The Journal of Ethics

, Volume 23, Issue 4, pp 369–386 | Cite as

Opportunity and Responsibility for Health

  • Eric CavalleroEmail author


Wealth and income are highly predictive of health and longevity. Egalitarians who maintain that this “socioeconomic-status gradient” in health is unjust are challenged by the fact that a significant component of it is owed to the higher prevalence of certain kinds of voluntary risk-taking among members of lower socioeconomic groups. Some egalitarians have argued that these apparently free personal choices are not genuinely free, and that those who make them should not be held morally responsible for the resulting harms to their health. I argue to the contrary that such choices usually are fully free, and that those who make them are responsible for their consequences. This does not imply, however, that society cannot also be responsible for those consequences. It is responsible for them if they are statistically foreseeable and avoidable outcomes of unjust public institutions and policies. I show that many of the harms to health that contribute to the voluntary behavioral component of the SES health gradient satisfy that description. Society can therefore be morally responsible for those harms, even though the individuals who suffer them are also fully responsible for them.


Health Personal responsibility Social responsibility Equality of opportunity SES gradient in health 



I am grateful to the Harvard Program in Ethics and Health for research support during an early stage of this project. For advice or comments on previous drafts I thank Hannah Byrnes-Enoch, Richard Volkman, and two anonymous reviewers for Journal of Ethics.

Compliance with Ethical Standards

Conflict of interest

The author declares that he has no conflict of interest.


