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Personal Responsibility

02/21/08 7:30AM By Bill Schubart
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In healthcare, we do know a few things. We know for example that very few will ever be able to afford on their own all the healthcare they will need during their lifetime. We also know that no government will be able to afford all the healthcare modern knowledge and technology can offer its citizens. The question for us is what is the most equitable and just form of triage? Healthcare access today is determined by who has insurance coverage.

The buzz now is "personal responsibility." That means that if one chooses health-compromising habits like drinking, smoking, drugs, extreme sports, bad diet or any other form of excess, that that "choice" might become a basis of exclusion from coverage.

So it becomes critically important to ensure that we have a common understanding of what constitutes "choice." Choice implies both knowledge and volition. We must not assume that everyone who perpetuates unhealthy behaviors is doing so solely by choice. Were we to assume that, we would have to exclude the majority of the 19 million Americans with Type II diabetes who are either somewhat or grossly overweight from healthcare coverage.

Nora Volkow, the director of the National Institute on Drug Abuse and a leading research scientist, supports the disease definition of addiction. Her extensive research with brain imaging and dopamine levels leads her to the conclusion that addictive behaviors are "a disease of the brain" and that all addictions, whether to drugs, alcohol, tobacco, sex, gambling or even food, are more medically alike than was previously thought. As to the issue of personal responsibility, she has frequently been quoted on the subject. "In all my years of work in this field, I have yet to meet an addict of any sort who has chosen to be an addict." She further states, "The disease of addiction can develop in people despite their best intentions or strength of character."

"Personal responsibility" implies that the addictive individual can simply choose to abstain and presumably should do so to qualify for healthcare. This is an arrogant assumption not supported by medical research. There are genetic, physiological, psychological and social impacts that all contribute to addiction.

How many among us know accomplished, otherwise disciplined individuals who have fought life-long battles against alcohol, smoking, obesity, or drugs? Best estimates of enduring recovery from alcohol and drug addiction is around 20%. Recovery rates for eating disorders are lower and somewhat higher for tobacco. How does the unregulated barrage of media commercials for tobacco, liquor, processed food and drugs play into choice and personal responsibility for children and teens?

Personal responsibility does count. People do make bad choices, but they do not make them in a vacuum that should preclude access to recovery. Addiction treatment itself a part of healthcare.

Triage will be a necessary part of any national healthcare system just as it is in an emergency room. Personal responsibility will be part of the triage ethos. But we must be careful to distinguish between personal responsibility and choice.

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