Introduction
In this article, I review current trends and prospects in Finnish healthcare literature and discourse. The Finnish healthcare system was long considered to be a showcase of an equal, universal, and solidaristic healthcare system in a Scandinavian welfare state. However, surveys conducted during the past decade demonstrate that the Finnish healthcare system entails structural elements that maintain and increase health inequity among different socioeconomic groups. The inequity derives from differences in access to healthcare, particularly special care. Whereas the crowded public healthcare sector has suffered from major funding cuts, occupational and private healthcare sectors are easily accessible to those with economic means or sufficiently good positions in the labor market. In addition, the latter creates a distortion in referrals to special care. The gatekeeping procedure of getting one’s healthcare needs met is significantly different among socioeconomic groups.
Despite these findings, the ideological aim in Finland still is to provide equal and top-quality healthcare services to the whole population. The view is that the state has the social responsibility to provide equal opportunity to its citizens, with health being of special moral importance as an essential factor in having real opportunities. Furthermore, the welfare state needs a healthy workforce to manage the welfare state itself. However, decreasing tax revenues due to political decisions, an aging population, unemployment, and expensive medical technologies, among other issues, raise the question of how the ideological aim translates into practice.
Apart from existing structural and resource-related challenges, the ongoing trend toward the responsibilization of the individual, “expert patients,” and consumerism in the political discourse brings potential challenges to healthcare structures. Although the professional and scientific view does not encourage it, there are signs of laypeople and politicians in Finland wishing to move the economic burden of “self-inflicted,” lifestyle-related diseases to individuals. These undertakings reflect responsibility-sensitive proposals deriving from the luck egalitarian tradition, which assigns conditionality to healthcare services according to individual responsibility for lifestyle choices.
However, these applications are representations of a theory that is unsuited to producing policy guidelines and real-life solutions. The proposed function of the theory of luck egalitarianism is to raise intuitions, but it faces severe challenges in attempts to actualize the theory. These limitations are not duly concerned with suggestions of adding consequential individual responsibility as a requirement in getting one’s healthcare needs met. It remains to be seen in which direction the Finnish political discourse will evolve.
I begin by introducing the basic elements of Scandinavian welfare states and the ideology that forms the background of the Finnish healthcare system. I then go on to demonstrate the inherent structural inequalities of the Finnish system and how they were discovered. Although the official line of thought in healthcare policy aims toward universality, equity, and solidarity, the trend toward the responsibilization of the individual, already present in other political sectors, creates a challenge for healthcare policy. I discuss this tendency in the following section. In the penultimate section, I elaborate on the tendency’s background in luck egalitarian theory, the tradition’s theoretical limitations, and how these limitations make the theory inapplicable in practice. Finally, I suggest that personal responsibility is already present in the Scandinavian welfare state ideology via the concept of reciprocity.
The Historical Ideal of the Scandinavian Welfare State
Different Welfare State Regimes
Modern welfare states, all of which are committed to social rights and capitalism, can be observed through different arrangements among the state, the market, and the family. A representative illustration by Gøsta Esping-AndersenFootnote 1 divides welfare states into three ideal types: liberal, corporatist, and social democratic regimes.
Liberal regimes of welfare capitalism—for example, in the United States—place most of the tasks of social responsibility in the market. Social assistance is means tested, mainly concerns low-income state dependents, and often comes with stigmas and strict entitlement rules. Universal transfers are modest. The state favors the market by subsidizing private welfare schemes or providing only a minimum level of assistance. Social responsibility is mostly assigned to market mechanisms and to the individual in the market sphere, and the theoretical background can be understood as emerging from classical liberalism.
A second welfare regime is the corporatist welfare state. Social rights are taken for granted, but their level is attached to class and status. The state is what ensures social rights, but they are determined by occupational and other positions. According to Esping-Andersen, the church typically shapes corporatist regimes, such as in Germany, France, and some other areas of Continental Europe; consequently, social norms encourage traditional family structures. Social benefits favor motherhood, and childcare services do not aim at providing genuine opportunities to combine work and family. Thus, social responsibility is mainly placed on the family or possibly, in addition, on the church, occupational sectors, or other such units; this approach is characteristic of communitarian ideology.
