Journal articles on the topic 'Pluralistic illness'

In this essay, I argue that structural approaches to narrative articulate identity and agency as internal constructs. As such, these analyses neglect the roles of institutional and social factors. A pluralistic analysis of these illness narratives, such as the one offered in this essay, can help narrative scholars better understand how these forces interact with the individual experiences of people living with illness in supporting and constraining agency.

Mental illness is a culturally laden phenomenon, and different cultures have unique ways of constructing mental illness. In this study, conceptions of mental illness were explored among 30 participants of Akan descent in Ghana through individual and group interviews. Participants demonstrated a wide range of knowledge on mental illness indicating that poor self-care, deficits in social functioning, and disordered behaviors are the cardinal features of mental illness. The data revealed that Akan cultural beliefs influenced notions of etiology of mental illness and care of the mentally ill. While participants recognized the role of multiple factors such as genetics, substance abuse, daily hassles (for example, concerns about basic needs such as food, clothing, and shelter), and trauma in the cause of mental illness, the predominant belief was that mental illness is a retributive and/or a spiritual illness. This belief encourages pluralistic health-seeking behaviors: use of hospitals, prayer camps, herbalists, and traditional healers. The implications of these findings for public health education on mental illness, and clinical training and practice are discussed.

Abstract1The popularity of faith-healing in sub-Saharan Africa has been widely acknowledged in research, but mostly treated as a phenomenon apart, instead of being viewed in relation to other modes of healing. In this article I focus on the reasons why believers choose faith-healing in a medically pluralistic situation and how they see other healing options available in a locally founded Charismatic church community, the Gospel Miracle Church for All People (GMCL), in the Southern Tanzanian city of Mbeya. I propose that, in order to see the medically pluralistic context in Tanzania through the journeys of health-seeking nomads, the focus must lie on two intertwined aspects of faith-healing: first, it is inevitably based on the need to be healed and speaks of a failure of biomedicine to explain illness and provide healing; and second, the long journeys that are made in search of healing mean traversing boundaries and switching between parallel healing systems: biomedicine, traditional healing, and faith-healing. While health seeking nomads are in many ways in a vulnerable position, I suggest that their ability to move from one healing option to another speaks of agency: not in the sense of full control over their life situations but, rather, as a way of coming to terms with their illness.

Modern bioethics, which is based on Western moral philosophy and Western biomedical perspectives, has evolved within a complex, highly individualistic culture that draws a sharp distinction between church and state and tolerates a multitude of values. This discipline defines its principles in secular and objective terms that often are bewildering to people of non-Western origin. Despite much discourse, principlism remains the fundamental framework of bioethics. Principlism is held in such high regard that many bioethicists equate autonomy with personhood, as if autonomy exists independently of specific beliefs and commitments.In addition, we continue to minimize the substantial differences in the way people of different cultures perceive, experience, and explain illness, although our views of the potential cultural limitations of Western medicine have grown and expanded in recent years. At the heart of it we continue to be tied to a biomedical focus that largely neglects the context of the situation.

Modern medicine owes many of its founding principles to a spiritual heritage. However, passage through the Enlightenment and entry into a secular, pluralistic health context have yielded an estranged relationship between care of the body and care of the soul.1 Scientific medicine now holds the primary role in care of the body while religious communities are solely responsible for care of the soul. The needs of both body and soul are in many respects served well by this specialization and division of labor, but ultimately, of course, human experience is not susceptible to such a simplistic dichotomization. The lack of integration of spiritual and material care of the human person in contemporary life has led to increasingly evident tensions, most notably in the mechanization and isolation of the experiences of illness and dying.2

Introduction: Complementary and alternative medicine (CAM) use has been increasing in the past decades in tandem with changes regarding the notions of health and illness. Comparing conventional medicine (CM) and CAM in how they address health problems has been a point of focus for both the health sciences and individuals dealing with health problems. Various social, cultural, political, economic, and personal factors play a role in whether different health approaches are integrated or not when addressing illness experiences. Methods: The qualitative study comprised semistructured interviews (N = 9) and participant observation involving 105 patients conducted between January 2015 and May 2017 at 4 clinics of Traditional Chinese Medicine in Budapest, Hungary. Code structures were created inductively with Interpretative Phenomenological Analysis. Results: The mutually exclusive view of CM/CAM use occurred due to loss of trust in the doctor-patient relationship causing problems in communication, and also as a result of the patient espousing certain cultural dispositions. Significant dispositions included a preference for the “natural” and psychologization, the latter often manifested in psychosocial etiology, vitalism, and illness symbolism. Discussion: A polarized choice of therapy may occur as a result of a competitive health care market in which medical modalities and their underlying cultural systems compete within a global milieu of information proliferation and a hybridization of individual worldviews. Through a process of “cultural creolization”, changing concepts of health and illness create varying patient expectations and meanings regarding illness, which in turn affect therapy choice as well. Conclusion: Mirrored in the articulation of an individual’s illness trajectory is a tension that is also reflected in the struggles in the health care system to more adequately understand health/illness processes from a pluralistic perspective. The power relations in the health arena (among CAM/CM practitioners and systems) play a role in legitimizing or undermining different health practices, which as consequence affects the possibility of integrating them into the processes of care. Thus, therapy choice is not only linked to changing notions of health and illness, but also to shifting conceptualizations of self, identity, and the practitioner-patient relationship.

