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Responsibility for Personal Health: A Historical Perspective
Abstract
Reflections about the role of human choice in determining personal health occur in the writings of practitioners and laymen
throughout history. The Greek and Roman writers emphasized the effect of life's activities. During the Middle Ages and Renaisance,
disease continued to be seen as a consequence of disorder of the bodily humors, which were under the individual's control.
The rise of the paternalistic national regimes in Europe produced the view that society had the responsibility to maintain
health. Jacksonian egalitarianism led to a reaction against the agressive therapies of established professional experts, a
view furthered by the Thomsonian belief that people should wrest control of their health away from orthodox physicians. Among
the twentieth century reactions was the movement to urge people to have doctors evaluate laypersons' health. By the 1970s
a movement emerged emphasizing again personal responsibility, which, in turn, produced a concern that this was merely “victim-blaming”.
Views on the role of lay people in determining personal health are heavily influenced by prevailing social, political, and
moral climates.
... Rather, Galen considered physical activity to be a behavior "over which a person had control" (Berryman, 1989(Berryman, , 2010(Berryman, , p. 195, 2012. In the view at that time, "physicians and lay people alike had responsibility for disease that was not the province of the gods and goddesses" (or, as we would now say, governed the laws of nature) (Berryman, 1989(Berryman, , 2010Reiser, 1985). As Berryman (1989) pointed out, "every person either independently or in counsel with their physicians, had the opportunity (emphasis added) to attain and preserve health" (p. ...
... The distinction between "natural" and "non-natural" events continued to be recognized and maintained through the 19th century (Berryman, 2010;Reiser, 1985). Although individuals could not directly control macro-social changes in urbanization, industrialization, and immigration, they were advised to conserve their own personal health by learning basic principles of health preservation and maintenance (Reiser, 1985;Verbrugge, 1979). ...
... The distinction between "natural" and "non-natural" events continued to be recognized and maintained through the 19th century (Berryman, 2010;Reiser, 1985). Although individuals could not directly control macro-social changes in urbanization, industrialization, and immigration, they were advised to conserve their own personal health by learning basic principles of health preservation and maintenance (Reiser, 1985;Verbrugge, 1979). Starting early in the 20th century, however, the relationship between exercise and medicine began to change (Berryman, 2010;Winter, 2008). ...
Despite the proliferation of theory-based behavior-change programs to promote physical activity, obesity and diabetes rates continue to rise. Given the notable ineffective interventions, it is important to examine why these efforts have been largely unsuccessful and to consider potential alternatives. The purpose of this article is to consider the role of values in understanding decisions about physical activity and to outline a more appropriate framework for investigating them. Aristotle originally proposed that human behavior may be better understood in terms of phronesis (practical reasoning), aimed at realizing valued goals rather than as the product of antecedent causal determinants. Instead of relying exclusively on scientific methodologies, a more comprehensive approach to study physical activity participation would also incorporate analytical processes used in the humanities, especially with respect to conceptualizing the role of values in guiding human behavior. Therefore, revising and expanding the research, teaching, and practice conducted in physical activity education are recommended. Copyright © National Association for Kinesiology in Higher Education (NAKHE).
... By the beginning of nineteenth century, as Reiser carefully describes, medical and social events produced again an emphasis on individual responsibility for health [42]. However, when the knowledge about the relation between diseases and social conditions increased, not only personal but also society's responsibility was at the forefront. ...
... In general, by the end of nineteenth century, scientific literature and public sphere of industrialized societies were focused at how to stay fit and control of personal health was an important issue. Reiser mentions the Ladies Physiological Institute of Boston and Vicinity, founded in 1848 in the USA, as an example of an institute devoted to instructing women on hygiene and the prevention and cure of disease [42]. ...
... In this article, Knowles wrote: ''The solution to the problems of ill health in modern American society involves individual responsibility, in the first instance, and social responsibility through public legislative and private voluntary efforts, in the second instance'' [24]. This being written at that time-the seventies of the twentieth century-is perhaps no coincidence, because during these seventies, a renewed debate over the issue of responsibility for getting ill, was certainly the case, as Reiser points out in 'Responsibility for Personal Health' [42]. ...
In this article, we focus at a key concept of today's healthcare, namely responsibility. Personal responsibility is so important today because it is obvious that the way society is organized, many people are facing a lot of difficulties to live their lives in a responsible way. We explicitly obtain an analysis of responsibility from a view which avoids the binary thinking which is so remarkably present in today's health care discourse. The aim of this pilot study is therefore to open up the horizon of the use of responsibility in today's healthcare. We develop the notion of 'co-responsibility' to understand how individuals, despite the fact they are responsible for their own agency, are always also affected by an ought which contaminates their efforts to fulfill their duties and obligations. We discuss co-responsibility not as conclusion or a magic formula to all problems, but as a new starting point of which we have to explore the opportunities for current and future health care dilemmas.
... The combination of limited budgets and changing patterns of disease seemingly invites a particular question: what role (if any) should we assign to personal responsibility when we decide which patients (or which diseases) to prioritize (Golan 2010;Leichter 2003;Minkler 1999;Reiser 1985;Sharkey and Gillam 2010;H. Schmidt 2009)? ...
... Reiser demonstrates that there has been a willingness to ascribe a certain degree of responsibility to the individual for centuries (Reiser 1985). Yet, the discussion in contemporary welfare states goes beyond the mere assertion that more prudent decisions are preferable to less prudent ones, as well as the recognition that there is a connection between the decisions we make in terms of food, alcohol, exercise, and our health. ...
... This view that individuals are responsible for their own (health) outcomes has existed throughout the Middle Ages and the Renaissance (Reiser, 1985). It is also common today. ...
... In sum, we offer a potential explanation for why conservatives might be more healthy, which has been observed at the macro-level (Cockerham et al., 2006;Cummins et al., 2005;Dorling et al., 2001;Kelleher et al., 2002;Kondrichin & Lester, 1998;Subramanian et al., 2010). We suggest that the conservative value of personal responsibility may explain why, given that personal responsibility is a strong predictor of physical health outcomes (Leichter, 1991;Reiser, 1985;Walker, 1994). We find support for this in three studies. ...
