Responsibility

It is not original or innovative to describe responsibility as a key concept of today’s healthcare. As we know, responsibility is crucial in the way we think about the causes and nature of diseases, about if someone (or who) is to blame, about the opportunity of preventing diseases, et cetera [10, 16]. Consequently, there is literature at hand which retraces the entire history of responsibility in western thought in general and health care in particular [42, 54]. As this has been done several times, we won’t do this over again.

In our article we focus on the meaning of responsibility itself and what we can learn from it. We explicitly obtain an analysis of responsibility from a view which leaves the binary thinking so remarkably present in today’s health care discourse: freedom versus paternalism, autonomy versus heteronomy, choice versus circumstances, individual versus social, et cetera. This is also the case for responsibility of which the discussion is dominated by the question whether the individual or the community responsibility should be more in favor [20, 25, 31].

The first aim of this study is to open up again the horizon of the use and discussion of responsibility in today’s healthcare. We will take a step back from current approaches to responsibility and concentrate on the diverse meanings of this concept. To do this, we will use a method derived from the work of the French philosopher Michel Foucault, the genealogical method. A genealogical analysis aims to unravel the previous turns and shifts of meaning of the central concepts of a given system of thought, in order to understand what is going on today [6, 17, 29]. Next to that, we will also sketch the etymology of the word responsibility to unravel any forgotten meanings of the word. The genealogy and etymology will enable us to map the semantic context of the notion of responsibility.

Secondly, against a narrow (individualistic) understanding of responsibility, we will develop a new notion of responsibility called ‘co-responsibility’ which avoids the pitfall of this binary thinking. Since the discussion on whether responsibility for health is individual or social goes on for a few decades now [30, 49, 50, 52, 56], maybe it is time to reframe the starting point of this debate in healthcare out of this new concept. We will illustrate this need with the case of so called risk behavior’. If today people are often incapable of making the ‘right’ (healthy) lifestyle choices, maybe the concept of co-responsibility can offer us a way out, as it opens up a non-binary thinking as a new starting point to handle today’s healthcare dilemma’s.

A Short Genealogy

Let us start with a basic, almost banal issue: what do we mean by personal responsibility? As medical ethicist Daniel Wikler has argued a decade ago, the seemingly simple premise that “individuals are responsible for their health” means very different things to different people. Also Meredith Minkler points out that, “depending upon which interpretation of personal responsibility for health is adopted, Wikler notes, one may invoke ethical or even judicial notions of paternalism, general utility, communitarianism, or fairness and compensation to, in turn, inform policy choices regarding health and health promotion and disease prevention” [31].

Evidently, responsibility is a container word which covered and covers a wide range of meanings. As it would ask for a book length study to map all the meanings and references in their historical context, we will mention a few exemplary illustrations. In the late eighteenth century for instance, the literature on hygiene increased and questions about how illness was a state which individuals brought upon themselves, as Thomas Percival wrote in his book Essays medical and experimental on the following subjects […] from 1767 that intemperance of habits can cause diseases [39].

By the beginning of nineteenth century, as Reiser carefully describes, medical and social events produced again an emphasis on individual responsibility for health [42]. However, when the knowledge about the relation between diseases and social conditions increased, not only personal but also society’s responsibility was at the forefront. As Michel Foucault described it in detail in his Birth of the Clinic, the rise of public health systems, clinics and a medical police—‘police’ understood as the originary meaning of the German word ‘Polizei’: survey or control—was the case [18].

This process is also described by Henry Sigerist in his Landmarks in the History of Hygiene [47]. He mentions the second half of nineteenth century as crucial for changing patterns in medical care. Sigerist refers to the collapsed German ambitions to construct a public health program at that time. It collapsed, Sigerist writes, because “the people’s health is the concern of the people themselves. It cannot be dictated from above, cannot be dispensed by means of charity. The people must work for it, must accept the responsibility for health […]” [47].

In general, by the end of nineteenth century, scientific literature and public sphere of industrialized societies were focused at how to stay fit and control of personal health was an important issue. Reiser mentions the Ladies Physiological Institute of Boston and Vicinity, founded in 1848 in the USA, as an example of an institute devoted to instructing women on hygiene and the prevention and cure of disease [42].

By the beginning of nineteenth century, in many industrialized societies, mass examinations of school children, workers or army draftees, laid bare that many people had some physical impairments. Periodic health evaluation was conceived as a necessary means to stimulate people from taking personally care of their health [4].