In this article, we examine illness narratives to illuminate the discursive work that patients undertake to construct themselves as “good” and adherent. Biographical narrative interviews were undertaken with 17 patients receiving anticoagulation for stroke prevention in atrial fibrillation, from five English hospitals (May 2016–June 2017). Through pluralistic narrative analysis, we highlight the discursive tensions narrators face when sharing accounts of their medicine-taking. They undertake challenging linguistic and performative work to reconcile apparently paradoxical positions. We show how the adherent patient is co-constructed through dialogue at the intersection of discourses including authority of doctors, personal responsibility for health, scarcity of resources, and deservingness. We conclude that the notion of medication adherence places a hidden moral and discursive burden of treatment on patients which they must negotiate when invited into conversations about their medications. This discursive work reveals, constitutes, and upholds medicine-taking as a profoundly moral practice.

African medicine is an important component of the cultural adaptive system. The system has been evolving interminably in response to changing environmental vulnerabilities and health care needs since primordial times. Flexibility of indigenous African ethnomedicine and its associated customs has since time immemorial incorporated new techniques and knowledge. The resulting textual and discourse heritage on African medicine has often depicted its dialectical interrelationship with western biomedicine and other medical systems. The oral and documentary records on the authenticity of African medicine either conceal or condescend to its contributions to overall healthseeking and illness behaviour. Tensions in conceptualisation of African medicine relate to its pragmatic borrowing from non-African medical systems that are compatible with local pluralistic systems and indigenous ontology. The advent of colonial and post-colonial health care paradigms further define the emergence of dialectics in the documentation and appraisal of African medicine against western standards of science and health care practices.

Two different health projects are evaluated in this paper. The Koster Health project taking place at the Koster Islands in Sweden and the Ametra project going on among the Shipibo-Conibo in Peru. Both projects focus more on the determinants of health than on sickness and more on the individual's subjective feeling of illness than on the biomedically "objectively" recognizable disease. "Mobilization" and "responsibility"for the individual's own health are central concepts in both projects. In the theoretical part of the paper a human ecological perspective is suggested to analyse the interaction between human health and environmental changes. The author emphasizes the importance of interdisciplinary research when evaluating how the external determinants from the natural and social environment affect human beings and health. The human ecological approach is seen as a complement to the biomedical research. Health and disease are two poles in a continuum. In a pluralistic society we should struggle towards the pole of health.

AbstractIn this paper I present the complex understanding of illness and healing in the Catholic Marian Faith Healing Ministry (MFHM) in Tanzania. The efficacy of religious healing should be understood as a social process dependent on the plausibility and attractiveness that the rituals have for the individual patients, as well as for their community. By contrasting an analysis of the publications of the leader of the group, Father Nkwera, with guided interviews among the members, I was able to develop a differentiated picture of the broad range of healing concepts within the group. While Nkwera translates local spirit beliefs into an apocalyptic worldview that associates physical healing with political critique—especially in the case of HIV/AIDS—his followers situate the healing process within a framework of personal salvation. In my study, I contextualise the MFHM within its pluralistic traditional, Muslim, Catholic, Pentecostal and biomedical environment that impact it on local and global levels.

Illegal drug use in Hungary became a mass phenomenon after the political changes of 1990. It is only recently that autobiographies of recovered drug users and their family members have been written and published. The present author suggests that since the Alcoholics Anonymous (AA) approach has no traditional roots in Hungary, recovery stories are obliged to follow another master narrative. All of these stories were published in book form. The author analyzes the various narratives partly through the lens of Frank-style illness narratives and partly using self-pluralistic theories. The latter (primarily using Hermans notion of the dialogic self) provide a good theoretical basis for analyzing the processes active in the personality of a drug user and for showing the “retrospective” construction work that accompanies recovery (which in fact takes place at the same time as recovery). In this case, the spatial interpretation of individual self-positions and the dialogical relationship that developed between them proved particularly useful.

AbstractPsychiatry has long debated whether the causes of mental illness can be better explained by reductionist or pluralistic accounts. Although the former relies on commonsense scientific bottom-up causal models, the latter (which typically include environmental, psychological, and/or socio-cultural risk factors) requires top-down causal processes often viewed with skepticism, especially by neuroscientists. We begin with four clinical vignettes which illustrate self-interventions wherein high-order psychological processes (e.g. religious beliefs or deep interpersonal commitments) appear to causally impact the risk for or the course of psychiatric/behavioral disorders. We then propose a model for how to understand this sort of top-down self-causation. Our model relies centrally on the concept of a control variable which, like a radio tuning dial, can implement a series of typically unknown physical processes to obtain the desired ends. We set this control variable in the context of an interventionist account of causation that assumes that a cause (C) produces an effect (E) when intervening on C (by manipulating it) is associated with a change in E. We extend this framework by arguing that certain psychological changes can result from individuals intervening on their own mental states and/or selection of environments. This in turn requires a conception of the self that contains mental capacities that are at least partially independent of one another. Although human beings cannot directly intervene on the neurobiological systems which instantiate risk for psychiatric illness, they can, via control variables at the psychological level, and/or by self-selection into protective environments, substantially alter their own risk.

AbstractIntroduction. Modern world map characterizes existence of pluralistic and multicultural societies formed as a result of increased citizens’ mobility and globalization process. Cultural diversity realizes its implications in all the aspects of social functioning and in significant share through the system of healthcare. Accepting the concept of illness as a social construct, intercultural attitudes become leading principle of education and practice of healthcare workers at every level. By the nature of their profession, nurses in the primary healthcare institutions acquire key role in the process of implementation of inter-cultural principles in clinical practice, with the aim for the healthcare system to become more open and more sensitive to specific social occurrences and culturally driven healthcare need of its users.Aim. The expected contribution of the work is oriented towards the possibility of theoretical and practical foundation of multidimensional and multi-perspective approach to healthcare.Discussion. The discourse of the cultural context of nursing in the field of outpatient healthcare in Serbia is based on the axiomatic assumption that illness is a social construct and that sociological and anthropological perspective can change the clinical practice. The work comprises basic cultural factors as a dynamic factor of health and illness, principles, elements and significance of cultural assessment of the patient in nursing practice; presents the differences in patient’s position within the Parsons concept and contemporary concept of post-modern approach to the patient. Cultural concept of nursing in Serbia has been analyzed through the prism of “5D Cultural model” by Dr. Geert Hofsted with presentation and interpretation of its basic dimensions.Conclusions. Healthcare system in Serbia is facing challenges of reforms – the introduction of socio-cultural aspect in creating of primary healthcare policy in the spirit of modern multicultural social tendencies. Aiming to provide quality healthcare it is necessary to understand how a society acknowledges the terms of health and illness and which cultural aspects lies in the base of individual’s behavior. If one healthcare is not founded upon cultural values then it is impossible to achieve its therapeutic goal, it will be incomplete and unsuccessful. The treatment plan and patient’s care must be individual, holistic and culturally appropriate.