Finally, social democratic regimes are those found in Scandinavia, where social democracy as a political movement has been the driving force behind social reform. The principles of universalism and decommodification of social rights are widest in this regime, and the ideal is to promote a high level of equality and to overcome the dualism between the state and the market, or between the working class and the middle class. In a sense, the model is a fusion of socialism and liberalism. On the one hand, many costs of living are mostly socialized by the state: for example, day care for children, healthcare, care for the aged, and social assistance.Footnote 2 On the other hand, this maximizes capacities for individual independence and capability: for example, enabling women to choose work over the household. Social responsibility is assigned directly to the state. The ideal of social democracy entails a commitment to guaranteeing full employment, which largely enables the maintenance of such solidaristic, universalistic, and decommodifying welfare state costs by maximizing the revenue income. The theoretical background for social democracy bears a resemblance to the ideals of liberal egalitarian theory, which holds the assumption that natural talents and the socioeconomic position in which one is born are a matter of luck and are morally arbitrary and, therefore, should not have a powerful effect on a person’s socioeconomic position and opportunities.Footnote 3
Thus, the Scandinavian welfare state can be understood as a system that involves a high level of state responsibility for securing a set of basic assets for its citizens, in contrast to systems that assign these collective responsibilities to the family or the market, or even deny the existence of collective responsibilities altogether.
In the Scandinavian welfare state, a certain clash between deontological and utilitarian ideals is especially visible. On the one hand, the concepts of social rights and social citizenship demonstrate that all citizens are considered to have equal standing in the state, and that persons are entitled to social rights based solely on their citizenship. On the other hand, granting social rights, which play the part of maintaining functional citizens, can be seen as an instrumental way of securing the functionality of the welfare state itself. The balance between these aspects and the constitution of social responsibility forms the defining characteristic of varying kinds of welfare states and is a continuous topic of debate in the Scandinavian welfare state.
Luck egalitarianism, a doctrine that I believe is gaining attention in Finland, is one such articulation. Luck egalitarianism has its starting point in Rawlsian liberal egalitarian theory, which widely recognizes the social responsibilities of the basic structure of society and is committed to social rights and to policies aiming at equality. However, the creed also advocates individual responsibility as a tool and condition for distribution, which makes its egalitarian character questionable. This issue is elaborated in subsequent sections.
The Ideology behind Scandinavian Health Policy
The ideology behind the health policy in Scandinavian countries, which I take here to include Finland, Denmark, Norway, Sweden, and Iceland, follows Esping-Andersen’s model of the social democratic welfare state regime. Means, goals, values, and outcomes are based on ideas of universality, equity, and solidarity—that is, citizens view themselves as being in the same boat. The core idea is to provide healthcare services equally and universally to all residents, with special consideration to the needs of the weakest.Footnote 4 Thus, the Scandinavian ideology aims at a system capable of responding equally to the medical needs of the entire population and holds that healthcare policies should meet this requirement at least in spirit.Footnote 5 This core ideology was maintained throughout the macroeconomic changes of the 1980s and 1990s,Footnote 6 although this era presented new challenges to the system. Healthcare is mainly supported by tax revenues and public funding, and both the wealthy and nonwealthy belong to the sphere of public healthcare.
The development of the Finnish healthcare system has been an essential part of its larger narrative—that of a small, persistent nation rising from the destruction of war with the strong will to build a new society. According to this narrative, the healthcare system was gradually perfected over the decades: in the 1940s the country developed its prenatal and childcare clinics; in the 1950s, the hospital network; in the 1960s, the national health insurance system; and in the 1970s, healthcare centers, the public health network, and occupational healthcare. In the beginning of the 1990s, the Finnish people’s image of their healthcare system was that of a strong and satisfactory system; they assumed it to be of exceptional quality and a showcase for the rest of the world as a system of justice and equality. The healthcare service system was considered to have been completed, and the central target of health policy during those decades—health equity and the ability to respond to health needs—seemed to be mostly conquered. Research data about health equity supported this conclusion, and the private and public sectors were seen as complementing each other. Each individual reform aimed to mitigate regional and socioeconomic differences, and it was thought that if these reforms were conducted efficiently and consistently, they would have just outcomes.Footnote 7
Providing healthcare that responds equally to the medical needs of the entire population, on the one hand, is the state’s way to ensure a healthy and able workforce, enabling a steady tax flow, and, on the other hand, reflects the social democratic respect for equality among citizens. Systems based on reciprocity entail an inherent aspect of instrumentalism, in which individuals are considered both as individual bearers of social rights and as instrumental enablers of the existence of the collective that guarantees the state’s capacity to bear its social responsibility.Footnote 8 This tension also creates a challenge to the Scandinavian healthcare system: the state must be able to bear the costs of the social sector, but it also must be able to meet the individual’s health needs. When faced with resource limitations, the state necessarily becomes a gatekeeper, prioritizing health needs and resource allocation. This gatekeeping effect can be understood as being in contradiction with respect for individual choice in that the state takes on the role of defining the individual’s health needs. As Tuija Takala encapsulates, “The system takes care of medical needs as defined by the system.”Footnote 9
The ideological challenge goes beyond the mere fact that some decisions are delegated to public organs, giving them the power to define which needs are more important than others. This can be seen as a necessary feature in democracy and the basis of most social policy. The true risk is in the nature of this gatekeeping effect. The prioritization and use of power can result from a process of public deliberation and a functioning democracy in which individual dignity and self-respect are highly appreciated. However, if the people in power make decisions by only being concerned with their own interest groups, neglecting expert opinions and going against the values and aims that they were supposed to represent in the first place, the result becomes obviously problematic. The gatekeeping process includes the risk that prioritization is hidden in bureaucracy and political games, resulting in, among other things, queues, difficulties in accessing needed care, oppression, and arbitrary moralism.
