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Abstract

There is an increasing recognition that noncommunicable diseases are overtaking infectious diseases as the world’s leading cause of morbidity and mortality. Many of the major risk factors contributing to noncommunicable diseases are potentially modiﬁable lifestyle factors. Normative controversies persist about governments’ role in protecting people from the adverse consequences of individual lifestyles. Justiﬁcations for interventions involve notions of risk to others, protection of incompetent individuals, risk to self, and justice. Further, lifestyle-induced diseases put strain on public health care, and there is a recurrent debate on the possibility to ration health care based on individual lifestyle information. As long as lifestyle choices are shaped by circumstances, such as social institutions, belief systems, and class orientation, lifestyle rationing should not be unconditionally supported.

Introduction

There is an increasing recognition that noncommunicable diseases (NCDs) are overtaking infectious diseases as the world’s leading cause of morbidity and mortality. Many of the major risk factors contributing to NCDs are potentially modiﬁable lifestyle factors. Controversies persist about governments’ role in protecting people from the adverse consequences of individual lifestyles. Should governments regulate unhealthy consumption and behaviors? Which criteria should be used to justify such interventions? The aggregate consequences of individual lifestyles put strain on the public health care sector. Is it fair that scarce resources are spent on treatment of diseases that, at least to some degree, could have been avoided through individual lifestyle changes? The discussions of such questions depend crucially on how lifestyle is conceived. Do individuals choose lifestyles or is lifestyle a matter of socialization? Who is responsible for a person’s way of living?

This entry provides an overview of some of the controversies in the debate on lifestyles and bioethics. After providing a summary of the history and the development of the term lifestyles, a short review of the global burden of disease associated with unhealthy lifestyles is given. A conceptual clariﬁcation of the term lifestyles follows. The entry then focuses on two ethical dimensions: lifestyles and prevention of disease and lifestyles and priority setting in health care. Lifestyles and bioethics are a broad topic, and the entry can only brieﬂy consider some of its important elements. For greater depth, a few recommendations for further readings are given at the end.

Lifestyles: History And Development

In the ﬁrst half of the twentieth century, Max Weber discussed how individuals’ choices of style of life were formed by their status and class backgrounds. While the individual was seen as free to make lifestyle choices, Weber emphasized how individual thoughts and behaviors were shaped by social intuitions and belief systems. The individual’s life chances, represented by class position, would empower or constrain choices. It was not until the 1960s and 1970s, however, that the meaning of lifestyle as a concept in medical science was explored more systematically. Over time, the concept was deﬁned as an intentional expression of a free choice of the individual, and its collective or structural characteristics were neglected. Responsibility for lifestyles was attributed to the individual, and interventions were designed to target the individual to change his/her harmful health behaviors primarily through information and education (Cockerham 2005).

The individual approach has limited applicability to a world where the aggregate consequences of individual lifestyles both put strain on peoples’ lives and on the public health sector. Disadvantaged groups of the population face greater associated health risks than other groups. The prevalence and the distribution of these risks contribute to health inequalities both within and between populations. As the burden of noncommunicable diseases on society increases, what used to be a private matter concerning choices of lifestyle is now seen as a public concern. More recently, the concept of health lifestyles has again incorporated the dialectical relationship between lifestyle choices and lifestyle chances and has been deﬁned by W.C. Cockerham (2005, p. 55) as “the collective patterns of health-related behaviour based on choices from options available to people according to their life chances.”

Attribution Of Lifestyles To Global Disease Burden

The contribution of different risk factors to disease burden has changed substantially over the last 20 years. There has been a shift away from childhood communicable diseases toward adult noncommunicable diseases, such as cardiovascular diseases, cancers, diabetes, and chronic respiratory diseases. The Global Burden of Disease Study 2010 reported that the major causes of global disease burden were associated with lifestyles (Lim et al. 2012). Among the leading risk factors for disease were high blood pressure, tobacco smoking (including secondhand smoke), and diet low in fruits, alcohol use, high body mass index, and high fasting plasma glucose. The exception from this global trend was sub-Saharan Africa, where childhood underweight and malnutrition were the leading risks in 2010. There were, however, enormous regional variations in risks to health. While the leading risk factor in Eastern Europe, Andean Latin America, and southern sub-Saharan Africa was alcohol use, high blood pressure was the leading risk factor in most of Asia, Latin America, North Africa, the Middle East, and Central Europe. Tobacco smoking remained the leading risk in North America and Western Europe. In Australasia and southern Latin America, high body mass index was the leading risk.