Abstract Remittances, financial support from family members who have migrated for work, are an increasingly important source of income for households left behind in many lower- and middle-income countries. While remittances have been shown to affect the health status of children left behind, evidence is very limited as to whether and how they affect children’s healthcare utilization. Yet, this is an important consideration for policymakers seeking to improve equitable access to quality care in settings where migration is common. I examine whether children under age five whose household receives remittances are more likely to utilize higher quality healthcare providers than those without remittances in Cambodia, a country with high rates of migration and a pluralistic health system. The analysis includes 2230 children reporting recent illness in three waves of the Cambodia Socio-Economic Survey with data on migration, remittances and children’s health expenditures. I use mixed-effects and fixed-effects regression analysis to estimate the effect of remittances on children’s likelihood of entering care with a formally trained provider, and among those attending a formally trained provider, likelihood of using a public-sector facility. Treatment expenditures are lower among households with remittances, while transportation expenditures do not vary significantly by remittance status. In mixed-effects and fixed-effect regression models, children who receive remittances have a lower likelihood of utilizing qualified providers (adjusted OR = 0.66, 95% confidence interval 0.44–0.98), though this effect is attenuated in fixed-effects models, and there is no association between remittances and attending a public-sector facility. These findings underscore that remittances alone are not sufficient to increase children’s utilization of qualified providers in migrant-sending areas, and suggest that policymakers should to address barriers to care beyond cost to promote utilization and equity of access to higher quality care where remittances are a common source of income.

<p><strong>Background.</strong> The Diagnostic and Statistical Manual of Mental Disorders (DSM) system has certain limitations when applied to two South African examples of dissociation, because it is descriptive (non-explanatory) and focuses on intrapsychic (non-communal) processes. Even the existing Western explanatory models of dissociation fail to accommodate fully the communal aspects of dissociation in our South African context.</p><p><strong>Objectives and methods.</strong> The aim was to explore an expanded perspective on dissociation that does not limit it to an intrapsychic phenomenon, but that accounts for the interrelatedness of individuals within their social context. Auto-ethnography was used. In this article a collective, socially orientated, contextual hermeneutic was applied to two local examples of dissociation. Three existing Western models were expanded along multicontextual, collective lines, for them to be more useful in the pluralistic South African context.</p><p><strong>Results.</strong> This preliminary contextual model of dissociation includes a person’s interpersonal, socio-cultural, and spiritual contexts, in addition to the intrapsychic context. Dissociation is considered to be a normal information-processing tool that maintains balanced, coherent selves-in-society, i.e. individuals connected to each other. In the South African context dissociation appears mostly as a normal phenomenon and seldom as a sign of mental illness. Dissociation is pivotal for the normal construction of individual and communal identities in the face of conflicting sets of information from various contexts. Dissociation may help individuals or communities to survive in a world of conflicting messages, where conflict is often interpersonal/cultural/societal in nature, rather than primarily intrapsychic.<strong></strong></p><p><strong>Conclusions.</strong> This model should be developed and evaluated further. Such evaluation would require suitable new local terminology.</p>

Barring a few exceptions (such as rauwolfia), most of the psychiatric medications have been developed in the West, especially the USA, the UK and Europe. Their safety trials have been conducted in the populations living in these parts of the world. Although these drugs are used all over the world there is a limited research to determine accurate pharmacodynamic and pharmacokinetic profiles across different ethnic groups. Hence, clinicians usually adopt a ‘universalist style’ (seeing every condition and treatment as similar) of managing psychiatric illnesses, but this appears to neglect the information from the emerging literature which advocates a relativist approach to pharmacotherapy (see Lin et al 1995 for review). Anthropologists have encountered ‘phenomenological absolutism’ in a general tendency of people from one culture to perceive and value other cultures in terms unconsciously based upon their own, but phenomenologically experienced as absolute and universally applicable (also known as ethnocentrism). In addition to ethno-biological determinants of drug response, there are significant cultural factors: the concurrent use of pluralistic health systems, alternative therapies and folk remedies which might support, hinder or complicate pharmacotherapy and treatment adherence. In this paper we highlight some key factors of which clinicians need to be aware. These include pharmacodynamic and pharmacokinetic principles, and application of these principles in pharmacological management of psychiatric conditions. Ethnic differences in pharmacodynamics are most clearly demonstrated in the greater sensitivity to a variety of drugs in Caucasians than in Asians or in African–Caribbeans.

Using the insights provided by Professor Michael Worton and sociologist David Baronov, the paper strives to show that the cultural aspect of medicine is intrinsic to health and illness. This paper seeks to present the vibrancy of pluralistic medical practices in contemporary Africa through Kenyan writer Ngugi wa Thiong’o’s novel Wizard of the Crow. It seeks to illustrate the pragmatic nature of African pluralistic medical practices that absorb and assimilate certain aspects from biomedicine, thereby paving the way for a distinctive blend that may rightly be termed as African biomedicine. It contends that African pluralistic medicine, biomedicine, and African biomedicine can coexist peacefully and contribute to the wellbeing of the African society in a highly globalized world.

