Schmidt, Harald
(2012)
Just health responsibility: a comparative analysis focussing on the role of individual behaviour in relation to cancer and weight-control policy in German and US health care systems.
PhD thesis, London School of Economics and Political Science.
Abstract
This thesis seeks to examine the appropriate role of individual behaviour and
responsibility in relation to cancer and weight-control policy in German and US
health care systems. It contains six main parts.
The first describes and compares the ways in which personal responsibility
features in law and policy in both countries. It analyses salient differences in
underlying motivation and characterization and highlights ethical tensions that arise
from these provisions and their implementation.
The second part reviews what established normative theories can do to address
the issues that have been identified. It argues that these frameworks lack specificity
and are ill-suited as a basis for policy in pluralist societies. It provides an analysis of
different notions of the concept of personal responsibility, and makes a proposal for
an overarching framework, adopting a procedural justice account that draws on work
by Norman Daniels, Jim Sabin and Thomas Scanlon.
The third part systematically reviews survey literature on the proper role of
personal responsibility and develops an instrument for semi-structured interviews
with physicians and population-level surveys in the US and Germany. The
instrument complements this earlier survey work and explores key themes that arose
in the analysis of policy documents and the philosophical literature.
Based on this instrument, the fourth part analyses the findings from twenty
semi-structured interviews with primary care physicians and oncologists in Berlin,
Germany and Philadelphia, USA.
The fifth part presents findings from three population level surveys of 1,000
respondents each. Two surveys with identical instruments were conducted with nonprobability samples (census-adjusted proportional quota sampling with regard to
income) in Germany and the US, and one, using a subset of questions, was
administered to a probability-based sample in the US. Findings are discussed
comparatively between countries and in view of the interviews with physicians.
The last part concerns the policy implications of the analysis, and applies the
framework proposed in the thesis to the case of colon cancer screening. It seeks to
defend an incentive policy that attaches financial advantage to attending counselling
on the advantages and disadvantages of colon cancer screening, building also on
findings from the surveys, and interviews with physicians. The final chapter
highlights a range of general policy implications for the evaluation and
implementation of programmes seeking to incentivise personal responsibility.
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