This only increased during nineteenth and twentieth century and the accent was put on personal hygiene and prevention. To mention only one example: in Belgium for instance, the movement of the so-called ‘hygienists’ was founded in 1877, the Société royale de médecine publique’ ([51], p. 300). The hygienists shared a fear of the spread of diseases due to a lack of hygiene. Consequently, people had to be disciplined and made personally responsible for their own health condition.

In fact, the accent on personal responsibility only increased during twentieth century. By the second half of the century, in particular since the seventies, individual responsibility is considered as crucial for health [40, 45]. As with the rise of medical ethics including rights for individual patients, the reverse side was that this individual had to be made responsible for its health condition, with always an emphasis on personal control and self-sufficiency. Despite this undeniable evolution towards more individual responsibility, in literature, there is no consensus about the time when personal health responsibility was more dominant than others. Minkler for instance, argues that several shifts in the assignment of responsibility for health have been witnessed, emerging in the early 1800s and again toward the end of the 19th century [31].

A major article in this discussion of responsibility in health is ‘The Responsibility of the Individual’ from 1977, written by John Knowles. In this article, Knowles wrote: “The solution to the problems of ill health in modern American society involves individual responsibility, in the first instance, and social responsibility through public legislative and private voluntary efforts, in the second instance” [24]. This being written at that time—the seventies of the twentieth century—is perhaps no coincidence, because during these seventies, a renewed debate over the issue of responsibility for getting ill, was certainly the case, as Reiser points out in ‘Responsibility for Personal Health’ [42].

Of course, it was only in the 1970s when rising health care costs were the case, that the political climate emphasizing individual control and responsibility over health turned into a priority on the health agenda. Wikler confirms this in ‘Personal and Social Responsibility for Health’ and talks about the dominant meaning of responsibility as the “call to attention of both physicians and the public to the importance of lifestyles in maintaining health” [55].

In his historical review of the evolution of personal health responsibility, also Stanley Reiser confirms that despite the diverse meanings personal responsibility had and still has today, a dominant meaning for personal responsibility has been noted throughout our history: the emphasis on personal control and self-sufficiency [40, 42, 44, 53]. On top of that, the shift from a more socialist perspective in the sixties when first of the all the ‘system’ was to blame, to a more liberal focus, results almost naturally into an increasing focus at the individual [7, 11]. consequently, if today in western societies, more and more we are talking about making the individual more responsible for his own health, this is no coincidence.

Generally, since the seventies, the discussion on responsibility has been a binary debate between the advocates of individual responsibility on the one hand and the pleads for social responsibility and the importance of circumstances on the other hand [10, 16, 24, 57]. Although recently, in literature the accent has shifted from personal responsibility towards a more extended notion of shared, social or community responsibility [46], and despite criticisms from Neil Mc Laughlin [26, 27] and others and pleads to stop blaming the patient and his unhealthy behavior, health insurances or organizations do in fact keep on punishing the individual for his lifestyle diseases as if the individual in the only responsible actor in society. Responsibility is a major dilemma in today’s healthcare.

In fact, the increasing focus at responsibility is quite analogous to the focus at lifestyle as a cause of disease [12]. Mainstream healthcare discourse is about facilitating individuals to make their own choices. From the seventies on, as Wikler writes, the dominant idea was by “giving individuals the information they needed, they could protect themselves by adopting healthy habits rather than counting on their doctors to restore health once it was gone. The sense of “responsibility” in this message was that of a duty to oneself, or perhaps that of the reciprocal obligations of partners in the patient-doctor team” [55].

Etymology

To answer our basic question—‘what do we mean by responsibility?’—not only we can fall back upon a genealogy of responsibility to unravel any forgotten meanings of the word; also an etymology of the word responsibility can be an interesting methodological tool in this context. Taking into account the origin of ‘responsibility’, obviously the word stems from Latin. The Latin words ‘respondere’ and ‘res-pondeo’ contain ‘res’ and ‘sponsio’. ‘Res’ stands for thing, matter, while ‘sponsio’ means a religious or judicial engagement—think about the English word ‘spouse’ or the French ‘épouse’ [37]. ‘Respondere’ or ‘spondere’ mean ‘answer to’ or ‘promise in return’; to respond was also part of the Christian liturgy said or sung by the congregation in reply to the priest [2, 5, 23]. A responsory is any psalm, canticle, or other sacred musical work sung responsorially, that is, with a cantor or small group singing verses while the whole choir or congregation respond with a refrain. Traditionally responsories are sung in Gregorian chant.Footnote 1 And finally, a respondant is a defendant, especially in divorce cases and in a more general meaning someone who is capable of fulfilling an obligation or someone accountable.

