MIT OpenCourseWare http ocw mit edu 24 06J STS 006J Bioethics Spring 2009 For information about citing these materials or our Terms of Use visit http ocw mit edu terms Public Health and Individual Responsibility Session L24 John H Knowles The Responsibility of the Individual Daedalus 106 1977 57 80 Roger Parloff Is Fat the Next Tobacco For Big Food The Supersizing of America is Becoming a Big Headache Fortune 3 February 2003 52 54 Gene Bishop and Amy C Brodkey Personal Responsibility and Physician Responsibility West Virginia s Medicaid Plan New England Journal of Medicine 355 24 August 2006 756 758 Valerie Ulene Let Real Healthcare Reform Begin With Me Los Angeles Times 13 April 2009 on line edition The readings for this lecture pick up on a theme raised by transplants and health care rationing are people responsible for their diseases and implicitly what consequences should this have Knowles emphasizes individual behavior and responsibility Parloff looks specifically at tobacco and food Bishop and Brodkey describe a recent effort to build responsibility into health policy Ulene argues that individuals must take the lead in producing healthier lives As you go through each reading keep the basis questions in mind what causes disease How do answers to these questions affect our understanding of who or what is responsible for disease How do answers to this question then inform public policy Knowles Responsibility of the Individual In the 1970s politicians and doctors became increasingly concerned by the rising costs of health care which consumed 5 9 of the DNP in 1965 and 8 3 in 1975 it is now 16 Not only were costs rising but there was little evidence that all this health care improved health outcomes One person interested in this problem was John Knowles one of the most influential doctors in the US in the 1960s and 1970s Trained as a cardiologist he was the director of Massachusetts General Hospital from 1962 to 1971 where he created both intensive care units and preventive health programs In 1971 he became president of the Rockefeller Foundation a post he held until his untimely death in 1979 aged 52 He wrote this article in 1977 to explain why health care had such a small impact on health and to show what people should be doing to improve health Specifically he argued that individuals need to take more responsibility for their health the idea of a right to health should be replaced by the idea of an individual moral obligation to preserve one s health a public duty p 59 What does he identify as the major causes of disease What sorts of things can individuals do to improve their own health e g pp 61 63 What limited role does he see for genetics and family planning pp 73 74 What in the US conspires against this rational ideal p 75 Is this all really a question of individual responsibility or do governments have the underlying obligation to create situations in which individuals can do the right thing pp 78 80 Read his arguments critically Are you convinced by his arguments Do individuals have a moral obligation to eat well exercise avoid alcohol not smoke and fornicate responsibly Ironically Knowles died of pancreatic cancer a disease can you can do little to prevent or treat Parloff Is Fat the Next Tobacco Until the 1990s tobacco companies defended themselves in lawsuits by arguing that smoking was a choice that people made despite knowledge of the risks Starting in the 1990s however plaintiffs successfully argued that tobacco companies had manipulated the situation to such an extent that they were responsible for the diseases suffered by smokers With that precedent in place plaintiffs and attorney have begun targeting the food industry Is this right In this article Roger Parloff an attorney journalist and senior editor at Fortune takes up these debates What specific claims are made to justify the lawsuits In what ways are the food and tobacco industries different The specific lawsuit against McDonald s was dismissed by a federal judge but similar cases are in process Other than lawsuits what measures might be appropriate to curtail the harms of over eating and junk food Bishop and Brodkey West Virginia s Medicaid Plan The United States government provides healthcare for several groups of people military veterans through the VA Medical System anyone over age 65 through Medicare and the very poor through Medicaid which is then administered through the states As health care costs have continued to rise health care providers and insurers have increasingly sought ways to cut costs As part of the Deficit Reduction Act of 2005 the federal government gave states increased flexibility to customize their Medicaid services e g require co pays when people show up the in ER with non emergent problems West Virginia has proposed the most controversial system it was approved by the federal government in May 2006 In this system most patients will be provided with basic health services However if they sign a Medicaid Member Agreement and achieve various health targets they will be rewarded with additional services e g more elaborate diabetes care smoking cessation programs nutrition education substance use treatment mental health treatment The designers hope that these extra services would provide an incentive to for patients to adopt good health behaviors There have been many concerns about this plan especially the fear that the patients most in need of special services e g those with chronic mental illness will be least likely to adhere to the agreement and thus lose their needed services What concerns do Bishop and Brodkey both physicians from neighboring Pennsylvania have with the plan What makes noncompliance e g failure to follow medical instructions an interesting problem In what ways is the system coercive Should mental health care be a reward for obedient patients or is it as much a right as other forms of health care Ulene Let Real Health Care Reform Begin with Me Ulene a specialist in preventive medicine writes a health blog for the LA Times In this recent piece she picks up the mantle of John Knowles and makes the case for individual responsibility As she describes we spend hundreds of billions of dollars each year treating the consequences of bad lifestyles Where do she and Knowles differ Is she justified in arguing that people who don t change are lazy that they simply don t want it badly enough Are we our own biggest barriers to more healthful living If she is right what