(1) The document discusses how to prioritize health care resources for those whose illnesses are partly due to their own choices or risky behaviors. It presents the "Potential Value of Opportunities View" which evaluates people based on the potential value of the opportunities available to them rather than just their outcomes. (2) Cappellen and Norheim argue that holding people substantively responsible for their health risks could be unfair, inhumane, or damage the doctor-patient relationship. They propose taxing risky behaviors rather than denying treatment or shifting all costs to patients. (3) However, not all risky behaviors actually increase total lifetime health costs - smoking and obesity may decrease total costs by reducing life expectancy. So

1. Personal Responsibility, the
Burden of Diseases, and Priority-
Setting in Health
Alex Voorhoeve (Philosophy, Logic and
Scientific Method, LSE)
1

2. 2
Core questions:
Should people who suffer harm that is due (in
part) to their own choices have lesser priority in
allocating health care resources?
Or should they ‘bear the costs of their choices’ in
some other way, or not at all?

3. 3
Percentage of QALYs lost due to behaviour in high-
income countries. Total is 57.8% (WHO 2002).

4. 4
Diabetes Case handout.
Many factors:
(a) Behaviour doesn’t lead to guaranteed outcomes; only
to elevated risk.
(b) People’s social and personal circumstances strongly
influence (i) the content of their options; (ii) the
information they have; (iii) their ability to choose well
from a given option set.
In the first part of this lecture, I shall ignore (a) and
discuss Scanlon/Voorhoeve focusing only on (b). I shall
then ‘add in’ (a) in discussing Cappellen and Norheim.

5. 5
Example (Scanlon 1998/Voorhoeve 2008
/Stemplowska 2013/Scanlon 2013):
Hazardous waste case
Inform Everyone
Vivid Warning

6. 6
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
Long,
healthy life.
1. Indoors;
2. Outside.
Not informed.
Severe health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
Severe
health
problems.
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Long, healthy
life.
Walker’s and Curious’ opportunities and outcomes

7. 7
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not
find (2)
tempting.
Long, healthy
life.
1. Indoors;
2. Outside.
Not informed.
Severe health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
Severe
health
problems.
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Long, healthy
life.
Utilitarians disregard opportunities (yellow)

8. 8
The Potential Value of Opportunities View:
(I) When a person is in a position to freely and
competently make an informed choice, we assess her
situation not by the outcome she achieves but by the
potential value of her opportunities. This value depends
on
(I-a) the value of the outcomes she can achieve; and
(I-b) how disposed she is to choose her better options
and avoid her worse options. (I assume these
dispositions are not something for which individual is
to be held responsible).
(II) When someone is not in a position to freely and
competently make an informed choice, we assess her
situation by her outcome alone.

9. 9
Wrt (I-b) Danger of choosing badly even though we are
able to determine and choose the best course of action
(Aristotle, NE 1146b33-1147b19):
(i) Not think things through.
(ii) Deliberate and fail to develop a proper appreciation
of the relevant reasons for action, because
deliberation is clouded by excessive desire:
(ii-a) Talk himself into adopting certain false beliefs. (X-
rated web-viewing at work).
(ii-b) Give the wrong weight to certain considerations.
(Beautiful car.)
(ii-c) Fail to acquire the conviction that correct beliefs
should bring. (Pictures of lung damage.)
(iii) Weakness of will.

10. 10
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not
find (2)
tempting.
Long,
healthy life.
1. Indoors;
2. Outside.
Not
informed.
Severe health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
Severe
health
problems.
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Long, healthy
life.
Information disregarded on the PVO View (yellow)

11. 11
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not
find (2)
tempting.
Severe health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Information used on the PVO View

12. 12
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not
find (2)
tempting.
Severe health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Principles of Evaluation (1)
(1) Each of the
opportunity sets is
more valuable than
the outcome.

13. 13
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not
find (2)
tempting.
Severe health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Principles of Evaluation (2)
(2) Walker’s
opportunities under IE
≥ Curious’ under VW >
Curious’ under IE.

