Health Policy 76 (2006) 312–319 Responsibility, fairness and rationing in health care Alexander W. Cappelen a , Ole Frithjof Norheim b,* a Department of Economics, University of Oslo and the Norwegian School of Economics, Norway b Division for Medical Ethics and the Philosophy of Science, Department of Public Health and Primary Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway Abstract Objective: People make different choices about how to live their life and these choices have a significant effect on their health, the risks they face and their need for treatment in the future. The objective of this article is, drawing on normative political theory, to sketch an argument that assigns a limited but significant role to individual responsibility in the design of the health-care system. Method: In developing our argument, we proceed in five steps. First, we review the literature on criteria for priority setting. Second, we explore the most prominent contemporary tradition in normative theory, liberal egalitarian ethics, with the aim to clarify the role of responsibility for choice. In particular, we discuss where liberal egalitarian theories would draw the ‘cut’ between the responsibility of the state (which is extensive) and the responsibility of the individuals (which is limited but significant). In the third step, we identify a priority setting dilemma where the commonly advocated criteria would assign equal priority. Finally, we develop a simple model in order to examine the implications of introducing a well-defined notion of responsibility for choice in a priority-setting dilemma of this kind. Results: Liberal egalitarianism holds individuals responsible for choices that affect their health, given that (i) the illness is completely or partly a result of individual behaviour and choice; (ii) the illness is not life-threatening; (iii) the illness does not limit the use of political rights or the exercise of fundamental capabilities; and (iv) the cost of treatment is low relative to the income of the patients. The paper shows how this type of considerations can be used to determine an optimal level of co-payments for diseases even when individual choices cannot be observed directly. Conclusions: It is possible to assign a limited but significant role to individual responsibility in the rationing of health-care resources. The liberal egalitarian argument captures a concern that is not captured by traditional criteria for priorities in health care. It can thus help policy makers in situations where the cost-effectiveness of different alternatives and the severity of the illnesses are approximately the same, or if the society wants to assign some weight to responsibility for choice. It can easily be linked to a system of graduated co-payments, but need not be. © 2005 Elsevier Ireland Ltd. All rights reserved. * Corresponding author. Tel.: +47 55 58 61 45/00; fax: +47 55 58 61 30. E-mail addresses: alexander.cappelen@nhh.no (A.W. Cappelen), ole.norheim@isf.uib.no (O.F. Norheim). 1. Introduction So-called life-style diseases, such as obesity, certain types of cancer and cardiovascular disease, constitute an increasing portion of health problems. The prob- ability of acquiring these diseases and the expected 0168-8510/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.healthpol.2005.06.013