Are conservatives healthier than liberals? Aggregate and macro-level evidence have provided support for this possibility, yet individual-level analyses are missing and underlying processes unclear. We study how a person's political orientation might influence her physical health. We propose that a conservative orientation might promote physical health behaviors by promoting personal responsibility-and being personally-responsible means taking care of one's health. Across three studies, we find evidence for this hypothesis, with mediation evidence supporting our proposed personal responsibility account. We test our propositions on overall health (Study 1), greater physical activity engagement (Study 2), and smoking cessation (Study 3). Thus, we provide the first empirical illustration why conservatives may be healthier, offering implications for medical doctors and public health officials in encouraging healthy lifestyles.
... Contemporary policy debates often emphasise the relationship between lifestyle and poor health outcomes, suggesting that this relationship may affect how we evaluate inequalities in health (1)(2)(3). ...
... This has brought forth the notion of personal responsibility, understood as the idea that we should give lower priority to those, who are deemed responsible for their own medical needs (1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17), and the developments of a series of attempts to introduce personal responsibility in health (18)(19)(20)(21)(22)(23)(24). But it has also spurred much criticism of such responsibility-sensitive approaches (17,(25)(26)(27)(28)(29)(30)(31)(32)(33)(34). ...
Under the heading of liberal egalitarianism, Cappelen and Norheim present a novel approach regarding how we are to assess health disadvantages reflecting people's choices. It seeks to uphold a commitment to principles of responsibility and egalitarianism, while avoiding objections that such theories fail for humanitarian, liberal or fairness reasons. The approach draws a line between those of such diseases which are life-threatening, costly to treat relative to income or undermining important political capabilities and those which are not. For the latter kind, their approach allows for co-payment, whereas the former requires a different measure. Here, the authors maintain that unhealthy choices should be taxed and treatment offered equally to everyone without further cost. While this is an interesting approach, it faces important difficulties. It consists of two elements, which can come into tension with each other when concerns for severity of disease and personal responsibility recommend the employment of different elements. Furthermore, as it stands, the approach is incomplete because it seems unable to address important non-monetary shortages, such as the organ shortage. Finally, it is not apparent how the approach is able to address the significant ways in which social circumstances influences people's choices in health and their ability to stay healthy.
... In practice, this concern translates into questions about whether we should tax risky behavior (including lifestyles or particular actions) or give lower priority at the point of care to those deemed responsible for their treatment needs. The supposed fairness of such solutions has of course been widely debated (Reiser, 1985;Cappelen and Norheim, 2005;Buyx, 2008;Feiring, 2008;Schmidt, 2008Schmidt, , 2009Nielsen and Axelsen, 2012;Andersen, 2013Andersen, , 2014Brown, 2013;Albertsen, 2015;Albertsen and Knight, 2015;Baerøe and Cappelen, 2015;Andersen and Nielsen, 2016;Friesen, 2016;Brown, Maslen, and Savulescu, 2019;Levy, 2019;Traina, Martinussen, and Feiring, 2019). ...
Should we let personal responsibility for health-related behavior influence the allocation of healthcare resources? In this paper, we clarify what it means to be responsible for an action. We rely on a crucial conceptual distinction between being responsible and holding someone responsible, and show that even though we might be considered responsible and blameworthy for our health-related actions, there could still be well-justified reasons for not considering it reasonable to hold us responsible by giving us lower priority. We transform these philosophical considerations into analytical use first by assessing the general features of health-related actions and the corresponding healthcare needs. Then, we identify clusters of structural features that even adversely affected people cannot reasonably deny constitute actions for which they should be held responsible. We summarize the results in an analytical framework that can be used by decision-makers when considering personal responsibility for health as a criterion for setting priorities.
... Through requiring mask wearing, state-level mask mandates limit the public's freedom to choose whether or not to wear a mask. Mandates usurp the public's autonomy to make decisions about their personal health-a freedom that Americans have increasingly come to perceive under their direct control (Reiser, 1985). In this way, mandates have the potential to create psychological reactance. ...
Rationale
Psychological reactance theory was applied to examine the implications of state-level mask mandates in the United States during the COVID-19 pandemic. We evaluated the role of political partisanship and COVID-19 risk on changes in self-reported mask wearing before and after the imposition and removal of state mask mandates.
Method
Secondary data from several sources were aggregated about self-reported mask wearing behavior, state mandates, COVID-19 infection rates, and state-level political partisanship. Difference-in-differences tests were performed using logistic regression to evaluate whether change in mask wearing behavior following the imposition or removal of a mandate was greater in states based on state-level political partisanship and COVID-19 infection rates.
Results
Although mask adoption generally increased following mandates, the amount of increase was smaller in more Republican states compared to more Democratic states. Mask wearing generally decreased following the removal of mandates, with greater decreases when COVID-19 infection rates were lower.
Conclusion
The results collectively offer insights about the nuanced role of contextual factors in the adoption and resistance to masks following state mask mandates. Partisanship was important in responses to the imposition of state mask mandates and COVID-19 risk played a critical role in responses to mandate removal.
... " (Jean, 1922, p. 162). This approach revolutionized public health thinking, which tended to resort to negative attitudes about lower class individuals and families and victim blaming (Dougherty, 1993;Reiser, 1985). Building on her pioneering views, groundbreaking works such as the LaLonde report of 1974 also encouraged health practitioners to consider the social determinants of health (Hancock, 1986). ...
Sally Lucas Jean, RN (1878–1971) pioneered health education in the United States and globally. At the time of her death in 1971, aged 93, her legacy included serving on boards of leading American health associations, spearheading public health projects worldwide and transforming thinking on contemporary public health education. Sally Lucas Jean's influence continues today, from her input on educational children's television programs, policies on child health and her involvement in developing the early foundations of health communication. In this historical reflection, we examine her role in defining health education and communication, alongside influencing and applying strategies to improve public health nursing.
... Ecological (Minkler 1994(Minkler ,1999Reiser 1985;Walker 1994). Ecological analysis has increasingly been seen as a second-rate way to approach individual risks because it is believed that further advances in health will come from the revolution in molecular biology and genetic approaches to combating disease (Marmot 1998 (Lomas 1998). ...
