View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by LSE Theses Online London School of Economics and Political Science Just health responsibility A comparative analysis focussing on the role of individual behaviour in relation to cancer and weight-control policy in German and US health care systems Harald Thomas Schmidt LSE ID: 200727771 A thesis submitted to the Department of Social Policy, London School of Economics, for the degree of Doctor of Philosophy London, March 2012 1 Declaration of Authorship I certify that the thesis I have presented for examination for the MPhil/PhD degree of the London School of Economics and Political Science is solely my own work other than where I have clearly indicated that it is the work of others (in which case the extent of any work carried out jointly by me and any other person is clearly identified in it). I consider the work submitted to be a complete thesis fit for examination. I authorise that, if a degree is awarded, a paper and/or electronic copy of my thesis will be deposited in the British Library of Political and Economic Science and that, except as provided for in regulation 32 it will be made available for public reference and inter-library loan. I authorise that by submitting my thesis to the Library, the Library is permitted to digitise it to assist in the long-term preservation and accessibility of my thesis. I authorise the School to supply a copy of the abstract of my thesis for inclusion in any published list of theses offered for higher degrees in British universities or in any supplement thereto, or for consultation in any central file of abstracts of such theses. The copyright of this thesis rests with the author. Quotation from it is permitted, provided that full acknowledgement is made. This thesis may not be reproduced without my prior written consent. I warrant that this authorisation does not, to the best of my belief, infringe the rights of any third party. I understand that if my thesis is not approved by the examiners, this declaration will become void. 2 Abstract This thesis seeks to examine the appropriate role of individual behaviour and responsibility in relation to cancer and weight-control policy in German and US health care systems. It contains six main parts. The first describes and compares the ways in which personal responsibility features in law and policy in both countries. It analyses salient differences in underlying motivation and characterization and highlights ethical tensions that arise from these provisions and their implementation. The second part reviews what established normative theories can do to address the issues that have been identified. It argues that these frameworks lack specificity and are ill-suited as a basis for policy in pluralist societies. It provides an analysis of different notions of the concept of personal responsibility, and makes a proposal for an overarching framework, adopting a procedural justice account that draws on work by Norman Daniels, Jim Sabin and Thomas Scanlon. The third part systematically reviews survey literature on the proper role of personal responsibility and develops an instrument for semi-structured interviews with physicians and population-level surveys in the US and Germany. The instrument complements this earlier survey work and explores key themes that arose in the analysis of policy documents and the philosophical literature. Based on this instrument, the fourth part analyses the findings from twenty semi-structured interviews with primary care physicians and oncologists in Berlin, Germany and Philadelphia, USA. The fifth part presents findings from three population level surveys of 1,000 respondents each. Two surveys with identical instruments were conducted with non- probability samples (census-adjusted proportional quota sampling with regard to income) in Germany and the US, and one, using a subset of questions, was administered to a probability-based sample in the US. Findings are discussed comparatively between countries and in view of the interviews with physicians. The last part concerns the policy implications of the analysis, and applies the framework proposed in the thesis to the case of colon cancer screening. It seeks to defend an incentive policy that attaches financial advantage to attending counselling on the advantages and disadvantages of colon cancer screening, building also on findings from the surveys, and interviews with physicians. The final chapter highlights a range of general policy implications for the evaluation and implementation of programmes seeking to incentivise personal responsibility. 3 Contents List of Appendices.......................................................................................................5 List of Tables and Boxes.............................................................................................7 List of Figures..............................................................................................................9 List of Acronyms.......................................................................................................11 Preface and Acknowledgements..............................................................................12 Chapter 1: Introduction .......................................................................................... 15 1.1 Background ..................................................................................................... 15 1.2 Personal responsibility in the US and Germany ............................................. 18 1.3 Research questions .......................................................................................... 20 1.4 The thesis structure ......................................................................................... 21 Chapter 2: Responsibility, ‘carrots’ and ‘sticks’ in health care policy in Germany and the USA ........................................................................................ 25 2.1 Introduction ..................................................................................................... 25 2.2 On ‘carrots’ and ‘sticks’: when is an incentive an incentive? ......................... 26 2.3 Health responsibility in the German statutory health insurance ..................... 29 2.4 Health responsibility in the US employer-based insurance system ................ 40 2.5 Conclusion ....................................................................................................... 51 Chapter 3: An ethical framework for evaluating health responsibility policies 55 3.1 Introduction ..................................................................................................... 55 3.2 Personal responsibility and behaviour change in the spectrum of coercion and ‘doing nothing’ ............................................... 56 3.3 Personal responsibility: conceptual analysis ................................................... 60 3.4 Personal responsibility as co-responsibility .................................................... 68 3.5 Assessing the reasonableness of health responsibility policies ....................... 71 3.6 Conclusion ....................................................................................................... 87 Chapter 4: Incentivising individual behaviour: review of the survey and interview literature, and development of an instrument for new research ........ 89 4.1 Introduction ..................................................................................................... 89 4.2 Key themes in relevant survey and interview work so far .............................. 91 4 4.3 Discussion of findings and development of a new survey instrument .......... 111 4.4 Conclusion ..................................................................................................... 117 Chapter 5: Health responsibility: physicians’ views ........................................... 118 5.1 Introduction and Aims ................................................................................... 118 5.2 Methods ......................................................................................................... 120 5.3 Findings ......................................................................................................... 127 5.4 Discussion ..................................................................................................... 156 5.5 Limitations .................................................................................................... 160 5.6 Conclusion ..................................................................................................... 161 Chapter 6: Health responsibility: views of the public ......................................... 162 6.1 Introduction and Aims .................................................................................... 162 6.2 Methods ......................................................................................................... 163 6.3 Findings ......................................................................................................... 174 6.4 Discussion ..................................................................................................... 220 6.5 Limitations .................................................................................................... 237 6.6 Conclusion ..................................................................................................... 239 Chapter 7: Policy implications: