsibility…………………… 144
Moral responsibility (1): Strawson and the
reactive attitudes………………………………… 146
Moral responsibility (2): the accountability
version…………………………………………... 150
Applying the framework to the case studies……………... 151
Applying the framework to health policy………………... 152
Moral agency……………………………………. 153
Obligation………………………………………. 156
Holding responsible…………………………….. 159
Conclusion……………………………………………….. 162

Chapter What’s wrong with tombstoning and what dos this tell us
6 about responsibility for health?................................................ 165

Abstract………………………………………………….. 165
Introduction……………………………………………… 166
The case of Sonny Wells………………………………... 167
The moral appraisal of tombstoning……………………... 169
Three moral positions…………………………... 170
Utilitarianism, public health and private morality 172
Acts and rules…………………………………… 175
The maximization of health…………………….. 176
What does this tell us about responsibility for health?....... 177
Epistemic duty…………………………………... 179
Reflective duty (1): harms……………………. 179
Reflective duty (2): benefits…………………... 180
Reflective duty (3): calculations - act or rule?.... 182
R.M.Hare’s dual level account………………… 184
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What to maximize and how………………………….…… 184
Policy implications……………………………………….. 186
Conclusion (1): what’s wrong with tombstoning?............. 190
Conclusion (2): responsibility for health……………..…. 191

Chapter Challenging the moral status of blood donation…………….. 193
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Abstract………………………………………………….. 193
Introduction……………………………………………… 194
Analytical framework……………………………………. 195
Part 1: description………………………………………... 197
The ‘official’ position……………………………. 198
The ‘official’ position: a critique………….…….. 200
Free will or legitimate pressure…………………... 201
A very brief review of the empirical literature…... 202
Part 2: normative…………………………………………. 205
The ‘official’ position: supererogation inferred…. 205
An alternative normative position………………………... 211
The argument from beneficence…………………. 211
The argument from justice: the wrongness of free
riding……………………………………………... 216
Arguments extended……………………………... 220
Advertisements, nudges and a threat to the
framework………………………………………... 222
Conclusion……………………………………………….. 224

Chapter Who can blame whom for what and how in responsibility
8 for health?................................................................................... 229

Abstract………………………………………………….. 229
Introduction………………………………………………. 230
The nature of blame……………………………………… 232
Moral agency……..……………………………………… 238
Holding individuals responsible for their health status….. 240
Methodological and reflective interlude………………… 242
A blameworthy and analogous tombstoning
son………………………………………..…......... 244
The nature of the obligation……………………… 246
The nature of the relationship………………..….. 247
The nature and purpose of blaming behaviour….. 249
Blaming and Health care practice: institutions……….… 251
Blaming and Health care practice: health care
practitioners ……………………………………….…….. 253
Conclusion……………………………………………….. 257

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PART III: CONCLUSION
Chapter Conclusion……………………………………………………... 261
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Summary of the thesis………………………………….... 263
A challenge to current practice: epistemic duty…….…… 265
A challenge to current practice: reflective duty…….…… 269
Impact of the thesis……………………………………… . 273
Nursing Philosophy (journal and activity)………………. . 276
A return to a smoking patient- advocacy and autonomy.. 278
Concluding remarks……………………………………… 281

References…………………………………………………………………… . 283

Appendix (pdf versions of published papers)…………………………...…… 329

Word count: excluding references, including footnotes:8 0,394

Tables

Table 1 Similarities between smoking and tombstoning. 127

Table 2 Costs and benefits of acts of tissue donation . 226-7

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ABSTRACT
The University of Manchester
PhD in Bioethics and Medical Jurisprudence
Paul Charles Snelling
th
24 July 2014

Personal responsibility for health: meaning, extent and consequences.
Like the rest of the western world, the UK faces a significant increase in the
prevalence of diseases associated with lifestyle. Smoking rates have reduced, but
increasing obesity has contributed to alarming increases in diabetes. Discovery of the
correlation between behaviour and poor health has, since the 1970s, resulted in
public health policies emphasising behaviour change, and personal responsibility; an
emphasis that survived later research which demonstrated social, genetic and
psychological determinants on behaviour and health. The latest version of the NHS
constitution exhorts us to ‘recognise that you can make a significant contribution to
your own, and your family’s, good health and wellbeing, and take personal
responsibility for it.’