The quality of the public's general health depends on the accessibility and quality of our public assets, the way that people live, work, learn, grow struggle, and play together (Judy Kurland, 2000). Ecological theory suggests that by evaluating and altering these conditions, it is possible to influence health behavior and, thus, the health outcomes of populations and their constituent individuals.
Various aspects of one’s community can either encourage or discourage public health. Accessibility and availability of products, physical characteristics and structures, inaccessible or poorly resourced health services, neighborhood socioeconomics, deteriorated neighborhoods, and the media are all examples of factors that can influence one’s health.
In this study the health of the city of Flint was researched by examining the features and characteristics of zip code areas using a variety of data sources and methodologies, including secondary health and census data, neighborhood drive-thrus and photographs, documenting grocery stores prices, and through mapping neighborhood resources and health data using Geographic Information Systems (GIS). Because of the varied nature of the data collected, different data analyses techniques were used.
A focused comparison of 5 health issues in two zip codes showed that no one variable in particular stood out as a major correlate of the health differences between the two zip codes. The data suggest that numerous factors jointly influence the health of the population, including lower income, fewer job opportunities, and less desirable neighborhood environment.
... Allocating medical resources in accordance with needs informs much contemporary thinking regarding the provision of health care (Jensen and Petersen 2017). The increased prevalence of noncommunicable diseases has, however, brought to the fore the alternative rationing criterion of personal responsibility (Golan 2010;Leichter 2003;Minkler 1999;Reiser 1985;Schmidt 2009;Sharkey and Gillam 2010). The recent Global Burden of Disease Study illustrates why: half the major causes of death are noncommunicable diseases Murray et al. 2014). ...
Allocating health care resources based on personal responsibility is a prominent and controversial idea. This article assesses the plausibility of such measures through the lens of luck egalitarianism, a prominent responsibility-sensitive theory of distributive justice. This article presents a framework of luck egalitarianism in health, which integrates other concerns of justice than health, is pluralist, and is compatible with a wide range of measures for giving lower priority to those deemed responsible. Applying this framework to oral health, the allocation of livers among potential transplant recipients and travel insurance demonstrates that this version of luck egalitarianism is a much more attractive and flexible theory than much of the contemporary discussion allows. This also pertains to its ability to provide plausible answers to two prominent critiques of harshness and intrusiveness. The discussion also shows that the luck egalitarian commitment to eliminating the influence of luck on people’s lives is likely to require substantial redistribution.
... The line between a fight for equity and terrorism becomes difficult to fathom at times, while contemporary boundaries within boundaries shift within ideologies of individualism, responsibility and neo-liberalism (Wonders, 2006). For example, people are increasingly held responsible for their own health and the way they are perceived to negotiate this responsibility sets boundaries around health care entitlements (Galvin, 2002;Reiser, 1985). ...
This thesis draws upon traditional and feminist theories of psychoanalysis, and
embarks upon a journey of inquiry initiated by a personal experience of end-of-life
care for my mother. Positioned as responsible caregiver, I found myself unable to
articulate my experiences as anything other than caregiver-patient who suffered a
combination of ‘exhaustion and grief’ leading to hallucination manifesting as
hysterical symptom. The constraints on positioning available to me generated the
following question as the catalyst for present study. How can mother and daughter
relations be spoken within contemporary discourse and how is care positioned in
relation to mother-daughter encounter? The inquiry begins with a critical reading of
contemporary literature on mothering, care and caring to locate the study within a
genealogy of feminist engagement with ethics of care. After situating both feminist
care ethics and hysteria within the trajectory of psychoanalytic development, I
explore Lacan’s rereading of Freud’s mapping of the unconscious, pre-conscious and
conscious as the initial theoretical framework for inquiry, given that this is where
hysteria linguistically intertwines with psychoanalysis as a product of caregiving
stress. Within the genre of searching, I follow a series of journeys, investigating texts
for gaps and pathways enabling a mother-daughter encounter to be remembered and
spoken differently. Each journey informs and transforms the problematics of
remembering and articulating mother-daughter encounter. Yet they reiterate
constrictions at the place where perception meets thought, and each journey is
hindered by a metaphorical wall of language. After discussing how the wall locates
mother-daughter encounter and care within discourse and shapes reality as a constant
series of assimilating, marginalising and discriminating I extend the scope of inquiry
ii
through reading feminist theorists of difference including Irigaray’s concepts of mimesis and fluidity, Ettinger’s matrixial borderspace and Braidotti’s nomadic subject. This allows a rereading of feminist care ethics and possibilities of transformations, where theorising a more inclusive grammatical structure can be thought as enabling possibilities for speaking, writing and remembering women’s encounters with women and a daughter’s encounter with her mother.
... sexual promiscuity) would lead to ill-health whilst other behaviours (e.g. chastity) would lead to good health (Reiser 1985). However, it was not until the dawn of the modern era that the association between behaviour and illnesses began to be properly understood. ...
With the ever rapid development of scientific and technological research in the 19th century, the power growth of scientific institutions and their specific influence have expanded incredibly due to the results they have achieved in several research areas.
... Personligt ansvar i sundhed er ikke et entydigt begreb, men diskuteres her som havende to elementer: 1) Når mennesker har muligheden for frit og informeret at vaelge mellem forskellige livsstile, så er de ansvarlige for de sundhedsmaessige konsekvenser af dette valg, og 2) vi bør holde personer ansvarlige for de sundhedsmaessige konsekvenser, der opstår som følge af sådanne livsstilsvalg. I de seneste årtier har implikationerne af personligt ansvar i en sundhedskontekst vaeret genstand for en omfattende akademisk debat (Buyx, 2008;Buyx og Prainsack, 2012;Dworkin, 1981;Leichter, 2003;Minkler 1999;Nielsen, 2013;Nielsen og Axelsen, 2012;Reiser, 1985;Veatch og Steinfels, 1974;Veatch, 1980;Wikler, 1987Wikler, , 2002. I politiske debatter spiller idéen ind. ...