Inequality in Finnish Healthcare
As indicated, the Finnish healthcare system strongly relies on the ideals of the Scandinavian welfare state. How far has the Finnish system come in realizing these ideals? A major challenge to the Finnish system has been the inability to see structural inequalities that have developed over the past decades. Partly due to its citizens’ satisfaction with the system, and partly due to a lack of data, these structural inequities were not detected and were able to exert a strong influence on socioeconomic differences.
In the beginning of the 1990s, there were no signs of the coming big depression, and economic growth was expected to continue. Economic growth was steady, and the welfare state was flourishing. There was low unemployment and lots of resources to distribute. The faith in the market’s ability to direct development was solid, and the estimates for the healthcare sector were high. Healthcare policy documents expressed the belief that, thanks to investments in previous decades, the Public Health Act of 1972, and the consequent systematic healthcare center network, the challenges and problems related to healthcare were mostly solved.Footnote 10
Research data partly supported this conclusion, but that was mostly due to a lack of adequate data and tools for comparison. It was only in the 1990s that sufficient data and methods made possible the relevant research. Empirical research based on this data received focal attention when the myth of the just Finnish healthcare system began to erode. Ilmo Keskimäki’s studies showed that upper socioeconomic groups received, without exception, more special care and medical procedures compared to what was needed among lower socioeconomic groups. At first the scientific community refused to believe the results, because its members were certain that the equity of the system remained steadfast.Footnote 11
The differences are due to structural issues in the healthcare system, even though it has plenty of features that enhance equity and satisfy needs. The structural defect is in the three-layered healthcare system, which includes public healthcare, occupational healthcare, and private practices. All these are cofunded by the state, and they were long considered to constructively complement one another. However, the multilayered system ended up being what separates patients according to social and economic position. The original source for inequity derived from a distortion in special care referrals coming from occupational health and private sectors to public hospitals. This pressure was and still is a major reason for differences in healthcare. People in different socioeconomic positions have different levels of gatekeeping, and inequality in access to health services spreads to other services.Footnote 12
Apart from this structural inequity, the cuts followed by the great depression that started in the mid-1990s were not distributed equally to health sectors. A big reform—the decentralizing of healthcare funding decisions—was designed before, and conducted despite, the depression. The reform could have been successful if the economic growth had continued, but at the time of quickly depleting resources it led to hasty and uncoordinated decisions. Cuts were made where they were most easily implemented: preventive measures, mental health services, and basic healthcare. The special care units, occupational healthcare, and private care cofunding remained untouched. Cutbacks in the public sector also made room for the enlargement of private healthcare.Footnote 13
Even though evidence emerged in the 1990s that the Finnish system is not as equal as it was thought to be, the results of the Organisation for Economic Co-Operation and Development (OECD)–coordinated study about justice in healthcare systems within OECD countries were surprising.Footnote 14 In the comparison, Finland, along with Portugal and the United States, was among the countries in which the use of healthcare services was most concentrated in the highest-income groups. In a later comparative study of EU countries and their levels of unsatisfied healthcare needs, Finland fared somewhat better but was still below average: unsatisfied healthcare needs were concentrated in lower-income groups.Footnote 15 Similar results were also found when observing the distribution of mortality that could have been prevented with properly-timed healthcare measures.Footnote 16 The study shows that during the past decades preventable mortality had been reduced overall, but the differences among income groups had increased.