The mental health of women living in poverty is a growing public health concern, particularly in India where the burden of illness is compounded by critical shortages in mental health providers and fragmented services. This was an exploratory study which sought to examine low-income women’s perceptions of mental illness and its management in the context of urban poverty in India. This research was prompted by the lack of empirical studies documenting how women in marginalized sections of society understand mental illness. Data were collected through a combination of 10 focus group discussions and two individual interviews with a total of 63 women residing in low-income areas of Mumbai. Social representations theory was used to explore shared meanings of mental illness among women in this setting. Thematic analysis of the data showed that women use the expression “tension” to talk about mental illness. Tension was described both as an ordinary part of life and a condition having its origins in more profound gender-related stressors, particularly pressures surrounding motherhood, chronic poverty and domestic conflict. Approaches to managing tension were pluralistic and focused on the resumption of social roles. Findings are consistent with other studies in similar cultural contexts, suggesting a shared, transnational character to women’s distress and the need for scholarship on women’s mental health in low-income settings to be more attuned to gendered forms of marginalization.

Abstract Background Pre-eclampsia is a leading cause of preventable maternal and perinatal deaths globally. While health inequities remain stark, removing financial or structural barriers to care does not necessarily improve uptake of life-saving treatment. Building on existing literature elaborating the sociocultural contexts that shape behaviours around pregnancy and childbirth can identify nuanced influences relating to pre-eclampsia care. Methods We conducted a cross-cultural comparative study exploring lived experiences and understanding of pre-eclampsia in Ethiopia, Haiti and Zimbabwe. Our primary objective was to examine what local understandings of pre-eclampsia might be shared between these three under-resourced settings despite their considerable sociocultural differences. Between August 2018 and January 2020, we conducted 89 in-depth interviews with individuals and 17 focus group discussions (n = 106). We purposively sampled perinatal women, survivors of pre-eclampsia, families of deceased women, partners, older male and female decision-makers, traditional birth attendants, religious and traditional healers, community health workers and facility-based health professionals. Template analysis was conducted to facilitate cross-country comparison drawing on Social Learning Theory and the Health Belief Model. Results Survivors of pre-eclampsia spoke of their uncertainty regarding symptoms and diagnosis. A lack of shared language challenged coherence in interpretations of illness related to pre-eclampsia. Across settings, raised blood pressure in pregnancy was often attributed to psychosocial distress and dietary factors, and eclampsia linked to spiritual manifestations. Pluralistic care was driven by attribution of causes, social norms and expectations relating to alternative care and trust in biomedicine across all three settings. Divergence across the contexts centred around nuances in religious or traditional practices relating to maternal health and pregnancy. Conclusions Engaging faith and traditional caregivers and the wider community offers opportunities to move towards coherent conceptualisations of pre-eclampsia, and hence greater access to potentially life-saving care.

Background: For many people in African countries, various forms of health care are utilised for the treatment of illness. This pluralistic nature of health seeking includes the use of indigenous, faith and allopathic medicines for care.Aim: In this article, our aim was to gain insight into the existing knowledge on indigenous and faith healing in Ghana, with a particular focus on mental health care. We first examine the reported mental health beliefs and practices of Ghanaian alternative healers. Following this, we look at the use and purported preference for non-biomedical mental health care by patients.Methods: Relevant literature was examined to explore the beliefs, practices and use of non-biomedical mental health care systems in GhanaResults: Evidence for the use and preference for non-biomedical mental health care is largely anecdotal. Similarly, the mental health beliefs of alternative healers have been documented in various small-scale studies. However, such information is important if mental health services in Ghana are to be improved.Conclusion: Integration of the different healthcare systems must be built on knowledge of beliefs and methods. A clearer understanding of the work of non-biomedical healers is important if appropriate recommendations are to be made for collaboration between biomedical and non-biomedical systems in Ghana.

Abstract Background Little is known about the medical material and practices of tribes in the western border areas of Pakistan. The local population has inhabited this remote and isolated area for centuries, and gained medicinal knowledge with personal experiences and knowledge learned from forefathers. Due to the geographical isolation of the communities in the Sulaiman hills of Pakistan and their unique culture, the area is of importance for exploration and assessment. Methods A total of 116 informants were interviewed in five foothill villages and the associated migratory mountain villages during 2010–2012 and 2015. Information was gathered mainly through semi-structured interviews and freelisting. Local diseases were categorized based on symptoms and affected organs. Descriptive statistics were used for data analysis. Results Depending on the type of illness, typically a pulse diagnoser or a religious specialist is consulted. Medicinal plant knowledge and use is mostly known and advised by elders within the family. A total of 44 plant species from 32 families (588 use reports), 7 animal species and 6 minerals and other sources (384 use reports) were documented as materia medica. Among the plants, the Lamiaceae is the most dominantly used plant family, followed by Pinaceae. The most frequently reported single species was Teucrium stocksianum. The most often mentioned diseases and treatments fall into the categories of gastrointestinal, ritual, and musculoskeletal diseases. The use of goat and sheep skin as medicine was pivotal in the local medicinal system. Remedies from animal parts and other biological and non-biological sources were mainly used for musculoskeletal ailments and ritual treatments. Overall, people rely on both traditional and biomedical medication and treatments and combination of these systems. Conclusion This paper provides insight into the pluralistic medication system of rural communities of northwest Pakistan. It highlights the materia medica most commonly in use. A considerable part of the documented materia medica and local practices is part of an oral tradition and cannot be found in written sources or scientific articles. The gaining of new medicinal knowledge in the area was the good sign of continuation of traditional medicinal practices.