Studies show that unhealthy behaviors are often clustered. The accumulation of tobacco smoking, high alcohol consumption, low levels of leisure time physical activity, and poor diet has been found to increase all-cause mortality about 2.5-fold (Martin-Diener et al. 2014). There is further a growing evidence of the role of midlife health and risk behaviors in healthy aging, and cognitive function and verbal memory among elderly people have been shown to be linearly, negatively associated with the number of unhealthy behaviors in middle age (Kesse-Guyot et al. 2014).

Lifestyles are potentially modiﬁable, and small reductions of population exposure to large risks may yield substantial health gains. Empirical studies show that adherence to multiple healthy factors simultaneously, such as avoiding smoking and hypertension and maintaining a lean body weight, more than triples the probability of survival to oldest-old age (Willcox et al. 2006). Yet, people do not easily adopt a healthy lifestyle. The epidemics of tobacco-related disease and rates of overweight and obesity indicate that making trade-offs between current pleasures of unhealthy consumption or risky behaviors and future health consequences is far from simple. Apparently, there is a wide range of personal, cultural, and socioeconomic determinants that result in individually different capabilities in adhering to healthy lifestyle factors.

Conceptual Issues: Lifestyle Risks, Choice, And Circumstances

Lifestyle risks relate both to substances (e.g., food, alcohol, tobacco, drugs) and behaviors (gambling, driving, extreme sports, and sexual behaviors) and arise because of something the person does or omits. Lifestyle risks occur along a line of abstinence-consumption-abuse-addiction (Planzer and Alemanno 2010).

Consumption of substances or engagement in behaviors may or may not be harmful to health depending on both the quantity absorbed and the degree of exposure. The relationship between consumption and health is complex: Some of the substances may be necessary in moderate quanta (food and prescribed drugs) or at least beneﬁcial (alcohol), some may have secondhand effect upon others when consumed (tobacco), and some may have physically addictive properties (alcohol, tobacco, drugs). Behaviors that may be beneﬁcial in one context may be dangerous in others (driving, sports, and sex).

The positive consequences and the adverse effects of consumption or behavior must be balanced to determine the appropriate point of equilibrium. This balancing is not easy, given that individuals face both internal and external constraints on their choices and their capacity to choose autonomously is limited. Choices are further taken under uncertainty about the consequences.

Internal Limitations On Choice

If an individual is to act rationally, the action must be the best means of realizing the individual’s desire, given his/her beliefs. The individual’s preferences for choice are thought to be stable and well deﬁned. Further, these beliefs must themselves be the best ones, given the evidence that is available. Finally, the amount of evidence collected must be optimal given the importance of the decision and the individual’s beliefs about the costs and beneﬁts of gathering more information. This model of rational decision-making is routinely violated in practice. Cognitive psychology and behavioral economics explain why individuals make inferior decisions in terms of their own welfare with reference to the limitations of people’s ability to make rational choices (Thaler and Sunstein 2008). Bounded rationality theories are developed that take into account that individuals often have incomplete information, limited cognitive abilities, and lack of self-control. In this literature, a number of limitations on rational choice are discussed.