  1. Adler, N.E., et al. 1993. Socioeconomic Inequalities in Health: No Easy Solution. Journal of the American Medical Association 269: 3140–3145.CrossRefGoogle Scholar
  2. Anand, Sudhir, Fabienne Peter, and Amartya Sen (eds.). 2004. Public Health, Ethics, and Equity. Oxford: Oxford University Press.Google Scholar
  3. Anderson, Elizabeth. 1999. What is the Point of Equality? Ethics 109: 287–337.CrossRefGoogle Scholar
  4. Arneson, R. 1990. Liberalism, Distributive Subjectivism and Equal Opportunity for Welfare. Philosophy & Public Affairs 19: 2.Google Scholar
  5. Barnett, W.S. 2008. Preschool Education and Its Lasting Effects: Research and Policy Implications. Boulder: Education and the Public Interest Center & Education Policy Research Unit.Google Scholar
  6. Bellinger, David C. 2008. Lead Neurotoxicity and Socioeconomic Status: Conceptual and Analytical Issues. Neurotoxicology 29: 828–832.CrossRefGoogle Scholar
  7. Blanden, Jo, Paul Gregg, and Stephen Machini. 2009. Intergenerational Mobility in Europe and North America. Sutton Trust Report.Google Scholar
  8. Blane, D., G. Davey-Smith, and M. Bartley. 2008. Social Selection: What Does It Contribute to Social Class Differences in Health? Sociology of Health & Illness 15: 1–15.CrossRefGoogle Scholar
  9. Bloom, David E., and David Canning. 2008. Population Health and Economic Growth. Commission on Growth and Development Working Paper; No. 24. Washington, DC: World Bank.
  10. Bloom, David E., Michael Kuhn, and Klaus Prettner. 2018. “Health and Economic Growth.” Program on the Global Demography of Aging at Harvard University, Working Paper Series; PGDA Working Paper No. 153
  11. Bratman, Michael. 1996. Identification, Decision, and Treating as a Reason. Philosophical Topics 24: 1–18.CrossRefGoogle Scholar
  12. Bratman, Michael. 2000. Reflection, Planning and Temporally Extended Agency. Philosophical Review 109: 35–61.CrossRefGoogle Scholar
  13. Bratman, Michael. 2005. Planning, Agency, Autonomous Agency. In James Stacey Taylor, ed. Personal Autonomy, 33–37. Cambridge: Cambridge University Press.Google Scholar
  14. Braveman, P.A., et al. 2010. Socioeconomic Disparities in Health in the United States: What the Patterns Tell Us. American Journal of Public Health 100: S186–S196. Scholar
  15. Brown, R.C.H. 2013. Moral Responsibility for (Un)healthy Behaviour. Journal of Medical Ethics 39: 695–698.CrossRefGoogle Scholar
  16. Brownell, K.D., et al. 2010. Personal Responsibility and Obesity: A Constructive Approach to a Controversial Issue. Health Affairs 3: 378–386.Google Scholar
  17. Campbell, Frances, et al. 2014. Early Childhood Investments Substantially Boost Adult Health. Science 343: 1478–1485.CrossRefGoogle Scholar
  18. Cappelen, O.W., and O.F. Norheim. 2005. Responsibility in Healthcare: A Liberal Egalitarian Approach. Journal of Medical Ethics 31: 476–480.CrossRefGoogle Scholar
  19. Case, A., et al. 2002. Economic Status and Health in Childhood: The Origins of the Gradient. American Economic Review 92: 1308–1334.CrossRefGoogle Scholar
  20. Cavallero, Eric. 2011. Health, Luck, and Moral Fallacies of the Second Best. Journal of Ethics 15: 387–403.CrossRefGoogle Scholar
  21. Chandola, T., et al. 2003. Health Selection in the Whitehall II Study, UK. Social Science and Medicine 56: 2059–2072.CrossRefGoogle Scholar
  22. Christman, John. 1987. Autonomy: A Defense of the Split-Level Self. Southern Journal of Philosophy 25: 281–293.CrossRefGoogle Scholar
  23. Christman, John. 1991. Autonomy and Personal History. Canadian Journal of Philosophy 21: 1–24.CrossRefGoogle Scholar
  24. Cunha, F., et al. 2006. Interpreting the Evidence on Life Cycle Skill Formation. In Handbook of the Economics of Education, ed. E.A. Hanushek and F. Welch, 697–812. Amsterdam: North-Holland.Google Scholar
  25. Cunha, F., et al. 2010. Estimating the Technology of Cognitive and Noncognitive Skill Formation. Econometrica 78: 883–931.CrossRefGoogle Scholar
  26. Davey Smith, George (ed.). 2003. Health Inequalities: Lifecourse Approaches. Bristol: Polity Press.Google Scholar
  27. Evans, G.W. 2004. The Environment of Childhood Poverty. The American Psychologist 59: 77–92.CrossRefGoogle Scholar