Integrating mental, neurological, and substance use (MNS) health care into the public health system has become a global priority, with mental health, and well-being now being part of the Sustainable Development Goals. In the aim to provide good quality care for MNS disorders, understanding patients' pathways to care is key. This qualitative study explores the pathways to care of patients attending an outpatient mental health clinic of a district hospital in eastern rural Uganda, from the perspectives of their caregivers. Twenty seven in-depth interviews were conducted with caregivers of MNS patients visiting the clinic, with a focus on four case-presentations. Data analysis consisted of thematic and emergent content analyses using NVivo 11. Results across all interviews highlight that chosen help-seeking itineraries were largely pluralistic, combining and alternating between traditional healing practices, and biomedical care, regardless of the specific MNS disorder. Intra-household differences in care seeking pathways—e.g., where one patient received traditional help or no care at all, while the other received biomedical care—depended on caregivers' perceived contextual illness narrative for each patient, in combination with a variety of other factors. If interpreted as a form of bewitchment, traditional medicine and healing was often the first form of care sought, while the mental health clinic was seen as a recourse to “free” care. Patients, especially younger children, who showed visible improvements once stabilized on psychotropic medication was a source of motivation for caregivers to continue with biomedical care at the mental health clinic. However, stock-outs of the free psychotropic medication at the clinic led to dissatisfaction with services due to out-of-pocket expenses and precipitated returning to alternative therapy choices. This article showcases the importance of understanding the complex and varied combinations of individual, cultural, socioeconomic and structural factors that may affect caregivers' choices of pathways to care for patients with MNS disorders in eastern rural Uganda. These cumulative complex processes and context-specific help-seeking behaviors, which ultimately impact patient treatment and MNS health outcomes, need to be first acknowledged, understood and taken into account if we are to promote more inclusive, effective and integrated public mental health systems globally.

Abstract Background Access to effective biomedical treatments for humans and livestock in Kenya is far from universal. Indigenous healing has a significant role to play in contemporary society in Kenya, yet access is not the only reason for this. Beliefs surrounding the composition of biomedicines, people’s experiences of biomedical care, and issues of counterfeit biomedicines sold over the counter have led to patients seeking care outside of biomedical institutions. Methods This study explores local realities of treatment seeking in one rural and one urban study site, for both humans and their livestock, including when, where and how people access certain types of medicines. Using an ethnographic approach to interviews, focus groups and observations, I explore the role that indigenous healing, both herbal and occasionally spiritual, plays within this context with healers and community members. Results Indigenous healing remains important for many people due to their mistrust and suspicion of biomedicine and big pharma. Their interactions with the healer or doctor, and the equity of these interactions, influence their decisions whether to access herbal or biomedical care, or a combination of the two. Indigenous healing bridges the gap many people experience when they are unable to access biomedical treatments and effectively creates a broader, more equitable coverage for healthcare. The plurality of reasons surrounding decision making is complex, but it is clear that many people often use indigenous healing, improvements in the regulation of both formulas and practice would assist people to access more effective treatment. Conclusions Indigenous healing is an important way in which Kenyans in rural and urban areas access healthcare for themselves and their animals. Issues of counterfeit biomedicines have led to broad mistrust and people favour indigenous healing, depending on the illness or severity of symptoms. Indigenous healing is a vital way in which people in underserved rural and urban populations access care. Herbal medicines and indigenous healing are trusted due to the greater transparency in their creation, and the more equitable relationship between indigenous doctor and patient. The study demonstrates that a pluralistic system is appropriate to increasing equity in access to healthcare in both urban and rural settings, as well as the importance of biomedical care providers respecting indigenous healing and viewing it with legitimacy. By taking a One Health perspective to understand the intersection of humans, livestock and the environment, we can better understand critical aspects affecting decision making for treatment and implications for healthcare equity in a rapidly changing world.

Absence of health, that is, sickness in Africa is viewed in personalistic terms. A disease is explained as effected by ‘the active purposeful intervention of an agent, who may be human’, non-human (a ghost, an ancestor, an ‘evil spirit), or supernatural (a deity or other very powerful being)’ (Foster). Illness is thus attributed to breaking of taboos, offending God and/ or ancestral spirits; witchcraft, sorcery, the evil eye, passion by an evil spirit and a curse from parents or from an offended neighbour. In view of these personalistic theories of ill health, treatment is through ritual purification, exorcism or sacrifices. For an appropriate diagnosis and intervention, it is imperative to determine ‘who’ caused the illness and then ‘why’ it was caused, to which answers are offered through divination by a healer. This interpretive framework, is applicable to all types of sickness, facilitates co-existence of African traditional healing and biomedical treatment, that is, plurality of health seeking practices. The approach fails to offer a constructive approach and contradicts the biblical healing framework whereby one may not have explanatory causes to a situation of ill health. This article engaged the biblical concept of shalōm as a relevant constructive framework. The Hebrew concept of shalōm, though distinctly salvific, is inclusive of holistic and personalistic healing aspects. The concept encompasses constructive aspects of completeness, wholeness, health, peace, welfare, safety, soundness, tranquillity, prosperity, perfectness, fullness, rest, harmony and the absence of agitation or discord, which provides a useful holistic healing theological framework. It therefore provides a health and well-being framework that is relational, sensitive and applicable to healing patterns in Africa. Using the case study of the Abaluyia people of East Africa, this article discussed bereavement as a state that requires healing and how the biblical framework of shalōm could be applied in fostering bereavement healing.