First, individuals may fail to choose what they believe to be the best option given their desires because of weakness of will. They may yield to present-oriented concerns that outweigh the claims of the future (present-bias) or to selﬁsh concerns rather than the claims of other people. A special case of weakness of will is the tendency to let present temptations prevent them from holding consistently to past decisions. Another case is loss aversion or the tendency to be reluctant to give up what they already have because they fear losses. Second, irrational behavior can stem from irrational beliefs, such as the tendency to believe that the facts are as they would like them to be. This pleasure principle describes the mind’s tendency to seek immediate gratiﬁcation. Wishful thinking may also distort their gathering of information, so that evidence is collected only to the point that the preferred belief is supported. This may lead to status quo bias, which is the tendency to not opt out of default options. Another example is framing, which explains how choices in part are dependent on the way in which problems are stated. Third, individuals may overestimate their abilities to act in their best interests. They may be overconﬁdent and may overestimate their immunity from harm. Fourth, people may attach excessive importance to personal experience and current events, at the expense of impersonal sources and past events. They have a tendency to resist change. They do also tend to underestimate clustering in random processes and thus infer incorrectly that there is a pattern. Fifth, peoples’ desires may be irrational. Most people attach some weight to the future but discount the future more heavily that can be justiﬁed on the basis of expected length of life. Individuals may, for example, focus heavily on the present and not engage themselves in long-term planning and lose opportunities in the future. Some people may then adapt and adjust to the opportunity set that now results from downgrading what one cannot get.

Lifestyles are often so integrated into routine behavior that the practices that result seem to be guided by habits rather than deliberation. The complexity and uncertainty of the choice situation regarding expected consequences of lifestyle changes is considerable. Cognitive psychology has identiﬁed how heuristics, rules of thumb, then come to play in decision-making.

In some cases, self-destructive behavior is a sign of addiction. Addiction is the pathological form of consumption or behavior and has been described with reference to the 5C’s: Addiction is “the Continued use of substance or behaviour in spite of adverse Consequences, the continuing being motivated by emotions ranging along the Craving to Compulsion spectrum, resulting in the loss of Control” (Planzer and Alemanno 2010, pp. 337–338).

Circumstances

While an individual approach focuses on understanding and modifying individual-level risk factors, a population approach is occupied with the wider determinants of risk and prevention. Are people compelled to start smoking, overeat, or drink excessively by social-cultural conditions? Does society as a whole bear responsibility for the distributive pattern of unhealthy behaviors? Why are certain populations more likely than the average consumer to make health-threatening decisions?

Preferences for lifestyles do not exist in a vacuum. Multiple levels of inﬂuence on risks and health behavior must be recognized, including individual, family, community, and society level. Choices are situated and at least partly determined by the circumstances understood as the social and cultural context in which the individual ﬁnds him-/herself. Sociological theory points out how social structure exists beyond the individual and gives rise to patterns of behavior. Both socialization and experience form dispositions to act. Individual behavior is shaped by class circumstances, age, gender and ethnicity, collectives, and living conditions and merges into behaviors representative of speciﬁc groups. These structural circumstances interplay with lifestyle choices to constrain or enable an individual’s actions. Health practices constitute patterns of health lifestyles whose reenactment results in their reproduction or modiﬁcation through feedback to individuals’ dispositions to act (Cockerham 2005).

Normative Issues

Society has a responsibility to protect and improve population health. Does this include preventing people from adopting unhealthy behaviors? When can interventions be justiﬁed if they infringe respect for autonomy, including liberty of action? Should individuals be held responsible for health care costs that can in some way be attributed to their own choices of lifestyle? How should these questions be understood in the light of the shift from infectious to chronic diseases as the leading global causes of morbidity and mortality?

The analyses of such questions seem to hinge on two distinct debates, one about governmental interventions, prevention, and paternalism and the other on the role of individual responsibility for health in the context of distributions of scarce health care resources.

Prevention: Governmental Interventions

In democratic societies, the government has a responsibility to protect the public’s health and welfare through the use of regulation, taxation, and expenditure of public funds and to provide public goods such as the social conditions that affect population health. Governments adopt a wide range of measures to regulate individual lifestyle behaviors, such as taxation, laws, regulations, statements, practices, interventions, and campaigns.

Some of these measures are positive, intended to increase the range of opportunities for healthy choice. Regulatory interventions may focus on improving the environment outside of the individual. Although governments are advising people to make healthier choices, their ability to do so hinges on access to an environment that is safe, where healthy foods are available and opportunities for sports and activity, such as playgrounds and bike routes, are given even in poorer neighborhoods. Zoning laws may, for example, be enacted to limit prevalence of fast foods and expand recreational opportunities and opportunities for sports. Other positive measures are tax breaks that may be offered for people who maintain low blood pressure or normal body mass index. Governments may approve smoking cessation programs and medications and cover comprehensive treatments. Fluoridization of drinking water is yet another example.