  28. Eyal, N., S. Hurst, O. Norheim, and D. Wikler (eds.). 2013. Inequalities in Health: Concepts, Measure, and Ethics. Oxford: Oxford University Press.Google Scholar
  29. D’Agostino, Fred. 1996. Free Public Reason: Making It Up as We Go. New York: Oxford University Press.Google Scholar
  30. Daniels, Norman. 2008. Just Health: Meeting Health Needs Fairly. New York: Cambridge University Press.Google Scholar
  31. Daniels, Norman, Bruce Kennedy, and Ichiro Kawachi. 2004. Health and Inequality, or, Why Justice is Good for Our Health. In Anand et al.Google Scholar
  32. Deary, Ian J., Lars Penke, and Wendy Johnson. 2010. The Neuroscience of Human Intelligence Differences. Nature Reviews Neuroscience 11: 201–221.CrossRefGoogle Scholar
  33. DiFranza, J.R., et al. 1991. RJR Nabisco’s Cartoon Camel Promotes Camel Cigarettes to Children. Journal of the American Medical Association 266: 3149–3153.CrossRefGoogle Scholar
  34. Duncan, Greg J., and Aaron J. Sojourner. 2013. Can Intensive Early Childhood Intervention Programs Eliminate Income-Based Cognitive and Achievement Gaps? Journal of Human Resources 48: 945–968.CrossRefGoogle Scholar
  35. Durkheim, Emile. 1982. In The Rules of Sociological Method, ed. Steven Lukes. New York. The Free Press.Google Scholar
  36. Dworkin, Gerald. 1981. Taking Risks, Assessing Responsibility. Hastings Center Report 11: 5.Google Scholar
  37. Dworkin, Gerald. 1988. The Theory and Practice of Autonomy. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  38. Ekstrom, Laura Wadell. 1993. A Coherence Theory of Autonomy. Philosophy and Phenomenological Research 53: 599–616.CrossRefGoogle Scholar
  39. Fields, Scott. 2004. The Fat of the Land: Do Agricultural Subsidies Foster Poor Health? Environmental Health Perspectives 112: A820–A823.CrossRefGoogle Scholar
  40. Fischer, J.M., and M. Ravizza. 1998. Responsibility and Control: A Theory of Moral Responsibility. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  41. Frankfurt, Harry. 1988a. The Importance of What We Care About. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  42. Frankfurt, Harry. 1988b. Freedom of the Will and the Concept of a Person. Cambridge: Cambridge University Press.Google Scholar
  43. Frankfurt, Harry. 1988c. Identification and Wholeheartedness. Cambridge: Cambridge University Press.Google Scholar
  44. Gaus, Gerry. 2011. The Order of Public Reason. New York: Cambridge University Press.Google Scholar
  45. Goldenberg, R.L., et al. 1994. The Effect of Income on Use of Preventive Care: An Evaluation of Alternative Explanations. Journal of Health and Social Behavior 20: 397–406.Google Scholar
  46. Gottfredson, Linda S. 2004. Intelligence: Is it the Epidemiologists’ Elusive “Fundamental Cause” of Social Class Inequalities in Health? Journal of Personality and Social Psychology 86: 174–199.CrossRefGoogle Scholar
  47. Habermas, J. 1995. Reconciliation Through the Public Use of Reason: Remarks on John Rawls’s Political Liberalism. The Journal of Philosophy 92: 109–131.Google Scholar
  48. Hackman, Daniel A., and Martha J. Farah. 2009. Socioeconomic Status and the Developing Brain. Trends in Cognitive Sciences 13: 65–73.CrossRefGoogle Scholar
  49. Hale, A.R., and A.I. Glendon. 1987. Individual Behaviour in the Control of Danger. New York: Elsevier.Google Scholar
  50. Harper, S., et al. 2015. Trends in Socioeconomic Inequalities in Motor Vehicle Accident Deaths in the United States, 1995-2010. American Journal of Epidemiology 182: 606–614.CrossRefGoogle Scholar
  51. Heckman, James J. 2006. Skill Formation and the Economics of Investing in Disadvantaged Children. Science 312: 1900–1902.CrossRefGoogle Scholar
  52. Heckman, James J. 2008a. The Economics, Technology, and Neuroscience of Human Capability Formation. Procedings of the National Academy of Sciences of the United States of America 104: 13250–13255.CrossRefGoogle Scholar
  53. Heckman, James J. 2008b. The Case for Investing in Disadvantaged Young Children. In Big Ideas for Children, ed. First Focus.