Summary Set in Espiritu Santo, Vanuatu, this study explores the relationship between cultural knowledge and beliefs concerning illness and health-seeking behaviour within the context of medical pluralism. Concentrating on the nation’s high rates of diabetes and non-communicable disease (NCD) risk factors, this research analyses the way in which understandings of disease aetiology and healing efficacy impact upon treatment-related decisions. Data were obtained through a mixed-methods community survey of 313 adult respondents developed in collaboration with ni-Vanuatu health experts, community leaders and survey enumerators, and comprised of open and closed-ended questions. As the results demonstrate, framed by cultural and religious beliefs, multifaceted indigenous conceptualizations of health and illness in Vanuatu are directly linked to pluralist health seeking practices, including the concurrent use of formal and informal health services. The interwoven identification of sociocultural, physical and clinical determinants of disease highlights the complex manner in which health is understood and maintained by ni-Vanuatu. In successfully addressing the rising burden of NCDs, it is integral that health interventions and service providers acknowledge the complex conceptualization of disease and ensure the provision of holistic care that embraces rather than ignores the steadfast role of local systems of belief, and of traditional, religious and other informal forms of healthcare provision.

This essay explores Dorothy Wordsworth’s collaborative, “pluralist” model of selfhood and authorship as it is elaborated in her Grasmere journal (1800-03). Nature and community, for her, are extensions of the self rather than (as they often are for her brother William) external forces to be subsumed by the self of the solitary artist. This model, however, is the site of ambivalence and conflict, and is therefore “imperfect” – a word Wordsworth herself uses to qualify the “summary” she believes her journal as a whole provides. It is “imperfect” not because it is inferior, weak, or deficient in some way, but because it is riddled with tension and inconsistency. Wordsworth embraces processes of collaborative creativity, but she also expresses – largely through her narrations of illness – dissatisfaction with such processes, and she sometimes finds relief in her solitary, melancholic musings. In these ways, she at once subverts, reworks, and reinforces conventional, ‘solitary genius’ paradigms of authorship.

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS I. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[i] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[ii] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. II. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[iii] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[iv] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[v] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[vi] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[vii] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[viii] In democratic societies, one must take into consideration community morals and values.[ix] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[x] III. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[xi] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[xii] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[xiii] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[xiv] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. IV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[xv] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[xvi] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[xvii] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[xviii] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[xix] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[xx] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[xxi] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. VI. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[xxii] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[xxiii] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[xxiv] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. VII. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [i] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [ii] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [iii] Moss, p. 1295-1298. [iv] Moss, p. 1296. [v] Moss, p. 1295-1298. [vi] Moss, p. 1295-1298. [vii] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [viii] Cohen, p. 1299-1301. [ix] Moss, p. 1297. [x] Cohen, p. 1300. [xi] Cappelen, p. 478-480. [xii] Cappalen, p. 478-480. [xiii] Cappelen, p.479. [xiv] Cappelen, p. 479. [xv] Cappelen, p. 479 [xvi] Cohen, p. 1301. [xvii] Cappelen, p. 478. [xviii] Cohen, p. 1299-1301. [xix] Cohen, p. 1301. [xx] Cappelen, p. 476-480. [xxi] Cappelen, p. 476-480. [xxii] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [xxiii] Kawachi, p. 18-33. [xxiv] Kawachi, p. 18-33.