Personligt ansvar er et centralt begreb i den politiske og den akademiske debat om
sundhedspolitik. Tanken er, at hvis folk er ansvarlige for at leve en livsstil med en
betydelig sundhedsrisiko, så har de også et ansvar for de konsekvenser, der kan
følge heraf. Trods denne umiddelbare appel er der fremført stærke kritikker af
personligt ansvar i en sundhedskontekst. Det fremføres, at sådanne tilgange overser
den betydelige effekt, sociale og naturlige omstændigheder har på menneskers
helbred, at det vil betyde en ubarmhjertig skæbne til dem, der træffer risikobetonede
valg, eller basere sig på en indsamling af information, der langt overskrider
privatsfærens grænser. Held-egalitarismen er et naturligt udgangspunkt for denne
diskussion. Denne teori om fordelingsmæssig retfærdighed fokuserer på individers
valg og ansvar. Dette muliggør en diskussion af, hvorvidt forskellige tiltag
fremført i og omkring den held-egalitaristiske litteratur undgår nogle af de kritikker,
der ofte rejses mod teorier, der søger at anvende idéen om personligt ansvar i
en sundhedskontekst. Hvilken model der er mest attraktiv, er stærkt betinget af
den kontekst, den søges indført i.
... Life-style choices regarding what we eat and drink, whether we smoke, and the extent to which we exercise, affect our longevity and general health. This has generated an intense ethical discussion regarding whether and how we should incorporate this relationship in public health policies and in rationing the scarce health care resources (Leichter 2003;Minkler 1999;Reiser 1985). To the extent that such life-style choices are genuine, luck egalitarianism, an influential theory in political philosophy, suggests that inequalities arising from such choices would be less of a concern. ...
Should we grant a fresh start to those who come to regret their past lifestyle choices? A negative response to this question
can be located in the luck egalitarian literature. As a responsibility-sensitive theory of justice, luck egalitarianism considers
it just that people’s relative positions reflect their past choices, including those they regret. In a recent article, Vansteenkiste,
Devooght and Schokkaert argue against the luck egalitarian view, maintaining instead that those who regret their past choices
in health are disadvantaged in a relevant way and should receive compensation. Employing the ideal that people should be made
equal as measured by equivalent resources, they purport to show the fairness of such an arrangement through a hypothetical
scenario. Relaxing the implicit assumptions of this scenario brings forth several unattractive consequences of the fresh-start
idea. The main problem is that in striving to ensure that people’s past choices do not affect their own opportunities, the
authors must accept that these choices put heavy strains on the opportunities available to other people. Furthermore, the
luck egalitarian position is more compelling than they admit.
... Personal responsibility is a core American value and its prominence in the context of health has a long history. 35 Over the past few decades the health responsibility debate has intensified and within political discourse often plays out in predictable * and unproductive terms. In its barest form, proponents of personal responsibility deny any role for structure in health and proponents of social responsibility downplay the role of health-related behaviors in poor health. ...
... [7][8][9][10][11] There could be a practical need for such a contribution, since references to personal responsibility are frequent in policy discussion. [12][13][14][15][16] However, several writers remain unconvinced of such an application and have raised important critiques in that regard. [17][18][19][20][21][22][23][24][25][26][27] A comprehensive application of luck egalitarianism in health and healthcare would presumably require a specification of what luck egalitarianism means. ...
Several attempts have been made to apply the choice-sensitive theory of distributive justice, luck egalitarianism, in the context of health and healthcare. This article presents a framework for this discussion by highlighting different normative decisions to be made in such an application, some of the objections to which luck egalitarians must provide answers and some of the practical implications associated with applying such an approach in the real world. It is argued that luck egalitarians should address distributions of health rather than healthcare, endorse an integrationist theory that combines health concerns with general distributive concerns and be pluralist in their approach. It further suggests that choice-sensitive policies need not be the result of applying luck egalitarianism in this context.
... Personal responsibility was also illustrated by references to taking a proactive approach to health (e.g., "be your own doctor") and adopting healthy behaviors to prevent illness (e.g., "you gotta check the motor or the oil will run out"). Previous research has shown beliefs valuing independence and autonomy shape how people respond to illness and perceive health in the USA in general [63]; our findings suggest that ...
This study investigated the beliefs and attitudes of older African American colorectal cancer (CRC) survivors that may influence health behavior changes after treatment. Drawing from existing theories of health behavior change and cultural beliefs about health, a semi-structured interview guide was developed to elicit survivors' perspectives. Qualitative focus groups and interviews were conducted with 17 survivors identified through the Detroit Surveillance Epidemiology and End Results registry. Using verbatim transcripts from the sessions and NVivo software, thematic analysis was conducted to analyze patterns of responses. Transcripts were coded for seven categories (health behaviors, who/what motivates change, self-efficacy, fatalism, religion/spirituality, beliefs about cancer, race/ethnicity). Five themes emerged from the data (personal responsibility, resilience, desire for information, intentions to change, beliefs in divine control). Findings support the relevance of existing theories of health behavior change to older African American CRC survivors. Cultural considerations are suggested to improve interventions seeking to maximize changes in diet and exercise among this group of survivors.
... One likely mediating factor of immunocompetence for an organism is stress (Bauer et al., 2001; Cohen et al., 1991; Esterling & Rabin, 1987; Keller et al., 1983; Palermo-Neto et al., 2003; for review, see Moynihan, 2003). Societies throughout history have proposed that, in one form or another, challenging life events and the personality reacting to them can influence an individual's wellbeing (Reiser, 1985). Some of the first experimental evidence for physiological manifestation of stress was provided by Hans Selye (1936) who, by accident, discovered that exposure to stress can lead to enlargement of adrenal glands, development of ulcers, and shrinking of immune tissues. ...