  54. Hurley, Susan. 2007. The ‘What’ and the ‘How’ of Distributive Justice and Health. In Egalitarianism: New Essays on the Nature and Value of Equality, ed. Nils Holtug and Kasper Lippert-Rasmussen, 308–334. Oxford: Oxford University Press.Google Scholar
  55. Jha, P., et al. 2006. Social Inequalities in Male Mortality, and in Male Mortality from Smoking: Indirect Estimation from National Death Rates in England and Wales, Poland, and North America. Lancet 368: 367–370.CrossRefGoogle Scholar
  56. Karoly, Lynn A., M. Rebecca Kilburn, and Jill S. Cannon. 2005. Early Childhood Interventions: Proven Results, Future Promise. Rand Corporation Monograph Series.Google Scholar
  57. Keister, Lisa A. 2005. Getting Rich: America’s New Rich and How They Got That Way. Cambridge: Cambridge University Press.CrossRefGoogle Scholar
  58. Kirkpatrick, R.M., M. McGue, and W.G. Iacono. 2015. Replication of a Gene-Environment Interaction Via Multimodel Inference: Additive-Genetic Variance in Adolescents’ General Cognitive Ability Increases with Family-of-Origin Socioeconomic Status. Behavioral Genetics 45: 200–214.CrossRefGoogle Scholar
  59. Knudsen, E.I., et al. 2006. Economic, Neurobiological, and Behavioral Perspectives on Building America’s Future Workforce. Proceedings of the National Academy of Sciences 103: 10155–10162.CrossRefGoogle Scholar
  60. Kuh, D., et al. 1997. Social Pathways Between Childhood and Adult Health. In A Life Course Approach to Chronic Disease Epidemiology, ed. D. Kuh and Y. Ben-Shlomo, 169–198. Oxford: Oxford University Press.Google Scholar
  61. Laflamme, Lucie, Stephanie Burrows, and Marie Hasselberg. 2009. Socioeconomic Differences in Injury Risks: A Review of Findings and a Discussion of Potential Countermeasures. Copenhagen: World Health Organization.Google Scholar
  62. Lippert-Rasmussen, K. 2013. When Group Measures of Health Should Matter. In Inequalities in Health: Concepts, Measures, and Ethics, ed. Nir Eyal, Samia A. Hurst, Ole F. Norheim, and Daniel Wikler, 52–65. Oxford: Oxford University Press.CrossRefGoogle Scholar
  63. Lantz, P.M., et al. 1998. Socioeconomic Factors, Health Behaviors, and Mortality: Results from a Nationally Representative Prospective Study of US Adults. JAMA 279: 1703–1708.CrossRefGoogle Scholar
  64. Lynch, J., G.D. Smith, S. Harper, and K. Bainbridge. 2006. Explaining the Social Gradient in Coronary Heart Disease: Comparing Relative and Absolute Approaches. Journal of Epidemiology and Community Health 60: 435–441.CrossRefGoogle Scholar
  65. Mackenbach, J.P., et al. 2008. Socioeconomic Inequalities in Health in 22 European Countries. New England Journal of Medicine 358: 2468–2481.CrossRefGoogle Scholar
  66. Marmot, Michael. 2004. The Status Syndrome: How Your Social Standing Directly Affects Your Health and Life Expectancy. London: Bloomsbury.CrossRefGoogle Scholar
  67. Marmot, M., et al. 1991. Health Inequalities Among British Civil Servants: The Whitehall II Study. Lancet 337: 1387–1393.CrossRefGoogle Scholar
  68. Marmot, M., and R.G. Wilkinson (eds.). 1999. Social Determinants of Health. Oxford: Oxford University Press.Google Scholar
  69. Masters, R. 1997. Brain Biochemistry and Social Status: The Neurotoxicity Hypothesis. In Intelligence, Political Inequality, and Public Policy, ed. Elliott White, 141–183. New York: Prager.Google Scholar
  70. McDonough, P., et al. 1997. Income Dynamics and Adult Mortality in the United States, 1972 Through 1989. American Journal of Public Health 87: 1476–1483.CrossRefGoogle Scholar
  71. McNeill, A. et al. 2017. Tobacco Packaging Design for Reducing Tobacco Use. Cochrane Database of Systematic Reviews 4.
  72. National Highway Traffic Safety Administration. 2016. Traffic Safety Facts: Seat Belt Use in 2015Overall Results. Washington, DC: US Department of Transportation, National Highway Traffic Safety Administration.
  73. Nisbett, R.E. 2009. Intelligence and How to Get It: Why Schools and Cultures Count. New York: Norton.Google Scholar
  74. Nisbett, et al. 2012. Intelligence: New Findings and Theoretical Developments. American Psychologist 67: 130–159.CrossRefGoogle Scholar
  75. Owen, M.J. 2006. Genes and Behavior: Nature-Nurture Interplay Explained. Oxford: Blackwell Publishers.Google Scholar