Since the 1980s, Finland has adopted the rhetoric of productivity as a focal parameter of development. In international comparisons, the Finnish healthcare system is relatively cheap, and the studies indicate that its productivity is good.Footnote 17 The parameter that has not had success in international comparisons has been justice, but this parameter has not yet gained much attention in healthcare reforms.Footnote 18
Despite potential methodological challenges in the studies, the results show that the healthcare system has developed along an unequal trajectory. As Keskimäki shows, the Finnish healthcare system currently offers better access, several times over, to healthcare services for well-off workers in permanent and typical jobs. Occupational healthcare is usually without queues and provides fast access to special care. Furthermore, the higher one’s position in the labor market is, the better are the occupational healthcare services one tends to receive. However, atypical jobs often fall out of the scope of occupational healthcare. In addition, steady income creates better opportunities to use private services; even though private care is cofunded by the state, the fees are much higher than the clinic fee of the public sector.Footnote 19
Thus, not only are the well-off able to pay for private healthcare, they usually do not even have to do so, because the occupational healthcare sector is in such great shape (none of these healthcare sectors have been the target of severe financial cutbacks). In contrast, individuals without occupational healthcare and without the ability to pay for private healthcare must queue for long periods of time in the public healthcare system (toward which large financial cuts have been directed). Furthermore, in geographical areas where most people are entitled to occupational healthcare or are able to access private healthcare there is less strain on public services. In contrast, the areas whose inhabitants are in the lower socioeconomic end have more pressure on public services, to which access is more difficult.
As Takala notes, economic difficulties and cuts in health services have encouraged an emphasis on equality of opportunity in place of the more traditional focus on equality of outcome. The combination of a system of equality of opportunity that merely relies on procedural justice without paying attention to real opportunities and encouragement to use those opportunities and a system involving many gatekeeping elements easily ends up creating an unjust environment. This happens when those who are able to utilize the system to its full potential will get better treatment than those lacking the necessary knowledge and/or those who are less insistent.Footnote 20
Despite the structural inequalities, the ideological aim is still to achieve health equality. According to the policy papers, the aim of the healthcare system is that all residents of Finland, regardless of socioeconomic position, are equally entitled to top-quality services, with special attention to those who cannot take care of themselves.Footnote 21 Along with an increasing acknowledgment of the structural inequality of the Finnish system, there are attempts to dismantle the multilayered funding structure.Footnote 22 However, there is a risk that healthcare reforms will be buried under organizational change with no real impact, and that the benefits of new, expensive technology will be overestimated.
Although the official line of thought in healthcare policy aims at universality, equity, and solidarity, the trend toward the responsibilization of the individual creates a challenge for healthcare policy. This discourse is especially visible in the discussion about chronic diseases related to lifestyles. The trend of regarding these diseases as self-inflicted, and the conclusion that this self-infliction should result in the individual being the bearer of the costs for her treatment, is contradictory to the Scandinavian healthcare ideology. In addition, the enlargement of the private sector and the increasing number of private health insurance plans—which emerge from the lack of resources in the public sector—create a habit of thinking that the individual herself should bear the responsibility for the costs of her healthcare.Footnote 23
The Trend of Responsibilizing the Individual
The responsibilization of the individual is a complex phenomenon with a wide political and sociological background. It relates to a discourse of increasingly scarce resources in the public sector and the suggestion that this scarcity be combated by desocializing problems such as poverty, unemployment, and health.Footnote 24 The argumentation concerning the individualization of healthcare issues in high-income countries concerns the disease burden and costs of the healthcare sector that are attributable to the use of tobacco and alcohol, high blood pressure and cholesterol, and obesity.Footnote 25 A framework that sees people as “expert patients,” consumers who manage their own lifestyles and exercise choices affecting their own health, allows society to hold individuals accountable for their own health.Footnote 26 It has been argued that allocating scarce resources for the treatment of conditions that could have been prevented through the choices of individuals is problematic for the just arrangement of healthcare services in affluent countries.Footnote 27 Studies indicate that this view became visible in policy documents across Europe in the beginning of the 2000s. Problems previously regarded as being under the influence of the public sector were altered to become issues to be solved by changing the behavior of people “at risk.”Footnote 28
The discussion is part of a wide political struggle about resources and power. The healthcare sector faces new challenges related to a decrease in tax revenue due to various changes: for example, an aging population and rising unemployment, new medical technologies that create more expensive methods of diagnosis and treatment, and the increased value of individual choice in healthcare decisions.Footnote 29 Thus, it is likely that costs in the health sector are increasing, but saying that the state cannot afford the costs is making a political statement.
For this country report, I surveyed the main Finnish scientific and professional journals in medicine and healthcare,Footnote 30 paying particular attention to the questions of lifestyles and individual responsibility. The survey covered both articles directly addressing the issues and contributions touching on them more indirectly. Because the main aim was to make visible general ideological trends, no in-depth analysis was necessary.