Photo by Tingey Injury Law Firm on Unsplash ABSTRACT The coverage of healthcare costs allegedly brought about by people’s own earlier health-adverse behaviors is certainly a matter of justice. However, this raises the following questions: justice for whom? Is it right to take people’s past behaviors into account in determining their access to healthcare? If so, how do we go about taking those behaviors into account? These bioethical questions become even more complex when we consider them in the context of a commitment to publicly funded, universal healthcare coverage. INTRODUCTION Healthcare coverage of lifestyle-related conditions is certainly a matter of justice. However, this raises the following justice-related question: Is it right to consider people’s past behaviors in determining their access to healthcare? If so, the methods of taking those behaviors into account must be fair and justifiable. This bioethical question becomes even more complex when we consider it in the context of a commitment to publicly funded, universal healthcare coverage. This paper takes an old, classic debate, evaluates newer approaches, and offers an argument favoring a combined approach which alters the liberal-egalitarian solution to account for social justice. ANALYSIS l. Causes of Disease If healthcare coverage were universal, irrespective of socioeconomic status and lifestyle, people would contribute to the cost of remedying the lifestyle-induced health problems of others. In the West, lifestyle-related diseases are burdensome.[1] This paper approaches this concern from a western lens that incorporates both a European tradition of “social safety nets” and an American tradition of personal freedoms. By taking such an approach, solutions to the consequences of one’s past behavior burdening others must consider an individual’s personal freedom to choose to act as he or she wishes, with the distributive social and economic equality of the many. The concept of disease caused by lifestyle and diet is proven. Many health conditions include behavioral risk factors. Multi-pack smoking increases the risk of chronic lung disease, while obesity increases the risk of type 2 diabetes. Inattention to high blood pressure, high cholesterol, and a lack of exercise leads to increased risks of coronary artery disease.[2] While poor lifestyle choices certainly influence these conditions, their causes are multifactorial, and it is difficult to say that any single string of poor choices led to their development. In a scenario where two men excessively eat fast food for 20 years, several discrete factors impact whether any of them might suffer an ischemic-embolic stroke or not. Genetics, circumstances, and activity will also contribute to outcomes. ll. Alcohol-Related End-Stage Liver Disease One paper suggests that alcohol-related end-stage liver disease (ARESLD) differs from other multifactorial disorders as alcohol alone causes the disease.[3] It justifies attributing personal responsibility to patients with ARESLD because the condition develops only after the cumulative effects of large quantities of alcohol consumed from years to decades.[4] However, the paper undermines its position by admitting that even the susceptibility to becoming an alcoholic has some degree of genetic predisposition.[5] Given the extreme scarcity of donor livers, some patients may be prioritized over others on the transplant waiting list. Since donor livers cannot be given to everyone, transplanting a liver into an alcoholic may result in death for competing candidates whose liver disease was not their fault. All else being equal, if bioethicists avoid claiming moral deficiency or judgment, those with apparently self-inflicted ARESLD will not be deprived of treatment but will have a lower priority for transplant.[6] In contrast, another position suggests that it is often difficult to define what behaviors are punishable as these are largely personal and value-laden.[7] Still, people do not support using their own resources to support the consequences of others’ poor choices, no matter how objective.[8] In democratic societies, one must take into consideration community morals and values.[9] Even if we were to punish people for their health-adverse behaviors, we could not logistically employ the vigorous and sustained efforts necessary to determine whose actions are morally weak.[10] lll. The Liberal-Egalitarian Proposal One past argument proposes a liberal-egalitarian solution to manage personal responsibility for so-called “lifestyle diseases.”[11] This Rawlsian system combines the European-style “social safety net” commitment to social and economic equality with the American liberal notion of pluralist toleration and personal freedoms. This idealized system aims to hold people responsible for their choices rather than the consequences to mitigate the downside of blaming those who might not be blameworthy. The approach avoids determining the questionable nature of luck and personal responsibility for health outcomes, fairness in the distribution of economic burden, and the intrusiveness required to practically determine who acts in a morally wrong and health-adverse way. The liberal-egalitarian model, a theory of distributive justice, has two facets: the liberal principle that people should be held accountable for their choices and the egalitarian principle that people who make the same choices should have the same outcomes.[12] This model attempts to fuse responsibility with equity by seeking to reward good behavior and tax bad behavior rather than punish the consequences of the action and navigate who deserves treatment. For instance, the hospital bedside is not the appropriate place to introduce responsibility for one’s health outcomes.[13] This appeals to the reality that, at that time, discerning the true causes of disease was not plausible and to humanity in avoiding a heartless and cruel approach. An argument in favor of the liberal-egalitarian model considers its method of implementation. This approach assumes that the healthcare system treats all individuals regardless of their choices or ability to cover costs. The liberal-egalitarian model also assumes that a certain adverse health condition is related, statistically speaking, to the consumption of a certain good and that good can be taxed. As such, it proposes to tax the consumption of that good to finance the collective burden which arises from that good’s consumption rather than require individuals to pay for their own treatment. In the example of ARESLD, the recommended solution would be taxing all alcohol. While a systematic infrastructure is not explicit, there is the implication that a per-unit tax can be imposed on alcohol so the total tax revenue would make up for the additional healthcare costs due to consumption.[14] Upholding the principle that all people who make the same choices should face the same costs, all consumers of alcohol would pay the same tax, regardless of factors such as genetic predisposition to alcoholism, lifestyle, or expected cost of treatment. Upholding the principle of individual responsibility, this model does not deny treatment to anyone, neutralizing factors outside that individual’s control by imposing the tax ex-ante. Other people are not burdened by those who consume the good. People who consume alcohol face a burden proportional to the amount consumed. This tax-based implementation is justified so long as the tax is not prohibitively high for the average consumer. Further, the model mitigates concerns over the intrusiveness of ascribing morality to health-adverse behaviors. lV. Moral and Social Arguments Against the Liberal-Egalitarian Position Arguments against the liberal-egalitarian model concerns its many assumptions. First, this model assumes that consumption of such goods is directly related to the health outcome and that these goods can be taxed.[15] Certain people genetically predisposed to alcoholism would be predisposed to consume more alcohol. The model falls short when applied to scenarios where health outcomes are not consumption-based, such as engaging in unsafe sex or abstaining from healthy lifestyle choices like exercise. Second, some might argue that the liberal-egalitarian model fails to remain neutral. Residual moral judgments tied to consumption choices introduce non-neutrality. Although taxation in free societies is determined by democratic procedures rather than by individuals in the healthcare system, moral and value-based judgments will be implicit in deciding what behaviors are taxable, such as the purchase of cigarettes. Third, the liberal-egalitarian model fails to determine whether one’s behavior is autonomous, as socio-cultural-economic factors may influence it and behavior is more a product of society, peer pressure, or income. Those also may reflect systemic inequalities. Therefore, this model, which rewards, or taxes based solely on decisions, regardless of their consequences and motivations, fails to consider that a person’s decisions may not be completely autonomous. V. Libertarian Arguments Against the Liberal-Egalitarian Model a. State Intrusiveness as Counter to the Liberal-Egalitarian Model Last, there is a libertarian worry that if the state guarantees universal healthcare coverage to all people, the state will have to become highly intrusive and investigate people’s morals.