  76. Palloni, Alberto, et al. 2009. Early Life Effects on Socioeconomic Performance and Mortality in Later Life: A Full Life Course Approach Using Contemporary and Historical Sources. Social Science and Medicine 68: 1574–1582.CrossRefGoogle Scholar
  77. Pereboom, Derk. 2003. Living Without Free Will. Cambridge: Cambridge University Press.Google Scholar
  78. Raizada, Rajeev D., and Mark M. Kishiyama. 2010. Effects of socioeconomic status on brain development, and how cognitive neuroscience may contribute to levelling the playing field. Frontiers in Human Neuroscience. Scholar
  79. Rakowski, Eric. 1991. Equal Justice. Oxford: Oxford University Press.Google Scholar
  80. Rawls, John. 1993. Political Liberalism. New York: Columbia University Press.Google Scholar
  81. Rawls, John. 1999. A Theory of Justice, Rev ed. Cambridge, MA: Harvard University Press.Google Scholar
  82. Roemer, John. 1993. A Pragmatic Theory of Responsibility for the Egalitarian Planner. Philosophy & Public Affairs 22: 142–166.Google Scholar
  83. Roemer, John. 1995. Equality and Responsibility. Boston Review 20.
  84. Roemer, John. 1998. Equality of Opportunity. Cambridge, MA: Harvard University Press.Google Scholar
  85. Salonen, J.T. 1997. Why Do Poor People Behave Poorly? Variation in Adult Health Behaviours and Psychosocial Characteristics by Stages of the Socioeconomic Lifecourse. Social Science and Medicine 44: 809–819.CrossRefGoogle Scholar
  86. Scanlon, Thomas. 1995. Comments on Roemer. Boston Review 20.
  87. Scientific American Editorial Board. 2012. For a Healthier Country, Overhaul Farm Subsidies.
  88. Segal, Shlomi. 2013. Equality of Opportunity for Health. In Inequalities in Health: Concepts, Measures, and Ethics, ed. Nir Eyal, Samia A. Hurst, Ole F. Norheim, and Daniel Wikler, 147–163. Oxford: Oxford University Press.CrossRefGoogle Scholar
  89. Sen, Amartya. 2004. Why Health Equity. In Anand et al.Google Scholar
  90. Sharma, R. 2018. Health and Economic Growth: Evidence from Dynamic Panel Data of 143 Years. PLoS ONE 13 (10): e0204940. Scholar
  91. Shonkoff, J.P., W.T. Boyce, and B.S. McEwen. 2009. Neuroscience, Molecular Biology, and the Childhood Roots of Health Disparities: Building a New Framework for Health Promotion and Disease Prevention. JAMA 301: 2252–2259.CrossRefGoogle Scholar
  92. Siegel, K.R., et al. 2016. Association of Higher Consumption of Foods Derived from Subsidized Commodities with Adverse Cardiometabolic Risk Among US Adults. JAMA Internal Medicine 176: 1124–1132.CrossRefGoogle Scholar
  93. Strawson, Galen. 1994. The Impossibility of Moral Responsibility. Philosophical Studies 75: 5–24.CrossRefGoogle Scholar
  94. Susser, M., W. Watson, and K. Hopper. 1985. Sociology in Medicine. Oxford: Oxford University Press.Google Scholar
  95. Tucker-Drob, E.M., et al. 2010. Emergence of a Gene x Socioeconomic Status Interaction on Infant Mental Ability Between 10 Months and 2 Years. Psychological Science 22: 125–133.CrossRefGoogle Scholar
  96. Turkheimer, E., et al. 2003. Socioeconomic Status Modifies Heritability of IQ in Young Children. Psychological Science 14: 623–628.CrossRefGoogle Scholar
  97. van de Mheen, H., et al. 1998. Does Childhood Socioeconomic Status Influence Adult Health Through Behavioural Factors? International Journal of Epidemiology 27: 431–437.CrossRefGoogle Scholar
  98. Whitehead, Margaret. 1990. The Concepts and Principles of Equity in Health. Washington, DC: World Health Organization Regional Office for Europe.Google Scholar
  99. Wikler, Daniel. 1978. Persuasion and Coercion for Health. Millibank Memorial Fund Quarterly/Health and Society 56: 303–338.CrossRefGoogle Scholar
  100. Wilkinson, Richard G. 1996. Unhealthy Societies: The Afflictions of Inequality. London: Routledge.Google Scholar
  101. Wilkinson, Richard, and Michael Marmot (eds.). 2003. Social Determinants of Health: The Solid Facts. Geneva: World Health Organization.Google Scholar
  102. World Health Organization. 2016. Plain Packaging of Tobacco Products: Evidence, Design, and Implementation.

Copyright information

© Springer Nature B.V. 2019

Authors and Affiliations

  1. 1.Southern Connecticut State UniversityNew HavenUSA

Personalised recommendations