Exposure to stress early in development can have lifelong effects on an organism's physiological and psychological health. Prior research suggests that prenatal stress exposure, among other effects, can lead to hyper-reactivity of the offspring's HPA axis and alterations in immune function. These stress-induced changes have been linked to a greater propensity to develop depression or an anxiety disorder in both human and non-human animals. Furthermore, prenatally stressed offspring have been found to be more susceptible to certain diseases, relative to non-stressed controls. The immune alterations induced by prenatal stress exposure may disrupt the normal communication between the immune system, endocrine system, and central nervous system, potentially making prenatally stressed individuals more vulnerable to the negative aspects of immune activation, namely cytokine-induced cognitive deficits and increased anxiety. The present study investigated whether prenatal stress exposure would exaggerate these detrimental effects of immune activation. Specifically, we hypothesized that prenatally stressed subjects would be hypersensitive to endotoxin administration and would therefore show exaggerated learning deficits, increased anxiety-like behavior, and increased peripheral and central interleukin-1b production. The observed results only partially supported our hypotheses, as prenatally stressed subjects showed evidence, albeit modest, of increased anxiety-like behavior following endotoxin administration relative to non-stressed controls. However, the data failed to support the primary hypothesis that prenatally stressed subjects would show exaggerated cognitive deficits, engendered via enhanced peripheral and central IL-1b production, following immune activation. Collectively, these data suggest that while prenatal stress exposure may lead to increases in anxiety-like behavior following a subthreshold dose of endotoxin, it does not appear to produce greater susceptibility to LPS-induced cognitive decline or elevations in proinflammatory cytokine production. Mode of access: World Wide Web. System requirements: Adobe Acrobat reader. Title from dissertation title page (viewed Sept. 11, 2007). Includes abstract. Thesis (Ph.D.)--Texas Christian University, 2007. Includes bibliographical references. Text (electronic thesis) in PDF.
Luck egalitarianism is a responsibility-sensitive theory of distributive justice. Its application to health and healthcare is controversial. This article addresses a novel critique of luck egalitarianism, namely, that it wrongfully discriminates against those responsible for their health disadvantage when allocating scarce healthcare resources. The philosophical literature about discrimination offers two primary reasons for what makes discrimination wrong (when it is): harm and disrespect. These two approaches are employed to analyze whether luck egalitarian healthcare prioritization should be considered wrongful discrimination. Regarding harm, it is very plausible to consider the policies harmful but much less reasonable to consider those responsible for their health disadvantages a socially salient group. Drawing on the disrespect literature, where social salience is typically not required for something to be discrimination, the policies are a form of discrimination. They are, however, not disrespectful. The upshot of this first assessment of the discrimination objection to luck egalitarianism in health is, thus, that it fails.
The benefits of exercise and physical activity is not a new concept but instead, one that has persevered for thousands of years. In this context, physicians emphasised the importance of physical activity and exercise in addition to eating a balance diet in order to promote health rather than just the prevention of disease. The earliest known population to have institutionalised medicine as a fundamental practice was the ancient Egyptians. Materials. The connection between exercise and medicine can trace its roots back to three ancient physicians; Herodicus (480-? BC), Hippocrates (460-370 BC) and Galen (129-210 AD) (5). Research methods. Information sources analysis and summarizing. Results. The first known study of what was termed "therapeutic gymnastics" or "gymnastic medicine" was conducted by Greek physician and paidotribes (a formal tutor in sport, wrestling and gymnastics), Herodicus. Herodicus, both a physical educator and physician, served as both a tutor and mentor to Hippocrates, commonly referred to as the "Father of Medicine". Much of what we know about medicine in the ancient world can be attributed to the writing of Hippocrates. Hippocrates advocated for the inclusion of exercise and physical activity in order to maintain health. Just as Herodicus influenced Hippocrates, it was Hippocrates who was a major influencing factor on Roman physician Claudius Galenus or Galen. Although much of what they believed to be true (Galenic Humoral Theory) has been disproved, they did emphasize the important of exercise and physical activity for health including laying the foundations for the development of exercise science and sports medicine as a medical discipline. Conclusion. Exercise and physical activity are commonly accepted as being beneficial to one's health. Beginning with the ancient Egyptians and spreading into Greece, sport medicine was developed in parallel to preventative medicine chiefly through the efforts of three physicians. It was also during this period that health and the practice of medicine was separated from the supernatural and spiritual world and began to basis it in empirical science. Practices in military medicine were therefore utilised in the gymnasium and at sporting events in order to return athletes to competitive effectiveness in the shortest period possible. Therefore, without Herodicus, Hippocrates and Galen, our understanding of exercise and medicine in sport would be incomplete.
Responsibility is a concept with multiple meanings and uses. In relation to wellbeing, it may be used, for example, to define causal agency or taking charge, as well as to define liability and moral obligations to lead a specific lifestyle. In addition, the same issues may also be discussed without using the responsibility concept at all. In this sense, responsibility talk expands beyond the concept and may be seen as a compilation of discourses circling around the concept from different perspectives.
In this article, 72 short texts written about personal wellbeing for a Finnish writing competition in 2010 were analysed in order to evaluate how the authors discuss responsibility. The analysis shows that an accountability‐ and blame‐oriented public debate on health and wellbeing is identified by many of the authors in the data. However, for the authors, being responsible mainly means listening to oneself, making decisions and choosing what is good for oneself and for one's loved ones, irrespective of outside pressure to act otherwise. This positively toned definition of responsibility provides a viable starting point for discussing wellbeing in the public domains. Yet the negative connotations also need to be acknowledged. Overall, more theorising and research are still needed.
Während die soziale Dimension von Krankheit beim Aufbau eines professionell organisierten Gesundheitssystems im Mittelpunkt der Diskussion gestanden hat und einer der Gründe für die Errichtung eines quasi-staatlichen Versorgungssystems war, finden derzeit die sozialen Bedingungen von Krankheit und die sozialen Aspekte bei der medizinischen Behandlung kaum noch Beachtung. Vor allem die Diskussion in Großbritannien zeigt, daß mit der Einführung eines nationalen Gesundheitssystems mit egalitärer Zielsetzung die Unterschiede hinsichtlich Morbidität und Mortalität zwischen sozialen Gruppen nur schwer wegzusteuern sind. Aus diesem Grund sollten Fragen, die den Ursachen und Interventionsmöglichkeiten nachgehen, einen hohen gesundheitspolitischen Stellenwert haben.