There are signs of laypeople and politicians wishing to shift the economic burden of “self-inflicted,” lifestyle-related diseases to individuals in Finland. When there is information about better health in society, it is deemed that the individual should be able to take responsibility for her health, control her health risks, and make the right lifestyle choices. The Finnish public discussion has focused on smoking, alcohol consumption, and obesity; the latter has featured lately in the discussion about the costs of the healthcare system. As survey studies indicate,Footnote 31 healthcare costs were discussed with particular attention in 2005, when an influential Finnish politician, Esko Aho, proposed that society cannot bear all the costs of lifestyle choices. Proposed solutions included increased taxation of healthcare payments on those with unhealthy lifestyles or bonuses for those with healthy lifestyles. This gave rise to increased public discussion of, in particular, obesity and its underlying causes. Discussion about the costs of obesity became prevalent in the media, and phrases such as “fat tax,” “fat war,” and “rebellion against fat” were bandied about.
Finnish health education is based on medical knowledge, but recent critiques suggest that mainstream obesity studies produce excessive blame and discrimination toward the individual, and that the harms of obesity might be exaggerated. In the lay discussion—especially on the Internet—blaming individuals, and even hate speech, is common. These arguments focus mainly on economics and the view that money used for obesity-related diseases has been taken away from someone else, or moralistic views blaming the obese for laziness and a lack of self-discipline.Footnote 32
In contrast, the scientific community shows little support for the notion of self-infliction and responsibilization of the individual. In particular, obesity, which plays a part in most chronic diseases, is discussed in a holistic manner, paying attention to the effect of food environment, socioeconomic issues, and other psychosocial factors.Footnote 33 When the constitution of a lifestyle is discussed, it is seen not only as an individual choice and habit but to a great extent as a coping mechanism. Scientists recognize socioeconomic position and its effect on one’s ability to make choices: the well-off have better opportunities in regards to good housing and living conditions, education, income security, healthy choices, access to a variety of hobbies, and a feeling of capability. The less advantaged suffer from insecurity in the labor market, income-related worries, and a cheap but less healthy diet.Footnote 34 Lifestyle guidance is discussed frequently,Footnote 35 but usually in the context of acknowledging that the time given to lifestyle guidance is insufficient. Furthermore, guidance is often considered to be ineffective due to a lack of knowledge of how to genuinely support and motivate patients and take more fully into account their social environment.
The scientific community often cites the difficulty of even properly applying the term “self-inflicted disease.” Because an individual’s lifestyle is a complex outcome of genetic inheritance, socioeconomic situation, the surrounding society, and individual choices, chronic diseases arising from individual choice cannot be separated from other health problems. The National Advisory Board on Social Welfare and Healthcare Ethics has stated that the concept of self-inflicted disease is difficult to define, constantly changing, misleading, and leads to blaming the individual.Footnote 36 The concept is rarely used in science.
Contributions seen as more strictly medical primarily pay attention to quantitative aspects of the individual, such as blood pressure and cholesterol. However, they do not intimate any conclusions about the most effective measures to tackle these factors. Although diet and exercise are largely discussed, the fact that it would be up to the individual to change these issues is not explicitly raised. Lifestyle matters are primarily referred to in a neutral tone.
The professional discussion assumes that people must be treated regardless of the reason for their health condition. Responsibility-sensitive accounts are criticized because healthcare is seen as a necessary primary good,Footnote 37 and inequity concerning this primary good should not be tolerated, even though it might derive from individual choice. Thus, even if a chronic disease resulted from choice, it should not affect how the patients receive healthcare.
On the other hand, a blaming discourse exists as well. Take, for example, an editorial in a leading medical journal in Finland entitled “The Long Shadow of an Obese Mother”Footnote 38: although it acknowledges the complex origin of obesity, the manner in which the mother is depicted as a cause of the future child’s risk for chronic disease points a finger at the mother and not the food environment. Another article in the same journalFootnote 39 states that if Finns would follow the lifestyle guidelines mentioned in the article (eat a lot of vegetables and fruits, exercise regularly, maintain a BMI of less than 25 kg/m2, refrain from smoking, and use alcohol at most moderately), a great part of the population would be healthier and functional, would have better stamina in work, and would have a healthier end life and a better quality of life. Consequently, resources would grow both for the individual and for the society as a result of smaller healthcare expenses. After these statements, the authors go on to recognize that our lifestyle choices actually are limited and are not the same for everyone, and that a healthier lifestyle requires action from individuals and social structures. The professional journals do regard the issue with balanced and careful scrutiny, but the partial statements speaking for enhancing individual responsibility are what eventually trickle down to public and political discussion.
