Citizens enjoy broad rights to promote their own values, and health care systems respect this autonomy by granting patients substantial control over decisions regarding medical treatments.

Increased emphasis on informed consent and informed refusal of treatment highlight the clear role of the patient as the ultimate decision maker.^1,2 This autonomy extends beyond the clinical context of informed consent and informed refusal to encompass a wide variety of health-related behaviors; people choose their diet, select which of their medicines to take, elect to continue or quit smoking, and make a multitude of other decisions that have significant impact on their health.

If we recognize personal autonomy in making decisions about health behaviors, we should also hold people responsible for the consequences.

Just as some patients lack the ca­pacity to make treatment decisions, however, several factors can limit the autonomy and responsibility people bear for their health-related behaviors. The best approach, therefore, will assess decision-making capacity, hold people with capacity accountable for their individual health behaviors, and provide an environment that supports and encourages decisions that are health promoting instead of defeating.

Autonomy requires respect for individual treatment decisions, but it must be based on an understanding of the expected benefits, risks, and costs of treatment and on the payer’s willingness to accept responsibility for those costs. The problems with health care utilization and increased costs might also come from the fact that patients and providers are often shielded from the cost of care by the third-party payer system.³

To determine which treatments are worth the costs, both patients and physicians must understand treatment outcomes and costs – and perhaps physicians should involve patients in the cost/value tradeoffs of medical decisions.⁴ If patients share in some part of the cost, they may be prepared to forgo some treatments when the cost/value balance is no longer favorable.

Even with increased awareness of health care costs, patients cannot be expected to bear sole responsibility for their individual health. Their choices are not made in isolation; they are a product of their environment, culture, education, and economic means. Socioeconomic disparities, in particular, highlight limits on an individual’s health behaviors. A review of several studies demonstrates the significant health disparities associated with limited access to produce and other nutritious foods in minority neighborhoods, compared with white neighborhoods.⁵

Another difficulty in assigning personal responsibility is the relationship between behavior and illness. It may seem easy to link diabetes to poor diet or lung cancer to smoking, but in reality many chronic and expensive conditions such as diabetes, cancer, and heart disease are multifactorial; factors beyond an individual’s choices contribute to the development and severity of disease.