Illness Is a Weapon presents an engaging portrayal of the everyday experience of disease in a remote Australian Aboriginal community. While chronic Aboriginal ill health has become an important national issue in Australia, Saethre breaks new ground by locating sickness within the daily lives of Indigenous people. Drawing on more than a decade of ethnographic research in the Northern Territory, Saethre explores the factors structuring ill health, the tactics individuals use to negotiate these realities, and the ways in which disease and medical narratives are employed to construct, manage, and challenge social relations. Reframing current debates, this book argues that disease and suffering have become powerful expressions of Indigenous identity. Through dialogues and interactions, Aboriginal and non-Aboriginal people engage in a reciprocal discussion about the past, present, and future of indigeneity. Rarely is disease and suffering understood as a form of protest, and in Illness Is a Weapon, Saethre confronts the stark reality of the current contest between all parties in this struggle. As Saethre explains, "Cursing at nurses, refusing to take medication, and accepting acute illness as unremarkable is simultaneously an act of defiance and a rejection of vulnerability."
In the recent past a number of empirical studies provided evidence that the increasing genetic knowledge leads to new forms of exclusion, disadvantage and stigmatisation. As a consequence, many states have inaugurated special legislation to fight »genetic discrimination«. This article focuses on some theoretical, normative and practical problems in the scientific and political debate on genetic discrimination. It puts forward the thesis that the existing antidiscrimination approach is based on the implicit idea that genes are the essence of (human) life. Since genes are held responsible for individual development and personal identity, genetic discrimination is granted a privileged legal status in comparison to other forms of discrimination. As a result the analytical and political concentration on processes of genetic discrimination may reinforce the »geneticization« of body, illness and deviance.
Morality and mental health are now inseparably linked in our view of character. Alcoholics are sick, yet they are punished for drunk driving. Drug addicts are criminals, but their punishment can be court ordered therapy. The line between character flaws and personality disorders has become fuzzy, with even the seven deadly sins seen as mental disorders. In addition to pathologizing wrong-doing, we also psychologize virtue; self-respect becomes self-esteem, integrity becomes psychological integration, and responsibility becomes maturity. Moral advice is now sought primarily from psychologists and therapists rather than philosophers or theologians. This book asks: are we replacing morality with therapy, in potentially confused and dangerous ways, or are we creatively integrating morality and mental health? According to the book, it's a little bit of both. It surveys the ways in which morality and mental health are related, touching on practical concerns like love and work, self-respect and self-fulfillment, guilt and depression, crime and violence, and addictions. Terming this integrative development "the therapeutic trend in ethics," the book uses examples from popular culture, various moral controversies, and draws on line of thought that includes Plato, the Stoics, Freud, Nietzsche, and contemporary psychotherapeutic theories. The book develops some interesting conclusions, among them that sound morality is indeed healthy, and that moral values are inevitably embedded in our conceptions of mental health. In the end, the book shows how both morality and mental health are inextricably intertwined in our pursuit of a meaningful life.
That people should take responsibility for their health is a prominent contemporary idea. But what does such responsibility actually entail, and what demands are being put on people? The objective of the dissertation is to describe and critically examine various ideas on personal responsibility for health. In the first step, I identify and describe a wide variation of uses of responsibility and in the second step, I problematize them. The analyzed material consists of Swedish government reports and various types of health advice literature, including traditional medical books and alternative medicine literature. I employed a framework of philosophical, social scientific, and developmental psychology theories on responsibility to critically examine the material.
The study shows that taking responsibility involves both body and mind.
Common ideas are that it requires maintaining a healthy lifestyle and
managing one's self-care. But it is also considered important to take
responsibility for beliefs and emotions and to adopt an accepting atti-tude. Another idea is that spiritual insights expand the scope of responsibility. Some important abilities required to take responsibility are conscious healthy choices, self-knowledge, and critical thinking. The view of
responsibility is also influenced by individual factors, cultural beliefs
about health and disease, and social structures. In the literature, health
responsibility is regarded both as a social duty and as a never-ending task
performed by an active individual.
Finally, I use Robert Kegan’s theory of adult development to show that taking responsibility imposes psychological demands on people’s awareness. The demands are often higher than many people can manage. Some of the stress and poor health that people experience may be the product of an inability to manage all of life’s demands. The developmental perspective also asserts that people can develop the requisite capacity. One conceivable conclusion of the study is that if we want people to take more responsibility, we should not only invest resources in health information, but also in measures that generate self-knowledge, reflection, and personal development.
If we are responsible for taking care of our health, are we blameworthy when we become sick because we failed to meet that responsibility? Or is it immoral to blame the victim of sickness? A moral perspective that is sensitive to therapeutic concerns will downplay blame, but banishing all blame is neither feasible nor desirable. We need to understand the ambiguities surrounding moral responsibility in four contexts: (1) preventing sickness, (2) assigning financial liabilities for health care costs, (3) giving meaning to human suffering, and (4) interacting with health care professionals. We also need to distinguish different kinds of blame, explore the interplay of justice and compassion in avoiding unjustified blaming of victims, and work toward a unified moral-therapeutic perspective that encourages individuals to accept responsibility while avoiding destructive forms of blaming.
Over the past 15 years, a series of empirical studies in different countries have shown that our increasing genetic knowledge leads to new forms of exclusion, disadvantaging and stigmatization. The spectrum of this “genetic discrimination” ranges from disadvantages at work, via problems with insurance policies, to difficulties with adoption agencies.
A move toward individual responsibility for health is gaining momentum in Canada. Whether or not individual responsibility for self-care practices is in the best interest of the public is debated in this article. The origins of the self-care movement in the Canadian healthcare system, its benefits and pitfalls, are explored. The role that the nursing profession can play is also discussed.
To examine how sociocultural factors influence transplant professionals' decisions about placing patients on the national transplant waiting list, I observed discussions at 15 candidate selection meetings at one urban transplant center. Transplant professionals are uncertain about whether to place marginally suitable candidates on the waiting list. Uncertainty derives from competing cultural and ethical imperatives: ensuring equal access to transplantation and efficient use of scarce kidneys to prevent waste. Patients with psychosocial contraindications to transplantation, e.g. noncompliance, drug use, ambivalence, present this ethical challenge most sharply to transplant professionals. Transplant professionals deal with this by either: routinely discussing patients' potential for noncompliance or delaying noncompliant patients' access to the waiting list through a probationary contract. Through ritual analysis of transplant candidate selection meetings, I explain why these approaches are pragmatic in that they help the transplant team resolve conflict between their competing values and thus resolve their uncertainty about wait-listing marginal patients for transplantation.