To respond therefore means to encounter, to answer a promise, to get engaged in something coming from elsewhere; which implies responsibility is always a matter of more than one individual enclosed upon itself. To be responsible is to answer an engagement or an appeal, to be opened towards the outside, towards others and to take part of the world. Dictionaries mention that only from the second half of nineteenth century, responsibility involves obligations or duties as we understand them today [5]. Earlier on, it was a word to express the capability of answering, to get engaged in a social relationship so to say (Fig. 1).

Fig. 1
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Etymology of responsibility

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Far from pointing at an individual action, responsibility in the original sense of the word is already an answer to something outside the individual: a question, an engagement, a relationship. Individual responsibility is so to say an internal contradiction, since to respond to something means not merely to be an individual but to be engaged or to be involved in a social way. As French philosopher Jean-Luc Nancy wrote a few years ago: “The responsible individual is not who responds at but responds to or for” ([37]; my translation). Consequently, to be responsible, is answering a more original act outside myself, to respond an appeal.

In this sense, responsibility is not only a well described duty to what can be foreseen, but also to what is not yet clear to me when I call myself responsible. To say I am responsible for a friend does not mean I can foresee what he will do or ask me. He could for instance get drunk on one night and misbehave in front of me. I cannot anticipate this as such but only to the likelihood this might happen once upon a time. We quote Nancy again: “Responsibility is the anticipated response to questions, demands or interpellations which are not yet formulated or exactly foreseen” ([37]; my translation). To say you are responsible for someone because he is your friend is exactly not weighing the part of his or your duty or responsibility or asking where yours start and his ends, but is simply to be engaged in a friendship.

In conclusion of the quest for the meaning of responsibility, the broad meaning of responsibility uncovered by the etymology contrasts with the the emphasis on personal control and self-sufficiency, the dominant meaning for personal responsibility which has been noted throughout modern health care. Compared to the debate on responsibility in healthcare, obviously, the etymological meaning of responsibility presents us a general idea of being responsible far beyond any calculus in which we obtain to get a grip on the amount of individual or social responsibility for our health. Responsibility is fundamentally to be involved in social relationships, to be in common and never merely to fulfill its obligations or duties.

Co-Responsibility

Since our first aim was to understand all the layers of its meaning and to open up our horizon of thinking, until now we talked about responsibility as a general philosophical concept in the most fundamental way, instead of narrowing it to the field to one or another concrete healthcare practice.

As stated in the introduction, next to that we obtain an analysis of the dilemma of responsibility from a point of view which avoids the binary thinking which is so remarkably present in health care discourse. Instead of rehearsing the discussion in terms of individual versus social responsibility, we therefore want to start from the idea of Jean-Luc Nancy that the individual and the social are intertwined with each other and that responsibility should be understood out of this horizon.

In concrete, we want to explore a broad understanding of responsibility as what we will call ‘co-responsibility’, in analogy with the way philosophers as Martin Heidegger and Jean-Luc Nancy describe human existence as co-existence. If to be responsible is understood as answering a more original act outside myself, to respond an appeal, what can we learn from this idea and what could be the consequences for the debate on responsibility in health care? Can we provide the broad meaning of responsibility discovered in the etymology with substantial philosophical and ethical arguments relevant for the debate on responsibility in health care?

As stated, we refer to two philosophers which offer a philosophical basis for the idea of co-responsibility. First of all the oeuvre of contemporary philosopher Nancy. For Nancy, existing always means co-existing. We are always in-common, he writes at several places in his work [33–36]. There is no existence into the world which does not take place as a co-existence. Being takes place as being-in-common. The in-common is not a substantial space where we either belong or not. It is the primordial co-existential structure in which every form of being together takes place. Being in the world determines us well before we or any community give it meaning.

For this elaboration of co-existence, Nancy leans a great deal upon the ideas of Martin Heidegger. In Being and Time, Heidegger makes it clear that our Dasein or being-there, the ‘there’ of every individual being somewhere in the world, means that no individual can place him- or herself over and against the world. Rather, the world is the horizon to which every individual existence is always and already related [22]. The individual is not a worldless entity but a Dasein that is always already thrown in-the-world, Heidegger emphasizes repeatedly in Being and Time. Being-there is always also being-with.

In a more radical way than Heidegger, Nancy posits a primordial being-with to clearly demonstrate how the self I am thrives only because it is always placed in a situation of plurality, of being-with-many (others) [14, 15]. By existing, Nancy writes, we are revealed as a plurality that is not to be reduced to ourselves, to an otherness that is not separated from us infinitely, but which disrupts and touches every self. It does not imply the end of individual responsibility, but merely that all individual responsibility is a priori exposed to something or someone other than the individual itself.