Other measures focus on information. The assumption is that individuals would prefer a healthy choice over an unhealthy choice if they are provided with information and educated about the consequences for health of consumption or behavior. Individual choice is not restricted by the use of information measures as the individual is free to disregard that information. One example is disclosure rules that may be used to inform the individual of the nutritional content of foods. Other examples are health warnings on tobacco packaging that are used as a strategy to inform the public about the adverse effects of tobacco use and public campaigns for safe sex.

More controversial are negative measures that are intended to limit the range of opportunities for choice by making certain choices more costly in terms of time, trouble, social sanctions, or money. Taxes on unhealthy substances such as tobacco and alcohol to increase the price are widely used, and there are discussions about whether or not to impose higher taxes on calorie-dense, nutrientpoor foods. Direct regulation such as mandatory seat belt and motorcycle helmet laws and prohibition of unhealthy substances (recreational drugs) or risky behaviors (gambling, BASE jumping) are well-known measures. More provocative are food prohibitions. In 2003, Denmark was the ﬁrst country to set an upper limit on the percentage of industrially produced trans-fat in foods. Other examples of negative measures are banning of food advertising intended to shape eating habits of young people or limiting the size of portions served in food service establishments.

Justifications For Interventions

It may be useful to separate between four various kinds of justiﬁcations for interventions: risk to others, protection of incompetent people, risk to self, and justice.

Risk to others: Government regulation of infectious diseases is commonly justiﬁed with reference to the harm principle, “Liberty may be constrained if it is necessary to reduce the imposition of a signiﬁcant risk of harm to others.” Personal freedoms extend only so far as they do not intrude on the health and safety of others. Infectious diseases may be controlled with the use of liberty-limiting measures such as vaccination, physical examination, treatment, and quarantine because infectious disease is a threat to the public’s health. The harm principle is sometimes invoked also in discussions about how to justify governmental interventions aimed at reducing lifestyle risks and lifestyle-induced disease. Consumption and behaviors may have negative externalities that induce costs upon others and society at large, and this argument may be used to justify why personal lifestyle preferences should be overridden. One example is bans on smoking in public places that is justiﬁed by the risks of passive (nonvoluntary) smoking.

Another example is the argument that the aggregate economic effects of unhealthy behaviors, such as overconsumption of foods, warrant interventions. However, the economic burden argument asserts that cost savings are the primary justiﬁcation for public health regulation, rather than avoidance of disease and disability.

Protection of incompetent individuals: A well accepted idea is that governments may intervene to protect the health and safety of those who are incapable to protect their own interests. To make autonomous choices, the individual must have freedom from external control as well as internal capacity for deliberate choice. Insufﬁcient understanding of the choice situation may then warrant intervention. The use of involuntary measures in mental health care is often justiﬁed on this basis, as mental illness is thought to diminish the individuals’ capacity for choice. Decisions are made on behalf of the incompetent, for example, by the use of substituted judgment and/or on the basis of best interests’ standards.

Regulation of lifestyle risks is sometimes justiﬁed by the need to protect incompetent individuals. One example is ban of food advertising targeted at young people. Another example is mandatory HPV vaccine targeted at girls. Human papillomavirus infection is a very common sexually transmitted infection and is associated with cervical, vaginal, and vulvar cancer in women, penis cancers in men, and cancers of the oropharynx and anus in both women and men. The HPV vaccine is found to be safe and prevents HPV infections. Mandatory vaccination is, however, controversial because the virus is sexually transmitted and does not pose immediate risks of transmission through casual contact or air. Viewed as a protection of incompetent individuals, the vaccine may seem easier to justify.