Luck Egalitarian Challenges
Luck Egalitarian Trends in Healthcare Ethics
The theoretical background for the described trend of thought can be found in theories combining both egalitarian aims and a sensitivity to individual responsibility, commonly known as luck egalitarian theories, or responsibility-sensitive egalitarianism. Although these theories derive from the tradition of egalitarianism, the application of luck egalitarian principles creates a major challenge to the ideology of the Scandinavian healthcare system. Whereas the luck egalitarian tradition considers healthcare a right, it highlights the normative distinction between chance and choice.
The basic tenet in luck egalitarian theories, viz., the principle of responsibility, states that normative power is given to the distinction between voluntary choice and circumstance as a condition for assigning the burden of responsibility. Inequalities that derive from unchosen features in people’s circumstances are unjust, whereas inequalities that result from the choices people make voluntarily are just. Responsibility depends on a person’s ability to make decisions and control her life, and possessing control means that any adverse consequences that follow can be assigned to the person in control. Conversely, the absence of feasible alternatives and the lack of control lessen responsibility.Footnote 40 The obviously difficult distinction between voluntary choice and circumstance (chance) is at the center of the original debate. In luck egalitarianism, responsibility is understood as consequential responsibility, in contrast to mere moral responsibility. This is due to the theory’s focus concerning responsibility as taking a normative stand on decisions about compensation of resources: that is, what the individual can or cannot claim from the society.
Drawing on responsibility-sensitive egalitarianism, recent proposals in the international scientific community of healthcare ethics regarding increasing the role of individual responsibility within healthcare suggest a limited but significant role for individual responsibility in the rationing of healthcare resources. Practical suggestions have included a forward-looking take on responsibility in which patients suffering from a chronic lifestyle disease should sign a contract for frequent medical follow-ups or otherwise risk getting lower-priority service in healthcare. Another idea has been the implementation of a bonus-malus system by using an algorithm to decide which interventions will be included in the basic benefits package system, with personal factors such as smoking behavior calculated into the algorithm.Footnote 41
These proposals, drawing explicitly from luck egalitarianism, reflect a discourse in the public and political discussion on Finnish healthcare. Everyone seems to agree, following Scandinavian welfare ideals, that healthcare is a social right and that the state has the responsibility to provide it for its citizens. No one is explicitly ready to cut healthcare as a social right, but on the other hand, it is questioned whether the state has the resources to pay for the healthcare of patients with chronic diseases that are related to lifestyle choices.
As Takala notes, the neoliberal or libertarian view of the Scandinavian model, viz., questioning the collective risk pooling in the first place, is considered to be politically incorrect.Footnote 42 However, the manner of thinking inspired by luck egalitarian principles seems to have hijacked the idea of the legitimate revoking of universalism and applied it also to the Scandinavian discussion, at least to some extent. Proponents justify this revoking of universalism by claiming that it sincerely aims at maintaining the universalism of social rights, with an addendum, however, regarding certain conditions related to individual responsibility for various issues, such as health. All of a sudden, the universalism of social rights has become conditional. The following discussion elaborates the incompatibility of luck egalitarianism with the Scandinavian welfare state.
Luck Egalitarian Vices and Virtues
The motivation for luck egalitarianism lies in an attempt to respond to an intuition about the need for individual responsibility in egalitarian theory. Many challenges to egalitarian theories and welfare states with universal social rights derive from the implicit role of personal responsibility. The “conservative,” or nonegalitarian, critique states that egalitarian theories enforce diminished agency and reward free riders, creating a culture of dependency.Footnote 43 The theoretical infrastructure of personal responsibility lies in egalitarian theory through the assumption of reciprocity between citizens and the state. This reciprocity is found in the idea of the Scandinavian welfare state, too: people have their social rights and contribute to the existence of the welfare state. However, as discussed previously, this implicit personal responsibility has been the target of criticism, and the luck egalitarians took to the task of incorporating stronger notions of personal responsibility into egalitarianism.Footnote 44
Luck egalitarianism does have an intuitive pull. It reflects a general assumption that people ought to be accountable for their actions; that is, people should take responsibility for their lives and not neglect responsibility—for what would result if we all just abandoned responsibility for our actions and choices? Ronald Dworkin emphasizes the importance of the distinction between choices and circumstances in our personal ethics. He states that we are to take responsibility for our voluntary choices—choices that are freely made and not dictated or manipulated by others. Furthermore, we must blame ourselves for the bad choices we have made and try to cultivate our ambitions in order to be able to make better ones. On the other hand, there is no reason to take responsibility for the outcomes of unchosen circumstances. Responsibility must be taken for one’s own choices, but one cannot be responsible for what is beyond one’s control.Footnote 45 All this can be said to have intuitive pull, and there is no reason why an egalitarian theory would not be able to answer to this view. However, luck egalitarianism seems to have failed in its task for several reasons.