This thesis seeks to clarify the meaning and extent of personal responsibility for
health, and at its core are four papers published in peer-reviewed journals. The first
clarifies the concept concluding that it is best understood in a tripartite conception of
a moral agent having obligations and being held responsible if he fails to meet them.
The following two papers discuss the nature of the obligations, using utilitarian
reasoning and arguments from analogy. First, an exploration of the moral obligations
for our own health is undertaken via an analysis of the practice of tombstoning,
jumping from height into water. I conclude that the obligations are of process rather
than outcome, consisting of an epistemic duty to determine the health related
consequences of our acts, and a reflective duty to consider these consequences for us
and for those who share our lives. Second, following an examination of the moral
status of blood donation, I conclude that despite its presentation as a praiseworthy
and supererogatory act, it is more properly regarded as a prima facie obligation,
supported by arguments from beneficence and justice.

The final paper discusses the final part of the tripartite conception of personal
responsibility for health: being held responsible. I discuss the nature of blame and
extend the tombstoning analogy as a way of testing my own intuitions in response to
an imagined adult son who has undertaken this dangerous activity. I argue that the
notion of blame is not generally allowed as part of the patient – professional
relationship, and yet without considering blame, the concept of personal
responsibility for health is incomplete. I conclude that if the epistemic and reflective
duties, individually applied, conclude that an obligation is owed, it is owed to those
within personal relationships, and holding people responsible for their health-
effecting behaviour is also best undertaken within these relationships.

I conclude the thesis by considering the implications for professional practice.
Inevitably this leads to consideration of the promotion of personal autonomy in
health care. A more relational account of autonomy is suggested. Facilitating the
epistemic duty so that individuals are better able to understand the risks of their
behaviour requires rethinking of the way that health promoting material and
information are presented.
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DECLARATION

No portion of the work referred to in the thesis has been submitted in support of an
application for another degree or qualification of this or any other university or other
institute of learning;

COPYRIGHT STATEMENT

i. The author of this thesis (including any appendices and/or schedules to this thesis)
owns any copyright in it (the “Copyright”) and s/he has given The University of
Manchester the right to use such Copyright for any administrative, promotional,
educational and/or teaching purposes.

ii. Copies of this thesis, either in full or in extracts, may be made only in accordance
with the regulations of the John Rylands University Library of Manchester. Details
of these regulations may be obtained from the Librarian. This page must form part
of any such copies made.

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intellectual property rights except for the Copyright (the “Intellectual Property
Rights”) and any reproductions of copyright works, for example graphs and tables
(“Reproductions”), which may be described in this thesis, may not be owned by the
author and may be owned by third parties. Such Intellectual Property Rights and
Reproductions cannot and must not be made available for use without the prior
written permission of the owner(s) of the relevant Intellectual Property Rights and/or
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iv. Further information on the conditions under which disclosure, publication and
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Reproductions described in it may take place is available from the Head of School of
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Sciences, for Faculty of Life Sciences’ candidates.

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ACKNOWLEDGMENTS

I was very happy to be part of the second cohort of students in the new PhD
Bioethics and Medical Jurisprudence programme in January 2008 and, as I kept
saying, the only part time student. However, the first four years of my journey was
also, to large extent, theirs, and I valued enormously the friendship and support from
my cohort colleagues, Dr Barry Lyons, Dr Fionnula Gough, Dr Maria de Jesus
Medina-Arellano and Dr Patrick Heavey. Since their successful completions,
opportunities for meeting have been fewer but their success has spurred me on and I
look forward to continued friendship and academic collaboration in the years to
come.

Supervision at Manchester enhanced the model of peer support. Professor Matti
Hayry and Dr Tuija Takala set up the programme and were initially very
encouraging and challenging, as was Dr Becki Bennett who took over as Programme
Director. My supervisory team was subject to some almost seamless changes after
moves. Dr Iain Brassington took over from Dr John Coggon just over half way
through; both were challenging to just the right (for me) extent, diligent, supportive
and patient, understanding that the challenges of studying part time while working
full time result in uneven production. Professor Margot Brazier was simply
inspirational and I’m grateful for her wisdom and tolerance of my legal naivety.
Thanks are also due to other members of the School of Law, especially Dr Charles
Erin. It really has been a pleasure to be associated with the Centre for Ethics and
Social Policy.

I would like also to record my appreciation for funding and some workload
remission to my former employer, the University of the West of England, and my
current employer, the University of Worcester.

Finally, my grateful thanks are due to my family. I’m very sorry that Dad, having
seen and encouraged the start of the PhD is no longer with us to see its completion.
He and Mum, and Iain and Mairi have been very supportive throughout and I’m very
grateful for it. My children Evie and Peter have understood with grace when I have
disappeared into the dining room. It will fall to their generation to sort out the
problems that mine will leave them, and sadly it will be of no comfort or use at all
that this thesis is dedicated to them.

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