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Causality and Responsibility Regarding Physical Illness

Before taking a closer look at causality and responsibility regarding physical illness, some comments about causality and responsibility are in order. Although causality is a controversial concept, what I mean here is the relationship of cause-effect which in modern physics is often called statistical causality, a relationship which is not influenced by man. When the cause-effect relationship can be influenced by man then it is responsibility. So causality and responsibility are mutually exclusive explanations for things that happen. They can also be complementary, namely when a certain event can be influenced to a certain extent by human actions or will.

In determining responsibility for human actions it is necessary to differentiate between the responsibility a person has for what he does or neglects to do and his responsibility for an effectively endless series of events which are secondary or an indirect effect of his (in)actions. For instance, by participating in traffic Jones takes a certain risk for which he is responsible (1). An accident occurs for which Jones is neither morally nor legally responsible. For example, a motorist runs into him from the rear while he is waiting for a red light (2). Is Jones responsible for the accident (2) due to the responsibility (1) which he accepted? On the one hand, no, as although the accident involved Jones, he could neither foresee nor forestall it. On the other hand, yes, because if Jones had not been there the accident would not have happened. Here is another example. Jones runs through a red light (1) and causes a collision (2). The motorist behind the other car cannot brake on time resulting in a chain collision (3). A passenger in one of the damaged cars is at risk of being fired from his job due to repeated tardiness. Due to the collision he will now again arrive late and thus be fired (4). This chain of events can be continued indefinitely. Each new link adds another element that was unknown and unforeseeable.

Obviously the word responsibility takes on a different meaning for each link. I show the difference using the terms direct responsibility (1), secondary, indirect responsibility (2), responsibility of the third order (3), etc.

In addition, when contemplating the concept of responsibility, distinctions must be made between being responsible, feeling responsible, and holding another person responsible.

After these introductory remarks we can say the following about causality and responsibility regarding physical illness. According to the biomedical disease concept illness is something that happens to a person. It is an event with natural causes of which he is a victim and for which he is not responsible. In other words, it is an event regarding which the concept of responsibility is irrelevant because it is not in the conceptual framework of this disease concept. Accordingly, Parsons describes not being held responsible for the illness as one of the elements of “the sick role.” Siegler et al describe this aspect as of utmost importance and unique to the medical model in psychiatry. All other explicatory models place responsibility as well as blame partly or wholly on the person who displays the experience and behavior being considered. In order to examine this premise further some examples will be given.

Example 1. Jones is hospitalized with a broken leg after having been involved in a traffic accident. If we assume that he caused the accident, he would be directly responsible for it, and indirectly responsible for his broken leg. If we assume that the accident’s cause cannot be clearly determined or someone else is to blame, then Jones is indirectly responsible for his broken leg all the same. Is the accident itself something that happened to Jones and for which he therefore cannot be responsible other than the general responsibility that each participant in traffic has? Research indicates that some people are often involved in accidents and many others seldom or never. “Accident proneness” seems to be related to personality factors such as depression, preoccupation, and feelings of inferiority. Apparently accidents do not occur completely at random although it may be unclear in specific cases whether the person was aware of his “accident proneness.”

Example 2: Jones is discovered to have been intoxicated. Again there seems to be indirect responsibility as he drank knowing that he would be driving. He was directly responsible for the drinking and indirectly responsible for the accident.

Example 3: A man becomes infected with venereal disease when visiting a prostitute. Here again there is indirect responsibility. He was responsible for his visit with the prostitute and knew that there is a certain risk in that, but he could not know that he would become infected with venereal disease. In Roman Catholicism it would indeed have been considered a punishment for sin.

Example 4: A person is a heavy smoker for 30 years and develops lung carcinoma. Here again there is a certain indirect responsibility as he knew that smoking is hazardous to health. He is to be considered responsible for his smoking but only indirectly responsible for the fact that the risk he took led to this particular disease.

The number of examples could easily be expanded. One form or other of indirect responsibility is involved in a number of diseases, such as the so-called occupational diseases, diabetes mellitus in the obese, etc. De Jonghe calls these illnesses behavioral diseases. In general it can be posited that when the cause of a certain illness is known and can be influenced this implies indirect responsibility for contracting the illness. The heavy smoker from the fourth example would not have been indirectly responsible for his illness before the link between smoking and lung carcinoma was discovered.

What about feeling responsible for illness? Zola relates a small-scale research project involving subjects aged 17 and 18. They were asked how they would describe a five-year-old’s most recent illness to him. All of the subjects employed moral terms. Illness and being ill were called bad; being healthy was called good. Zola concluded, “In short, despite hopes to the contrary, the rhetoric of illness by itself seems to provide no absolution from individual responsibility, accountability, and moral judgment.” The constant connection between sickness and sin in religion deserves mention here too. Trimbos stated, “Everything that is objectionable can be called sick.” That way sick becomes synonymous to sinister. Trimbos laments that this synonym is also often found in medical and psychiatric judgments.

In conclusion, a person is not held responsible for physical illness even though a usually indirect responsibility is often indicated. There are, however, indications that people tend to feel guilty, and thus responsible, for their being ill.
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