[16] At least one-third of all disease burden in North America, Europe, and the Asia-Pacific is attributable to lifestyle measures such as tobacco smoking, alcohol consumption, high cholesterol, and obesity.[17] With these various lifestyles, it is not likely to agree on what conduct to tax or condemn.[18] The fine-toothed comb required to determine whether each citizen has been engaging in these behaviors would intrude on daily life and personal freedom. Libertarians champion the argument that impractical intrusiveness would result from universal healthcare, and such a degree of intrusiveness would likely be universally unacceptable.[19] The liberal-egalitarian model mitigates the libertarian worry about state intrusiveness as it does not involve prying into one’s life and choices other than taxing goods. A liberal state should ideally be neutral to how people decide to live their lives. In all, libertarians can rest assured that the liberal-egalitarian tax-based model, through its ex-ante implementation, will require no prying state eyes. States that provide universal healthcare coverage and wish to condemn certain misconduct do not need to become overly intrusive to carry out measures to hold individuals accountable. b. Fairness Another libertarian worry regarding the guarantee of universal healthcare coverage in the context of lifestyle-driven diseases is that the public will be burdened unfairly with covering others’ ill-advised mistakes or bad luck. An ideal system to address this worry would link treatment or payment for treatment with whatever behavior caused that need.[20] The distribution of burdens should be linked to how different individuals contributed to the creation of those burdens. Applied to health policy, we should ask how the need for a certain treatment arose when determining how to distribute its cost.[21] The liberal-egalitarian model aspires to hold individuals responsible for their choices, not for the consequences of such choices. This model significantly mitigates the libertarian worry over unfair burdens for covering other people’s mistakes or social conditions, which lead to those bad outcomes, by ensuring to not burden others with any of the costs for the treatment of people who decide to engage in certain health-adverse behaviors. The aforementioned taxation-based system would only tax those who also engage in the health-adverse behavior through consumption, and that tax directly pays for the necessary collective treatment. As such, those who do not consume the good are not involved with the payment scheme, while those who do consume the good are responsible for payment in a matter proportional to the amount of the good they have consumed. Vl. Universal Coverage Taking a step back, one should consider whether these worries regarding the coverage of apparently self-inflicted health conditions in the context of universal healthcare are worthwhile issues. One perspective raises what is called the culturally imagined objection — an idea erroneously held by many that sick people, especially those who are poor and uneducated, bring these illnesses upon themselves due to poor decision-making and irresponsible risk-taking.[22] This perspective critiques the uniquely American view that, since individuals are free to choose their lifestyles, they should bear the costs of their lifestyle.[23] Taking this argument further, some (perhaps the strongly libertarian) would say that the poor health status among many individuals is the price individuals must pay for their American way of life and the liberty and freedom to live as they wish. However, people should not completely punish individuals for their health-adverse behaviors because these choices are largely pre-determined by a person’s socioeconomic influences.[24] The outcomes from these allegedly ill-advised behaviors, which largely affect poorer people, are not just poor behavior but rather a public health crisis. Perhaps the state and its people should take collective responsibility and cover the costs of treatment for those health outcomes without question, as a form of public service. Rather than worrying about accountability and taxing bad behavior or intrusiveness into personal decisions, some might argue that people need to collectively take responsibility for reducing the overarching systemic inequalities and covering the associated treatment costs as a measure of public health. Vll. Proposed Solution Given the strengths of the liberal-egalitarian model and taking into account libertarian and social justice-oriented objections, an ideal solution for the coverage of lifestyle-related health problems needs to consider the complex relationship between a person’s behaviors and their apparent health outcomes. It must consider how society as a whole passes judgment on behaviors and how to take into account that many health-adverse decisions are not truly autonomous decisions, as various genetic and socioeconomic factors influence them. An ideal solution combines the liberal-egalitarian tax-based model with the social justice concerns of universal coverage. Whatever the cost for the treatment of medical issues resulting in part or entirely from lifestyle and diet, taxes collected from spending associated with the behavior (like the purchase of alcohol, junk food, and cigarettes) ex-ante should fund 50 percent of the cost of treatment, while the universal healthcare taxation scheme should include the other 50 percent. Such a system would provide an incentive to avoid the purchases that can lead to unhealthy consumption and make healthier choices, slightly punish and discourage such purchases through taxation, yet not overly punish people whose outcomes may have more to do with socioeconomic factors and genetics. Adding public responsibility demonstrates acknowledgement that health care is in the public interest and can mitigate public health inequalities. This solution would fuse personal responsibility with the public responsibility of state-sponsored social improvement while ensuring that all people have fair access to necessary treatment, no matter their ability to pay. CONCLUSION The 50-50 system this paper proposes reflects both justice and personal responsibility in covering healthcare costs allegedly brought about by people’s own health-adverse behaviors. By allocating tax revenue from consumption that contributes or even alone causes poor health outcomes, such a system incorporates personal responsibility. By using general tax revenue for health care, such a system would meet the libertarian requirement of providing care without any moral investigation of past behaviors and the social justice consideration of providing health care to those who may have unwittingly ventured into ill-health due to systemic injustice, socioeconomics, or genetics. - [1] Cappelen, A. W. (2005). Responsibility in health care: A liberal egalitarian approach. Journal of Medical Ethics, 31(8), 476–480. https://doi.org/10.1136/jme.2004.010421 [2] Moss, A. H. (1991). Should alcoholics compete equally for liver transplantation? JAMA: The Journal of the American Medical Association, 265(10), 1295–1298. https://doi.org/10.1001/jama.1991.03460100097032 [3] Moss, p. 1295-1298. [4] Moss, p. 1296. [5] Moss, p. 1295-1298. [6] Moss, p. 1295-1298. [7] Cohen, C. IS THIS SUPPOSED TO BE COHEN AND BENJAMIN (1991). Alcoholics and liver transplantation. JAMA: The Journal of the American Medical Association, 265(10), 1299–1301. https://doi.org/10.1001/jama.1991.03460100101033 [8] Cohen, p. 1299-1301. [9] Moss, p. 1297. [10] Cohen, p. 1300. [11] Cappelen, p. 478-480. [12] Cappalen, p. 478-480. [13] Cappelen, p.479. [14] Cappelen, p. 479. [15] Cappelen, p. 479 [16] Cohen, p. 1301. [17] Cappelen, p. 478. [18] Cohen, p. 1299-1301. [19] Cohen, p. 1301. [20] Cappelen, p. 476-480. [21] Cappelen, p. 476-480. [22] Kawachi, I. (2005). Why the United States is not number one in Health. Healthy, Wealthy, and Fair, 18–33. https://doi.org/10.1093/acprof:oso/9780195170665.003.0013 [23] Kawachi, p. 18-33. [24] Kawachi, p. 18-33.