Eigenverantwortung als Verteilungskriterium im Gesundheitswesen. Theoretische Grundlagen und praktische Umsetzung

Definition of the problem: Personal responsibility of patients for their own health is often cited as a means of allocating health care resources. It is, however, unclear whether applying responsibility as a distributive criterion is just. Several difficulties are associated with the concept of personal responsibility in the medical field. These include in particular theoretical considerations of justice and practical consequences of using personal responsibility as a criterion for distribution. This article investigates these problems and tries to determine conditions of a fair use of self-responsibility as a criterion for allocation of resources in health care. Arguments - Theoretical considerations: Several theories of a just allocation of resources employ personal responsibility, either as a criterion or as a consequence of allocation. For luck egalitarians, personal responsibility based on free choice is the sole foundation to determine whether persons are entitled to compensation in cases of inequality. In a society structured according to libertarian tenets, personal responsibility is of great importance to large parts of the population. Communitarians value the common good higher than the individual good and regard responsible behaviour to be the individuals' obligation towards their society. In this article the arguments put forward by proponents of the three standpoints are explored and it is concluded that none of these serves as an adequate starting point for a reform of health care allocation in Germany. Arguments - Practical consequences: Problems associated with the use of personal responsibility as a criterion for allocation in health care include causality and freedom of personal health behaviour in medicine, information and health literacy of patients, as well as possible impacts on institutional medicine and the patient-doctor relationship. These problems are examined and the conclusion is drawn that personal responsibility for health should only be used as a criterion for the distribution of resources on the macro-level of allocation in health care. Conclusion: Solidarity, understood as a dual principle of justice, can serve as a justification for employing personal responsibility as a criterion for allocation on the macro-level of health care. In the conclusion of the article, the notion of solidarity is analysed and three possible modes of implementing personal responsibility as a criterion for allocation in a reform of German health care are sketched.