Since the discussion on whether responsibility for health is individual or social goes on for a few decades now, maybe it be interesting to reframe the starting point of this debate in healthcare out of this horizon of co-existence and co-responsibility. As announced in the introduction, today’s health care discourse is deeply characterized by what we call ‘binary thinking’, thinking starting from concepts which seem to be their opposites: freedom versus paternalism, autonomy versus heteronomy, choice versus circumstances, individual responsibility versus social responsibility. In earlier publications, we contested this binary logic and described it as unfruitful to tackle today’s healthcare dilemmas [12, 13].

As long as we understand these dilemma’s as a binary matter of the individual versus the social, we misarticulate the questions to be posed. It is not a matter of the individual versus the social and how to differ between these two, but rather the other way round: how not to differ them as opposites and how to think them together, as two perspectives being intertwined with each other. Consequently, we prefer to speak of co-responsibility instead of individual versus social responsibility.

Also in the case of responsibility, we therefore explicitly plead for a debate or an analysis from a view which avoids the binary thinking. As a concept, co-responsibility starts from the idea that responsibility is never simply mine or the other’s. It is neither simply a matter of ‘shared responsibility’. ‘Shared’ would only be the next step in the dialectics of a binary logic in which thesis and antithesis have become one, sublated as they would be into a new dialectic synthesis as Friedrich Hegel pointed out: no individual (thesis), social (antithesis) but shared (synthesis) [21]. With ‘co-responsibility’ we are not obtaining a synthesis. The ‘co’ in co-responsibility is not a matter of replacing ‘or … or’ by ‘and … and’, but by mingling these two together. When we talk about responsibility, the ‘co’ is always at stake.

Co-responsibility means that responsibility is never me or the other’s, but the intermingling of the other’s and me, not in the way that they are shared, but that they intrude or contaminate one another. Co-responsibility means that responsibility is divided between several instances or people and that it first of all comes down to understand the social horizon out of which responsibility as co-responsibility pops up.

Despite the obvious difference between the philosophical understanding of this concept and its application within healthcare debates, it is remarkable that responsibility as co-responsibility is also already analogously elaborated in contemporary health literature. In his ‘Just health responsibility’ Harald Schmidt talks about co-responsibility: “Since health is affected both by personal behaviour and factors generally beyond immediate individual control (socioeconomic status, access to healthcare, infrastructural arrangements, etc.), it is neither an exclusive matter of personal or social responsibility. As the element of personal control admits of degrees, conceptually, personal responsibility also needs to admit of degrees. By necessity, health responsibilities are therefore co-responsibilities” [46]. In his article, Schmidt also refers to the fact that the concept of co-responsibility also features in article 1 of the German Social Security Code (SGB V), although in a somewhat different and narrower sense, as responsibility for health is viewed as shared between the healthcare system and patients.Footnote 2

Risk Behavior

Contrary to common sense, to think about a philosophical horizon for healthcare dilemma’s can have the most practical implications, not to mention such questions as: is our taste the result of our personal choices or are there other circumstances to deal with?; do we make every lifestyle-choice—of eating and drinking in particular—autonomously or are there social circumstances which made us choose that particular thing? Let us therefore illustrate the opportunities of the idea of co-responsibility with one particular case, the so-called ‘risk behavior’. When it comes down to risk behavior, again the whole discussion is about autonomy and the responsibility of the individual for its own health [10]. The a priori choice to limit our scope to individual autonomy and responsibility not only narrows in advance the horizon of the discussion, it leads to a debate which necessary will get stuck in its own binary logic: this or that, me or the other. Despite the recent emphasis on community or social responsibility [8], Reiser and others have argued that, since the seventies, the idea is put forward that, since we as individuals are personally responsible for our lifestyle and therefore lifestyle diseases, the consequences of so called ‘risk behavior’ are on our individual account [40, 42].

Since quite a few years, it is popular to relate responsibility or autonomy to the idea of ‘empowerment’, the enhancement of people’s capacities to live their own lives in an autonomous way; translated to the debate we are in: to make them able to be more responsible for themselves [3, 9, 19, 28, 32, 38, 41, 43, 48].