Risk to self: Lifestyle choices appear to primarily affect the individual concerned. Should the government make decisions in the competent individual’s best interests? Some would endorse the Millian argument which claims that the state will impose the wrong values if it attempts to beneﬁt people against their consent, because the individual should herself choose how to rank different values. The state acts paternalistically. Paternalism involves an interference with the liberty or autonomy of the individual subjected to the paternalism, and it does so without the consent of this person. The aim of the interference is to improve the welfare or the interests, values, or good of that person (Dworkin 2010).

In contemporary discussions about paternalism, all the three conditions are contested. What does it mean, for example, that paternalism interferes with autonomy? Respect for autonomy may be understood as to show respect for those choices and preferences that are rooted in the individual’s value system. To fail to do so involves a deep violation of that individual. His/her ﬁrst-order autonomy is disregarded. However, some have argued that autonomy bears on the capacity to reﬂect upon the expressed values themselves (second-order autonomy). The question remains whether interference with ﬁrst-order autonomy counts as paternalistic.

The second condition poses a special problem in the context of public policy formation. How should consent be understood? Policy initiatives will inevitably interfere in the public’s lives whether or not the individual consents to speciﬁc interventions. In democratic societies, public policy interventions may be thought to have the presumed consent of the people. The regulations are the result of democratic mechanisms that reﬂect the will of the people and imply that they are object of public debate. Does this lift the action out of the paternalist category?

The third condition focuses on the intention of the interference rather than the actual consequences of the act. This is not uncontroversial. Further, according to this deﬁnition, interference aimed at some other end than improving good is not a case of paternalism. Public policy initiatives will, however, typically have more than one goal. For example, legislation against smoking in public places may partially be motivated by an appeal to risk to self and partially by an appeal to harm to others. This is an example of what can be denoted impure paternalism (Dworkin 2010).

Paternalism is commonly understood to be soft or hard. Soft paternalism involves interference with a person’s choices where those choices are reasonably believed to be less than voluntary. Hard paternalism involves interference with choices which are known to be voluntary. As such, whether the measures used are coercive or not is irrelevant to the distinction between soft and hard paternalism.

Soft paternalism: Soft paternalism aims at preventing a person from acting upon involuntary or ill-informed decisions. Given that individuals are systematically limited in their capacities to make decisions, state regulation may be necessary to overcome constraints due to imperfect information or lack of knowledge or motivation.

Libertarian paternalism is an approach to policy-making that incorporates this notion into a framework for reforming both public and private sector. The idea is to design policies that nudge individuals toward better choices while leaving their choice set essentially unchanged. In situations where individuals lack clear, stable, and well-ordered preferences , their choices will be strongly inﬂuenced by the details in the context. To overcome such ﬂaws in individual decision-making, libertarian paternalism prescribes educational campaigns, warning labels on tobacco packages, and signs warning people on a hot day to drink water and putting fruits at eye level in cafeterias. A nudge is an intervention that alters behavior in a predictable way without forbidding any options or signiﬁcantly changing their economic incentives (Thaler and Sunstein 2008).

Soft paternalism, such as the use of informational and educational campaigns, is often regarded as uncontroversial. The government seems to be justiﬁed in intervening to inform the public about the consequences of different lifestyles in order to provide opportunities to make knowledgeable choices about lifestyle. Some have argued that rational persuasion respects both individual liberty and autonomy and is, as such, not paternalistic at all. Nudges may, however, interfere with the individual’s autonomy by shaping choices for their own beneﬁt by playing on emotions. One example may be the use of pictures of damaged lungs on tobacco packages. This may, on a comparison of beneﬁts to the loss of autonomy, turn out to be indefensible paternalism (Hausman and Welch 2010).

Hard paternalism: Some people sacriﬁce health in order to further other goals that they may ﬁnd valuable (sedentary life, smoking, high-risk sports). An interference with a competent person’s voluntary and well-informed choice for her own good is called hard paternalism.

Paternalism is criticized for treating people as less than moral equals, because paternalistic interventions denies people the right to chose their own ends. Implicitly, people are thought to be irrational or victims of circumstances if they engage in unhealthy behaviors contrary to their “real” self-interest. Anti-paternalists argue that permitting an individual to decide for him-/herself even if he/she makes unhealthy choices has intrinsic value. Allowing people to make decisions respects the person as an autonomous agent, while coercion undermines dignity.