Many physicians exhibit reluctance to care for 90 million Americans who are uninsured or on Medicaid, citing concerns about litigation, reimbursement, and complexities inherent in treating indigent patients. This paper uses open-ended data from a nationally representative group of 275 doctors to explore physician perceptions of indigent patients and the strategies they use in caring for this population. This work reveals negative physician views about the medically indigent, critical of patient consumptive habits, health decisions, and 'abuse' of the system. I argue that despite negative perceptions of the underserved, physicians engage in innovative strategies to assist indigent patients by distinguishing between the deserving and the undeserving poor. This distinction, based on physician perceptions of the constraints and choices in patients' lives, enables doctors to exercise agency in choosing who and how to serve. Physicians commit 'ultimate attribution error' in perceiving patients as active agents, in stark contrast to viewing their own actions as dictated by rules of medical practice. This work adds critical insight to our understanding of relational power and the recursive nature of structure and agency between doctors and patients.
Empowerment of the elderly within the health care system is a concept increasingly discussed in clinical and policy-making contexts. An examination of its current expressions and underlying philosophical principles reveals four different interpretations: empowerment as political activism and social process, empowerment as effective deliberation and moral reflection, empowerment as personal process. and empowerment as balance and interdependence. How empowerment is defined and expressed has distinct implications for the practitioner. who must be sensitive to tile underlying value conflicts that are at the core of decision making in the clinical or the public policy setting.
Childhood obesity is associated with serious health complications that can begin in childhood. Within the last 20 years, the prevalence increased in most countries throughout the world, prompting some to identify the problem as a global epidemic. Work towards solutions to the crisis is beginning and generally involves not only treatment of those affected but individual and population-based prevention approaches. The current evidence on obesity prevention interventions for children is weak and serious limitations exist. The time has come to change the paradigm from interventions that emphasize individual behavior changes to political, policy, social and economic strategies that involve broad changes at the population level. A society-wide cultural transformation, similar to what took place with tobacco control, is proposed.
Individuals who become ill as a result of personal lifestyle choices often shift the monetary costs of their healthcare needs
to the taxpaying public or to fellow members of a private insurance pool. Some argue that policies permitting such cost shifting
are unfair. Arguments for this view may seem to draw support from luck egalitarian accounts of distributive justice. This
essay argues that the luck egalitarian framework provides no such support. To allocate healthcare costs on the basis of personal
responsibility would arbitrarily and publicly burden socially detectable risk-takers while undetectable risk-takers continue
to get a free ride. That problem is unavoidable even on the assumption that distributive institutions outside the healthcare
sector are fully just. In actual, farfrom-just societies, imposing personal liability for the costs of voluntary risk taking
would be wrong for an additional reason. Doing so would tend to magnify existing distributive injustices. These conclusions
draw attention to two common ‘moral fallacies of the second best’ that can arise when applying ideal normative theory to matters
of institutional design and in real-world policy contexts.
Personal responsibility is a powerful idea supported by many values central to West European thought. On the conceptual level personal responsibility is a complex notion. It is important to separate the concept of being responsible for a given state of affairs from the concept of holding people responsible by introducing measures that decrease their share of available resources. Introducing personal responsibility in oral health also has limitations of a more practical nature. Knowledge, social status and other diseases affect the degree to which people can be said to be responsible for their poor oral health. These factors affect people's oral health and their ability to take care of it. Both the conceptual and practical issues at stake are not reasons to abandon the idea of personal responsibility in oral health, but they do affect what the notion means and when it is reasonable to hold people responsible. They also commit people who support the idea of personal responsibility in oral health to supporting the idea of societal responsibility for mitigating the effects of factors that diminish people's responsibility and increase the available information and knowledge in the population.
Advance planning by the elederly for long-term care decisions promises to enhance personal responsibility and autonomy while improving their quality of life. Such planning becomes an extension of the concepts of client empowerment and self-care and is based on the ethical principles of individual autonomy and freedom of choice. These have clear implications for the content and process of advance planning, including the activities of “effective deliberation” and “moral reflection.” A sense of self-respect and the provision of care-provider support and social resources become key ingredients in this process, leading to the development of the concept of “cooperative empowerment.” Broader risk assessment methodologies are proposed to encourage the planning process, which can be given direction by the development of a personal planning guide and workshops. Attention must be drawn particularly to the importance of human values at the core of personal decisions and life plans.
There is a growing trend in policy making of holding people responsible for their lifestyle-based diseases. This has sparked a heated debate on whether people are responsible for these illnesses, which has now come to an impasse. In this paper, I present a psychological model that explains why different views on people's responsibility for their health exist and how we can reach a resolution of the disagreement. My conclusion is that policymakers should not perceive people as responsible while health care personnel should take the opposing view.
It has become very popular to apply the highly inflated language of rights in addressing issues of personal health status and of priorities in allocation of taxpayer’s resources. Such an intellectual
and political fashion fad, however, seems to have little or no basis in our everyday and common sense approach to health and
health care [14]. Whenever I personally think about health, apart from those intellectual debates and public policy discussions, it is not
the term “right”, nor the term “obligation”, nor “resource” that comes to mind first. I feel I have a responsibility to take care of my health. It is not only an asset; it is an end in itself, inasmuch as its absence or deterioration is painful,
harmful, fatal. It is also a commodity, a precondition, which I use to achieve other goals in life: satisfaction, social integration,
love, reputation, power, contribution to the common good, and working hard. I am using health as a means; I might trade it
for other values, assets, or valuables, according to personal choice or milieu. Protecting or improving or trading health,
its quantitative length as well as its qualitative standard, is a result of living, of voluntarily or involuntarily making
decisions, choosing, managing risks. Health is a risk factor in life; I therefore deal with it appropriately when using the
arts and sciences of risk analysis, risk assessment, and risk management. It seems to me that the risk language is more appropriate to deal with issues of personal health care as well as of health policy than the rights language [13, 15].