The basic tenet of luck egalitarianism—the principle of responsibility—has been especially challenged because of the obscure line between voluntary choice and circumstance, and the moralistic tendency in attempting to define this distinction. Furthermore, the theory seems to have difficulties in guaranteeing the egalitarian ground for assuring each citizen’s ability to cooperate as a full member of the society.Footnote 46 If the reasons for one’s deprivation happen to be placed—after a justified or unjustified interpretation of choices and circumstances—in the category of choice, what will happen to the disadvantaged person? Has she lost all her claims to have her basic needs satisfied?
I suggest that the biggest failure in the luck egalitarian conception of personal responsibility is the one-sided focus on consequential responsibility. By making basic social rights conditional on individual responsibility, the citizen’s ability to function as a full member of a society is easily compromised.Footnote 47 This proposition makes the theory vulnerable to criticism for not being egalitarian in the first place, and, consequently, for being against the ideals of the Scandinavian welfare state. As Norman Daniels states, health is a major component of a person’s life opportunities, and denying the right to healthcare would be a serious limitation to being able to function as a full citizen.Footnote 48
The most concrete challenge to the theory is the distinction between choice and circumstance. As indicated in previous sections, lifestyle and health are complex outcomes of social, cultural, and environmental factors and individual choices. Finding the causality and varying influences on different health outcomes seems to be an impossible task. Even the luck egalitarian theorists admit this, and the distinction between choice and circumstance is a much-debated topic within the theory.
For example, Dworkin states that the category of choice entails a person’s personality, including her tastes and preferences for making one choice rather than another, as well as a person’s character, such as her energy, industry, and persistence. This outlining seems to place a powerful burden on personal responsibility. However, according to Dworkin, circumstances involve physical and mental health and ability, general fitness, and capacities, including what Dworkin terms “wealth-talent”—the innate capacity to produce goods or services that will result in wealth—along with wealth, property, and the provided opportunities that one commands. Thus, the outcomes of a person’s preferences or industry are not compensable, whereas the outcomes of the lack of wealth-talent or opportunities are.Footnote 49 How does one make a distinction among these elements? Richard Arneson continues the list by stating that the notion of preferences ought not to be simplified straightforwardly as falling in the category of choice, due to the circumstantial origin of such preferences.Footnote 50 In addition, G. A. Cohen argues that the conceptions of personality and expensive tastes cannot, in principal, be placed merely in the category of choice.Footnote 51 Andrew Mason strongly emphasizes the influence of different social structures on “voluntary choices” as limiting elements of responsibility.Footnote 52
Thus, luck egalitarians make a remarkable case about the fact that they themselves wish to present the principle of responsibility in a sensible and holistic manner, understanding the influence of social, cultural, and other environments on the choices people make. Altogether, it seems that the conception of personal responsibility in luck egalitarianism is either too harsh and similar to nonegalitarian theories, making luck egalitarianism incompatible with any version of egalitarianism, or it diminishes its own central principle and, consequently, raises the question of what the point of the principle is in the first place. The question remains as to how this distinction between choice and circumstance, being so ambiguous, could bear the enormous political and economic weight of the principle of responsibility.
Moreover, tracking responsibility according to the distinction would be, in practice, nearly impossible. There is no way of telling, without the most extreme surveillance mechanisms and continuation of qualitative interviews of personal reflections and behavior—which are difficult from the point of view of efficiency and privacy—whether an outcome is the result of choices or circumstances. This extensively invasive effort would be incompatible with liberal egalitarianism in that it has a far too invasive emphasis on efforts by the state to monitor citizens’ behavior in the name of civic responsibility.
The moralistic tendency in defining choices and circumstance holds that, in practice, decisions of compensation in healthcare following the principle of responsibility would encourage fellow citizens and healthcare authorities to scrutinize the deepest aspects of the person and to judge the degree of her responsibility.Footnote 53 These judgments would presumably be highly moralized, employing a “moralism of responsibility,”Footnote 54 and would use a simplified discourse of individual responsibility for health. This moralism of health derives from an overvaluation of health that creates new, questionable norms and classifications, enticing people to follow a strict discipline of health. A person’s status is more and more defined according to her health. In this manner, the ideal of an expert patient and health consumer becomes a new manner of oppression, in which the assumed liberty is only a token, because the expert patient is expected to make the “right” decisions.Footnote 55
This moralism can also be observed through an arbitrary definition of the issues within which individual responsibility is discussed. It seems that, among all possible health risks, most attention is given to lifestyle risks, especially obesity. This attention is often justified by referring to enormous healthcare costs. However, if the main point were to compare healthcare costs, premature infants, cancer patients, and victims of serious accidents could also be considered costly users of healthcare services.Footnote 56 Nevertheless, public discussion lacks passionate disapproval of, for example, motorcycling, speeding, risky sports, and risky pregnancies. As a professional contribution points out,Footnote 57 if the principle of responsibility were also applied to areas of healthcare other than lifestyle-related chronic diseases, healthcare for a large group of people could just be given up. This follows for three reasons: first, chance and choice cannot be separated; second, even if they could be separated, healthcare ethics would still imply that people must be treated despite the reason for their need; and third, the question of why the focus is merely on responsibility for lifestyle matters remains unanswered.