In 2012, the New York City Board of Health adopted a portion cap rule that aimed to limit the size of sugar-sweetened beverages in food service establishments. The regulation was, however, not found to be viable by the New York Court of Appeals because the board exceeded its authority and engaged in policy-making. However, limiting portion sizes was tried out as an option available to support public health. Some argued that this measure was paternalistic in nature because it restricted people’s choice to improve their health. This ban was not stated to be aimed at the disadvantaged but was still thought to be paternalistic against a speciﬁc group.

Three normative reasons support, however, the view that paternalism is (sometimes) justiﬁable (Dworkin 2010). First, one may appeal to consequentialism and show how more good than harm is produced. Second, one may think that individual second-order or long-term autonomy is advanced by restricting ﬁrst-order and short-term autonomy. Third, paternalism may be justiﬁed on the contractualist basis that all would agree to such interventions given suitable knowledge and motivation. For example, individuals may agree to being required the use of seat belts knowing their disposition to discount the future beneﬁts for present ones.

A more pragmatic approach to justiﬁcation has been given by Childress et al. (2002). They ﬁnd that paternalistic interventions that are nonintrusive and do not threaten individuals’ core values and at the same time probably will protect them against serious risks are justiﬁable.

Justice: Public health initiatives to reduce lifestyle risks may be justiﬁed on grounds of solidarity or justice rather than for an individual’s own good. Questions of how goods and burdens should be allocated within a whole community should be addressed. How should competing claims be assessed, how should an uneven distribution of beneﬁts and costs be justiﬁed, which public health objectives should be pursued, and who should beneﬁt from public health interventions?

Different theories of distributive justice suggest that society should mitigate lack of opportunity to achieve one’s full potentials because of corrigible social conditions. Society should have a special concern for those who experience unnecessary and intolerable disadvantages inﬂicted by current practices of various social institutions. Health risks are not distributed evenly in society, and the disadvantaged groups have been shown to bear a disproportionate health burden associated with lifestyle risks. Social determinants such as poverty, stress, and adverse environment give rise to clustered behaviors (Marmot et al. 2012). Reducing health inequalities is an acknowledged aim in its own right, since a large socioeconomic gradient in health deprives individuals of opportunities for a good life.

The obesity epidemic is an example. An obesogenic environment has been discussed as one of the contributing factors to obesity, describing how fast food, increasing portion sizes, aggressive marketing, lack of ﬁelds for recreation, and violent neighborhoods that discourage outside activity reduce the chances to live a healthy life. This has led to calls for interventions at targeted groups. Then, regulation is no longer paternalistic but rather based on what it takes for a society to be just and what public policies would reduce disease, disability, and premature death (Gostin and Gostin 2009).

A further question is whether or not the fact that systematic patterns of disadvantage and determinants of disease of the disadvantaged involve choices about lifestyle should be taken into consideration. Many contemporary egalitarians believe that an unequal distribution that is not a matter of bad luck for the worst off could be just. This argument is presented in the next section.

Lifestyles And Priority Setting

Health care authorities face difﬁcult priority setting problems due to scarcity of resources. In publicly funded health care systems, there is a recurrent debate on the possibility to ration health care based on individual health behaviors. The reason is that scarce resources are spent on treatment of diseases that, at least to some degree, could have been avoided through individual lifestyle changes (Feiring 2008). Health care expenditure following from NCDs may pose a challenge to the sustainability of public health care. Welfare states depend on ﬁnancial transfers based on solidarity, and lifestyle-induced disease burden may increase the costs of the social welfare.

In England, the NHS integrated the following statement in its constitution of 2012: Please recognise that you can make a signiﬁcant contribution to your own, and your family’s, good health and wellbeing, and take personal responsibility for it. Empirical studies of attitudes toward lifestyle rationing suggest that it is fairly common among doctors to support information about lifestyle to be part of priority setting. Other studies have concluded that policies advocating rationing based on individual responsibility will be unlikely to gain unconditional support among the general public.

