An exercise in applications of the salience and representativeness heuristics at CleanMed Europe 2013. I: Responsibility

A few reflections on themes in the CleanMed Europe 2013 conference rendered salient by the heuristics and biases that cut the lens through which I viewed it. Some covered in depth, some conspicuous by their absence; many found regularly hanging around the margins of the presentations and debates, never quite daring to step into the limelight.  

The first of these: responsibility. Responsibility – whether being seized or shirked, assigned or misplaced, was always being talked about. Blair Sadler in the Tuesday evening plenary raised the question of employers’ responsibilities for their workers’ health; on Wednesday morning Dr Hugh Rayner regaled us of being in the bizarre situation of having reduced rates of renal failure in his community – and it being ‘his fault’; a rather pessimistic view reported from focus groups suggested that health professionals confronted with the reality of catastrophic climate changed “desperately wanted someone to handle it” – but assumed it would be someone else; rather more hopeful stories throughout told us of the many ways in which groups of health professionals had taken it upon themselves to act. 

One might rather call this two – albeit interrelated – themes; those of backward responsibility (or, whose fault is it that things are the way they are?) and forward responsibility (whose job is it to sort said things out?). Backward responsibility is predominantly a descriptive notion – let’s say that someone is historically responsible for some state of affairs just in case their actions were causally implicated in bringing about that state of affairs (there’s a lot of unpacking to be done there, but leave it there for now). Forward responsibility, meanwhile, is largely normative, both in the sense that is teleological – it describes a desired end to be achieved (‘sorting things out’) – and deontological – in that it makes achieving that end the particular duty of some agent(s). The two, however, are clearly interwoven; but not, I’d maintain, in the ways the dominant model of responsibility suggests. Rethinking that model is an implicit dimension of the radical transformation needed to achieve a more sustainable future.

 This ‘dominant model’ of responsibility is an individualistic, moralistic, and myopic interpretation of the relationship between backward and forward responsibility. Roughly, it assumes that those backward-responsible for some state of affairs are those whose decisions constitute proximate causes of the state – that is, they occur last in the causal network leading up to that state of affairs (those who, in effect, pull the trigger). Implicit in this assignment is that the causal networks of most states of affairs can be modelled in ways that sensibly identify trigger-pulling individuals. According to this picture, the people who eat hamburgers are responsible for obesity; those who drive cars, buy plane tickets, and eat beef responsible for climate change. This then feeds directly into a model of forward responsibility, what might be called the ‘you-got-yourself-into-this-mess’ approach; those forward-responsible for altering some undesirable state of affairs are then those backward-responsible for creating it. If no one can be identified as being backward-responsible, then market logic kicks in – the assumption of rational self-interested choosers entails that those who stand to benefit most from the change will be responsible for creating it. The end result is that it is obese individuals’ responsibility to deal with obesity, because they got themselves obese in the first place. Smokers, or alcoholics, or drug users, with health problems aren’t owed any health support by the rest of society because they’re the ones who made themselves ill. No one is responsible for dealing with crippling poverty, because after all there’s no one person who made them poor in the first place – but since those in poverty are the ones who benefit from the change, they can surely help themselves. And…well, whose responsibility is it to deal with climate change, or other existential environmental threats?  

This model is ‘dominant’ in several respects. Firstly, and most directly relevant to this context, it dominates public health research and practice funding and thinking – as a comment from the floor in one session noted, health promotion is overwhelmingly conducted within the framework of modifying individual lifestyle choices – largely, it was suggested, because it’s ‘easy’ doing things that way – the research and funding framework is geared towards intervention and measurement at the individual level.¹ Secondly, it adheres to methodological individualism – explaining the occurrence of social and public health problems at the level of individual choices – and is thus reconciled with the economic thinking in political vogue. Thirdly, it underpins a moralistic, just-desserts narrative that has been particularly in evidence since the onset of the financial aspect of our present global crisis – in the rhetoric of strivers versus skivers, the recurrent debates on charging smokers, overweight persons, or IV drug users more for healthcare, indeed in the entire psychological pull of austerity economics.

Through the three days of CleanMed Europe 2013, I saw this model in action several times; I also saw a plethora of counter-arguments to it, and some inspiring attempts to break free of its ideological confines.

So, what exactly are the problems with the model, which admittedly (despite my less-than-symphathetic presentation) has some intuitive appeal. Firstly, and most obviously, its approach to causation. Listening to Hugh Barton and Andy Pratt discuss how the geography of urban development determines car use over active transport, poor diet over healthy and local food choices, and directly impacts on wellbeing, one could scarcely be left in any doubt that the level of individual behaviour is inadequate to explain unsustainable and unhealthy patterns of living. More widely, the abundance of work on the social and ecological determinants of health – from green space to labour conditions – highlights the weaknesses of this methodological individualism.

