The recent increased prevalence of diseases related to unhealthy lifestyles raises difficulties for healthcare insurance systems traditionally based on the principles of risk-management, solidarity, and selective altruism: since these diseases are, to some extent, predictable and avoidable, patients seem to bear some responsibility for their condition and may not deserve full access to social medical services. Here, we investigate with objective criteria to what extent it is warranted to hold patients responsible for their illness and to sanction them accordingly. We ground our analysis on a series of minimal conditions for ‘practical’ and for ‘moral’ responsibility attribution. By applying these criteria consistently, we highlight that individual responsibility applies to risk-taking life choices rather than stigmatized sickness. We explain that responsibility is a matter of degree, that it varies across life-history, and can be affected by factors beyond the patients’ grasp. We point out that scientific knowledge about the effect of these factors generates responsibilities for other parties such as public health agencies and private industry. The upshot of our analysis is that health policies targeting the ‘liable’ undeserving sick are mostly unwarranted, and tend to increase unequal treatment of already vulnerable groups: the unlucky sick.

As pressures increase to contain growing healthcare expenditures, there is currently a prominent rise in the shift of healthcare costs to patients in the form of deductibles, co-pays, and co-insurance. Rising co-payments are part of a larger picture of increasing overall out-of-pocket healthcare expenditures. From 1990 to 2000, per capita out-of-pocket payments for healthcare reached $707 in the United States, and doubled in several European countries with universal health insurance, reaching $396 in Denmark, $290 in Germany, and $466 in Italy in 2000.The authors thank Dan Brock, Nir Eyal, Alex Rajczi, and Dave Wendler for their invaluable criticism of the manuscript. This study was funded by the National Institutes of Health. The National Institutes of Health was not involved in the design of this study. SAH was partially supported by a grant from the University Hospitals of Geneva. This work was conducted while Dr. Hurst was a fellow in the Department of Clinical Bioethics at the National Institutes of Health. The views expressed here are the authors' own and do not reflect the position of the National Institutes of Health, the Public Health Service, the Department of Health and Human Services, or the University Hospitals of Geneva.

Health care costs have been rising steadily in most industrialized countries. These increases are driven primarily by technological advances and, to a lesser degree, by aging of the population. Many factors make it unlikely that market forces alone will limit increases in the costs of health care. These unremitting increases make health care rationing appear both necessary and inevitable.One of the least controversial mechanisms for rationing could be to allow patients to make their own choices as to which kinds of care they would be willing to forgo. This is appealing because it preserves individual freedom of choice regarding health care in a way that other rationing mechanisms often do not. Rationing by patient choice, however, can only happen if patients recognize that resources are limited and need to be conserved, and are willing to forgo marginal benefits.