Although this seems to be a logical step in solving the problem of individual responsibility, it runs the risk of misarticulating a problem. If we conceive risk behavior as a deliberate and rational choice of an independent individual, and consequently view responsibility as the result of this, then the answer can only be that the individual is indeed fully responsible for its own behavior. If we for instance drink too much alcohol or ate too much fat and sugar, we chose to do so. But if all behavior is understood as an individual matter, then the question remains why are so many people acting in the same way at the same time and place? Is this really because all of a sudden, one by one, half of the western population quite independently chose to eat and drink too much and/or to no longer have any physical activity? The obviously rhetorical nature of our question indicates that the answer “no” can be taken as a given, and yet the point is nevertheless of crucial importance for the current debate on responsibility in health care.

Conversely, we do not opt for the former “Marxist” thesis by saying that the “system” is responsible for everything. It is not that our choices are determined solely by social circumstances; it is not because our particular social context offers us fewer opportunities for physical activity that we are destined to live our life as obese. It is not a matter of simply shift the responsibility of the individual’s behavior to society, but all the more of understanding why structural givens in society also determine the horizon out of which individual responsibility rises up, which obviously illustrates the need for a notion which facilitates our understanding of this horizon such as ‘co-responsibility’.

Contrary to the notion in the German Social Security Code, co-responsibility as developed in this article is not merely a notion of sharing perspectives, but of perspectives being intertwined. The question is not if the individual or society is responsible; of course, they both are, and another conclusion would be rather banal. Despite the overwhelming amount of research and evidence in quest for an answer to it, the primordial question to be posed is not who is responsible. Much more important is to understand how individuals, despite the fact they are responsible for their own agency, are always also affected by something or someone else which contaminates their efforts to fulfill their duties and obligations.

To put it bluntly: personal responsibility is so important today because it is obvious that the way society is organized, many people are facing a lot of difficulties to live their lives in a responsible way. In western societies for instance, people can eat whatever they want and as much as they want, as long as they have the money for it; and of course, they are personally responsible for their choices. If they live an unhealthy lifestyle, it is strictly speaking their choice and the options obviously seem transparent: you choose for it or not. But what if we formulate this problem in another way: today, it is much easier to live an unhealthy than a healthy life. Up to what level can we hold people personally responsible to live a healthy live while the whole of society is organized to prevent them from this? How many efforts do individuals have to make not to live an unhealthy life, while cheap junk food is everywhere?

From the perspective of co-responsibility, these questions should be put on top of the agenda of the responsibility debate in healthcare, even at the level of the most practical problems people are faced with, for instance: where to find healthy and affordable food and the time to cook it properly, after your daytime job and the kids?; how to resist the overwhelming presence of commercials seducing us all the time to eat the most unhealthy stuff because they are easy to find and often much cheaper than vegetables?; how to find the time and the place to practice sports or doing some physical activity?; et cetera.

Conclusion

Responsibility is not a question of more control and power but of being able to respond future challenges which today are not yet formulated or exactly foreseen. To be responsible is to be able to respond something or someone from outside, and to be responsible is to be co-responsible for the conditions we are faced with. Talking about responsibility therefore is always already talking about the ‘co’.

This change of perspective in the responsibility is urgent. Today more and more, individuals are faced with insurance companies punishing them for their risk behavior, while leaving the conditions out of which individual behavior rises, unquestioned. You can punish obese people for their eating behavior—in industrialized societies, obese often represent more than 20% of the population—or you can ask why today so many people are obese. Are they all irresponsible people, or are they faced with new existential conditions which make it harder for all of us not to become obese?

Consequently, thinking today about responsibility and health is also thinking about the starting point of the debate itself. As we understand it, following Zizek, Badiou and other contemporary philosophers [1, 58], the task of philosophy today is not to offer expert solutions for policy problems, but all the more to ask for the right question and sometimes this implies to reformulate questions in order to clear up the horizon out of which they are used or applied.

Concerning the starting point of the responsibility debate, we need to find new paradigms of thinking the dilemma’s we are faced with. As long as we consider an individual as autonomous and regard the way he lives as largely a matter of his own free choice, it is logical to hold the individual personally responsible for making (un)healthy life style choices, when he obtains insurance or when monitoring entrance to training programs or healthcare facilities. And if this individual is unwilling to change his risky behavior, it would also be logical no longer to obtain him health care services.

In this article, we plead in favor of a broader framework for handling the question of responsibility in healthcare. By narrowing the field of intervention in advance, the fundamental options are too easily taken for granted. The etymology of responsibility has made it clear that there are alternatives to limiting our concept of responsibility to the results of the personal choices made by an individual on its own. To discuss responsibility in healthcare, is to start with co-responsibility, not as conclusion or a magic formula to all problems, but as a new starting point of which we have to explore the opportunities.