Secondly, and relatedly, its model of agency. With the fall of the simple, direct and proximate model of causation in favour of an interactive, multifactorial account, the individualistic approach to agency falls too. It is no longer enough to look at individual choosers; the social, political and cultural conditions shaping the choices available to them and they environment in which they choose also come into play. It is only in a health systems environment where success is measured in terms of profit, and profit is achieved by performing as many and as complex health care interventions as possible, that it could make sense to ‘blame’ someone for improving population health through primary prevention in renal failure. That such an environment should be found in a public sector health institution is a salutary warning about NHS culture.

As for this model’s account of forward responsibility, the necessary re-envisioning of backward responsibility is enough to transform such an understanding radically from its usual applications – once we acknowledge that the factors shaping individual choice are perhaps even more important than the choices themselves, the onus shifts – to companies lobbying to prevent clearer food labelling or defend fossil fuel subsidies, to politicians refusing to embody in tax law (or otherwise) the externalities of resource use, to all living in more-industrialised countries whose lifestyles are materially dependent on the systematic exploitation of workers worldwide. 

These are strong conclusions (and public health at its finest), but the moralistic language of misdeed and atonement by which they are reached is, perhaps, an unhelpful manner in which to view them. While there are strong arguments against any kind of normatively-significant tie between backward and forward responsibility (see e.g. Parfit’s On What Matters, and Hannah Pickard on ‘Responsibility without blame’), there are also rather more pragmatic reasons. By entailing a proportionality between backward and forward responsibility, it can predispose to powerful mechanisms for the evasion of responsibility – ‘moral offsetting’ and ‘duty dumping’. The former, a recurrent theme of Dr David Pencheon’s work on sustainable healthcare, refers to the tendency for people to think that, having done some definable good, they’ve therefore done enough good – so the rest is someone else’s problem. The latter is the flip side of this coin – because there are others who may have contributed more to some problem, then the responsibility can be conveniently placed on their shoulders and the rest of us may wash our hands. The problems with these phenomena run deeper than the psychological temptation to underestimate our own responsibility and overestimate others’ (or to overestimate our contributions and underestimate others’); as Buchanan and DeCamp note, sometimes backward responsibility simply cannot be assigned to identifiable individuals in any principled fashion:

Whenever human needs are not fulfilled, this need not be the result of someone‘s failure to fulfill a determinate duty; it could be primarily a failure of collective action. […] the fact that millions of people are dying whose lives could be prolonged by antiretroviral drugs does not necessarily show that any particular party has failed to perform a determinate duty. Instead, it may indicate a deeper failure of many people to undertake collective action to establish the sorts of institutions that make the ascription of determinate duties both morally justifiable and efficacious.²

Moreover, relying on the association between backward and forward responsibility risks missing out on the greatest opportunity for transformative change: sometimes those least (backward-)responsible for problems are best positioned to be (forward-)responsible for them. Privilege can be blinding; as Donna Haraway famously put it, “vision is better from below the platforms of the powerful”. From organised labour’s successes in creating a more just society to the work of the Idle No More movement to safeguard healthier relationships between society and environment than the exploitative neoliberal model, grassroots movements have the capacity to imagine answers inconceivable from within the corridors of power.  

So, in an attempt to return this rant to some semblance of relevance to the original subject: what made the thread of responsibility running through the conference so salient to me? Two observations, illustrative of an answer: one highlighting the limits of the dominant model of responsibility in achieving sustainable transformation; the other, demonstrating the degree to which alternatives are already being embraced.

The first came in one of the plenary sessions, when a group of senior health services personnel were discussing the relationship between employers and employees’ health; the approach suggested was to focus on “what percentage of employees were having that extra hamburger.” Not to ask whether they were being paid a living wage; or whether job stress, job insecurity, or discriminatory employment policies were compromising employees’ health. The latter considerations were not even mentioned, evidence perhaps of the degree to which the dominant model can shape people’s perspectives.

The second, meanwhile, was not a discrete event, but rather an undercurrent present throughout. The respect for, and desire to collaborate with, student and youth movements in all stages of the projects being shaped at the conference was conducted in inspiring fashion: the potential for new perspectives to reshape the conceptual resources used to approach problems of sustainability was embraced, but none sought to abdicate responsibility by putting the burden of action on the next generation. This culminated in Izzy Braithwaite’s tone-perfect reflection on past motivations and call to future action in the final session. Reviewing some of the comments made on Twitter during her presentation, those in attendance found it “inspiring”, “honest”, “challenging” (and many things besides); and judging by the proliferation of suggestions of partnership with Healthy Planet (and the weight of business cards in her pocket), those in attendance intend to act on that inspiration and that challenge.

.1.               Goldberg, D. S. Social Justice, Health Inequalities and Methodological Individualism in US Health Promotion. Public Health Ethics 5, 104–115 (2012).

2.            Buchanan, A. & DeCamp, M. Responsibility for Global Health. Theor. Med. Bioeth. 27, (2006)