The luck egalitarian applications for increasing population health can hardly be considered to be effective or egalitarian. With consequential responsibilities, these measures weaken the position of those who already have the least control over their lives and the fewest opportunities to make the “right” choices, whereas the advantaged will always have the necessary economic resources for private healthcare. The responsibility-sensitive measures pose different standards of behavior to those who cannot afford private healthcare assistance.Footnote 58 Those with better opportunities will always get their treatment in occupational or private sectors, even though they might not comply with some conditionality in the public sector.
Thus, regardless of the original aims of the theory—for example, the aim of answering to the conservative and nonegalitarian critique of egalitarianism, or demonstrating the obscure distinction between choice and circumstance—the tradition unwittingly inherits some of the vices of the original conservative critique.Footnote 59 The recent developments in the tradition answer many critiques, for example, by questioning the brute luck/option luck distinction, and by combining sufficientarist principles with the theory that would guarantee that the basic needs of all citizens are answered.Footnote 60 These developments might increase the validity of the approach at the theoretical level. After all, the theory might well be said to be a mere theoretical framework guiding intuitions about responsibility and fairness.Footnote 61 The remaining question to be debated would be whether the thesis, having such fundamental problems with its basic tenet, has any guiding potential even for intuitions.
However, even if the theory were not even supposed to be a guide for actual policies, and the theorists were not the ones to be accused of supporting unfair policies, the appeal to luck egalitarian applications is a substantial phenomenon. As Kristin Voigt notes: “Given the social inequalities that shape and constrain individuals’ ‘lifestyle choices,’ luck egalitarians may find few health inequalities in the real world that they would consider fair.”Footnote 62 Despite this remark about the original theory, lifestyle-related diseases are the very matters that are under consideration for luck egalitarian applications. The approach currently belongs to one of the most prevalently discussed theories in healthcare ethics, seeking actual policies to be implemented in actual healthcare systems. In the real-life applications of the theory, its limitations are not sufficiently addressed. The theory is not realizable, but it is being realized widely. In its applications, the category of choice is not holistic and lacks the plethora of specifications that luck egalitarian theorists have affixed to it.
Do We Need More Responsibility?
The development of the discourse on the responsibilization of the individual, and luck egalitarian trends of thought, will be an important question in the future of the Finnish healthcare system. In this article I have demonstrated that the luck egalitarian principle of consequential responsibility, assigning conditionality to basic social rights based on individual responsibility, is contradictory to the Scandinavian welfare state and its healthcare system. The possible intuition that there is a need for a stronger conception of individual responsibility must be answered by other means that are able to maintain the ideal of social responsibility, leaning toward universality of social rights, equity, and solidarity.
The proper answer is found within the original ideal of the Scandinavian welfare state itself. In this model, personal responsibility exists—indeed, specifically historically: the whole idea starts from the notion that the residents of the nation pay taxes and contribute to the social infrastructure. Thus, the whole system is founded on a strong conception of reciprocity. The current ideological and political trend of individualization invites us to neglect the meaning of this reciprocity, and it invites us to think that those who do not reciprocate at a certain moment are individually responsible for their inability to contribute; however, the reasons for noncontribution are much more complex and dynamic.
Thus, if there is a need for a more explicit conception of personal responsibility, it will be found in the moral responsibility to try one’s best to reciprocate. Reciprocation includes both individual and social responsibilities for reciprocation, not only individual requirements. What, then, does reciprocation related to health issues entail? This question might be, in the first place, overly particular. Altogether, reciprocation implies the citizen’s ability to function as a full member of society, and this ability to function is a wider conception than that of mere clinical health.
Finally, the whole discussion about prioritization, health, and social rights ought to be of separate concern from the discourse of scarcity of resources. Other than being an intrinsic good for a person’s ability to live a good life, healthcare and healthy citizens are an investment for society, and neglecting health needs might end up being much more expensive for society than supplying the health needs in the first place. The question is not about the existence of needed resources; it is about how the resources are distributed.