The debate on health care resource allocation and rationing includes arguments in favor of the view that governments should provide a criterion for denying treatment to, for according lower priority to, or for requiring a greater ﬁnancial contributions from patients who are seen to be responsible for disease (Voigt 2013). Lifestyle induced diseases may be thought of as self-inﬂicted, and some think that the individual must bear a share of the health care costs related to their health behavior. Some ﬁnd it unfair that those who make imprudent health choices should burden those who make healthy choices. Should individuals be held responsible for health choices, regardless of social circumstances?

The idea that people should be held responsible for their choices may ﬁnd some support in luck egalitarianism theories of distributive justice. Luck egalitarianism holds that the concern of distributive justice is to eliminate so far as possible the impact on peoples’ lives of bad luck that falls on them through no fault or choice of their own. Inequalities generated by the individual’s voluntary choices are, however, acceptable and do not give rise to redistributive claims on others. Different versions of this theory of distributive justice have been developed by R. Dworkin, G.A. Cohen, and R. Arneson, and the implications for health care have recently been analyzed by several authors, such as S. Segall.

Luck egalitarianism is an ideal theory. If lifestyle preferences : are formed under conditions of justice and circumstantial differences in opportunity to choose a healthy lifestyle are neutralized through preventive means, then outcomes that are suitably related to one’s choices (option luck) need not be compensated. This seems to indicate that the individual may be asked to bear the costs of engaging in risky behavior. It would not, however, be reasonable to hold people wholly responsible for outcomes that reﬂect option luck, because disease is only partly caused by lifestyle risk factors. Other factors contributing to disease are factors the individual cannot reasonably avoid the possibility of (brute luck). One central argument is that it seems that when a person has had an opportunity to avoid a certain outcome by choosing appropriately, this fact weakens his/her grounds for rejecting a principle that would make him/her bear the burden of that result. What matters is the value of the opportunity to choose that the person is presented with (the idea of reasonable avoidability of risks).

Further, an individual may be responsible for the outcome of bad option luck. This does not imply, however, that the individual deserves the bad outcome and thus has no claim on society for help. Other values than justice may then come to play. The harshness objection, i.e., that luck egalitarianism commends the abandonment of victims of bad option luck, is not well placed.

The theory is, however, not easily translated to actual health policy recommendations. As long as social and economic inequalities are important determinants for health and risk behaviors are unevenly distributed across the population, it becomes unreasonable to ration health care solely on the basis of lifestyle. Luck egalitarianism prescribes to spilt compensation between people according to which extent they can be held responsible for their choices. But what is to count as choice and what is to count as circumstances? Are lifestyle choices informed and deliberate in the way that ought to be conditions for personal responsibility?

The decision on how to classify persons according to moral responsibility is likewise controversial. Who should make the judgment in order to classify persons according to the degree of their irresponsibility of their lifestyle choices and from which basis? Critics, such as E. Anderson and J. Wolff, have pointed out that the social process of distinguishing the responsible from the irresponsible and deserving from undeserving citizens is inherently disrespectful and unfair to all members of society.

Individual responsibility still may come to play in a forward-looking version. Even if lifestyle rationing is found to be unfair as a backward-looking criterion, the individual may be in a position to improve some of the factors that may reduce expected beneﬁt of outcome. The individual may, for example, be asked to join a program to lose weight, to stop smoking, or to stop drinking. By giving lower priority to patients who are not expected to respond well to treatment due to continuous unhealthy lifestyle, considerations of individual responsibility may be an incentive for behavioral change (Feiring 2008).

Conclusion

Individuals’ abilities to coping rationally with human being’s propensity to behave irrationally are unevenly distributed and a result of a complex mix of genetic factors and social and cultural environmental factors. Individuals do not have stable preferences and lifestyle choices are inﬂuenced by the context in which they make their choice. In complex or uncertain situations, individuals tend to make use of heuristics, i.e., approximate rules that may bias individual choice. Thus, governmental regulation is necessary to safeguard the population from chronic diseases. Lifestyle rationing of health care should, however, not be unconditionally supported.

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