14. 14
Inform Everyone
Opportunities Outcome
Vivid Warning
Opportunities Outcome
Walker * 1. Indoors;
2. Outside.
Informed,
does not
find (2)
tempting.
Severe health
problems.
Curious * 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed;
finds (2)
tempting but
easy to resist.
Principles of Evaluation (3)
Choice: IE, because best
under IE ≥ best under
VW and worst under IE
> worst under VW.

15. 15
In sum, in this case, we give lower priority to
preventing harm that people could have avoided
through their choices than to preventing harm that
they could not so avoid.

16. 16
Inform Everyone
Opportunities Outcome
Low Emissions
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
Long,
healthy life.
1. Indoors;
2. Outside.
Not informed.
Moderate,
temporary
health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
Severe
health
problems.
1. Indoors;
2. Outside.
Informed; (2)
not tempting.
Long, healthy
life.
New Case.

17. 17
Inform Everyone
Opportunities Outcome
Low Emissions
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
Moderate,
temporary
health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed; (2)
not tempting.
Information used in evaluation.

18. 18
Inform Everyone
Opportunities Outcome
Low Emissions
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
Moderate,
temporary
health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed; (2)
not tempting.
Principles of evaluation (4)
(4) Curious’
opportunities under
LE > Walker’s outcome
under LE.

19. 19
Inform Everyone
Opportunities Outcome
Low Emissions
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
Moderate,
temporary
health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
* 1. Indoors;
2. Outside.
Informed; (2)
not tempting.
Principles of evaluation (5)
(5) Best under LE ≥
best under IE.

20. 20
Inform Everyone
Opportunities Outcome
Low Emissions
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
* Moderate,
temporary
health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
1. Indoors;
2. Outside.
Informed; (2)
not tempting.
Principles of evaluation (6)
(6) Worst under LE ≥
worst under IE.

21. 21
Inform Everyone
Opportunities Outcome
Low Emissions
Opportunities Outcome
Walker 1. Indoors;
2. Outside.
Informed,
does not find
(2) tempting.
* Moderate,
temporary
health
problems.
Curious 1. Indoors;
2. Outside.
Informed;
strongly
tempted by
(2).
* 1. Indoors;
2. Outside.
Informed; (2)
not tempting.
Principles of evaluation (7)
(7) Choice by
dominance: LE.

22. 22
Summary
Potential Value of Opportunities View explains:
• common intuitive judgments
by drawing on
• the value of opportunity to avoid harm; and
• the value of being placed in circumstances in which
one is disposed to choose well & the disvalue of
circumstances in which one is disposed to choose badly.

23. 23
2. Cappellen & Norheim
How should patients whose behaviour increases risk of
health conditions be held substantively responsible for
the consequences of their behaviour?
(a) These behaviour are merely risk factors.
(b) Behaviour is influenced by biological and social
factors.

24. 24
Cappellen and Norheim argue that we must
(i) avoid unfairness;
(ii) avoid inhumane treatment;
(iii) avoid corrupting the doctor-patient relationship.
No denial of treatment (except when behaviour change
is required for effectiveness);
No shifting of the entire costs of treatment onto patients
with risky behaviour.
Instead: tax risky behaviours to include social cost.
NOTE: there may be no social cost!

25. 25
“Take obesity: it already costs
our NHS a staggering £4
billion a year. But within four
years, that figure’s expected
to rise to £6.3 billion.” David
Cameron, 16 May 2011.

26. 26
But:
Smoking and obesity reduce the
life expectancy of 20-year-olds by
8 and 5 years respectively and
increase health spending related
to these behaviours, but “total
lifetime health spending was
greatest for healthy-living people,
lowest for smokers, and
intermediate for the obese” (van
Baal et al. 2008).
So the fairest tax may be: NONE.

27. 27
Conclusion
1. Taking account of the potential value of people’s
opportunities can account for:
a. Why we can give lower priority to those who
have come to harm through their own choices;
b. Why people also have a claim to be placed in
good circumstances of choice.
2. In risky cases, we can choose to charge “up front”
(taxes) rather than “after the fact” (treatment costs)
to minimize unfairness; inhumane treatment; and
preserve the doctor-patient relationship.
3. Not all risky behaviour is socially costly!