The concept of responsibility for health is a significant feature of health discourse and public health policy, but application of the concept is poorly understood. This paper offers an analysis of the concept in two ways. Following an examination of the use of the word 'responsibility' in the nursing and wider health literature using three examples, the concept of 'responsibility for health' as fulfilling a social function is discussed with reference to policy documents from the UK. The philosophical literature on moral responsibility is introduced, and in considering two versions, reactive attitudes and accountability, it is argued that in application both can be regarded, though with different emphasis, as being constituted in three parts: (i) a responsible agent; (ii) having obligations (responsibilities); and (iii) being susceptible to being held responsible (that is blamed) if he fails to meet them. The three-stage model is consistent with the examples of the word responsibility in use, but application to the social function model causes a number of problems for healthcare practice, especially for the reactive attitudes account. Apart from considerable problems in stating what exactly the obligations are and how they can be justified; and how blame might justly be apportioned and by whom, the very ideas of obligation and blame are in conflict within healthcare systems and professional nursing practice which have foundations deeply embedded in the notion of the supremacy of personal autonomy. It is concluded that current application of the concept of responsibility for health is conceptually incoherent, and if it is to retain its place in health policy and discourse, urgent remedy is required.
Despite advances in medical approaches to the management of chronic illnesses, relatively little is known about how older members of ethnic minority groups view their chronic illnesses or how they manage them in daily life.
We recruited 35 African-Americans, 61 Latinos, and 55 Filipino-Americans, all over age 50. Criteria for entry into the study was the presence of one or more chronic illnesses. Findings are based on structured and semi-structured questions in one in-depth interview. Qualitative data on transcribed interviews with 151 respondents was analyzed.
Comparison of the three groups revealed social and cultural differences and similarities that affected the management of chronic illness. The extent to which respondents demonstrated an understanding of their illnesses as chronic varied considerably, with discernible differences among groups about knowledge of illness and self-care practices.
Our findings showed that although major chronic illnesses were, for the most part, the same for all three groups, each group differed in its response to and management of its illnesses. These findings have implications for the education of physicians in training.
In the recent past a number of empirical studies provided evidence that increasing genetic knowledge leads to new forms of exclusion, disadvantage and stigmatisation. As a consequence, many states have inaugurated special legislation to fight "genetic discrimination".
This article focuses on some theoretical, normative and practical problems in the scientific and political debate on genetic discrimination. It puts forward the thesis that the existing antidiscrimination approach is based on the implicit idea that genes are the essence of (human) life. Since genes are held responsible for individual development and personal identity, genetic discrimination is granted a privileged legal status in comparison to other forms of discrimination. As a result the analytical and political concentration on processes of genetic discrimination may reinforce the "geneticization" of body, illness and deviance.
The effects of ambiguous responsibility in the doctor-patient relationship on persons undergoing medical treatment for infertility are examined through the negotiation process that ensues following diagnosis. Through the analysis of 79 interviews with women and men undergoing infertility treatment, it was found that: (1) diagnosis reinforced individuals' sense of responsibility for their infertility; (2) ambiguity in the doctor-patient relationship affected shifts in patients' perception of physician responsibility, and (3) patients eventually re-established responsibility for their medical treatment. The implications of ambiguous responsibility for symbolic meanings in biomedicine and the way those meanings are linked to power and authority are explored through an examination of power in patient and physician roles, clinical uncertainty, and medical competence.
Asthma remains a frustrating and underestimated threat to health. Non-compliance with medication is a frequent problem, especially when asthma attacks are difficult to predict, and amongst children and young adults. Non-compliance has been attributed to shortfalls in patient education. There may, however, be an attitudinal-altered image dimension to the problem.
Asthma is an invisible and unpredictable chronic illness characterized by recurrent episodes of airflow obstruction and airway inflammation. Until recently, psychological factors were thought to play a major role in this condition. The notion of an emotionally-based illness serves to discredit asthma as a 'real' illness among health professionals and patients alike, contributes to the sense of stigma that persons who have asthma experience, and impedes effective management. Findings from research with a sample of 95 adults with physician diagnosed and documented asthma indicate that persons who have asthma walk a tightrope between delaying formal medical intervention and seeking treatment too soon. Uncertainty about the quality and speed of care available in an emergency department shapes, in part, the nature of the lived experience of asthma and affects feelings of control over the illness. These concerns create a push-pull dynamic, as individuals struggle to make decisions about emergency department use that will provide relief, ensure autonomy, deter the experience of stigma, and diminish the threat of death.
Only a minority of women in an urban random sample have the opportunity to exercise at work, and even fewer women use these opportunities. Lack of time and inconvenient times are the major reasons for not participating in exercise programs at work. Exercise programs at work are used by women who are already physically active, suggesting that workplace exercise programs do not serve the needs of women who may need exercise programs most. Multivariate analysis shows that age, having children, lack of energy, and lack of support are significant barriers to women's exercise participation at work. The results of this study suggest a leadership opportunity for on site occupational health nurses in addressing these barriers to workplace exercise.
This article examines the continuing controversies regarding personal versus social responsibility for health as they are being played out at the turn of the century. Following a brief examination of the contested meaning of "personal responsibility for health" in recent historical context, attention is focused on the arguments for and against holding the individual to be primarily accountable for his or her health behavior. The paper then makes the case for more balanced, ecological approaches that stress individual responsibility for health within the context of broader social responsibility. The article concludes by briefly summarizing the Canadian approach to health promotion as a useful example of what such a balanced, ecological approach might look like.
Two models of the relationship between individual behaviour and health status are examined. On the Freedom Model, the individual is presumed to be capable of free choices including many that have important health consequences. Freedom entails accountability. Thus individuals can be held responsible for health conditions that result from choices they have made. To hold otherwise--to refuse to acknowledge the freedom and responsibilities of individuals--is bad faith. On the Facticity Model, behaviour is a result of facts--genetic and environmental--beyond an individual's control. There is little or no freedom; people are the bodies and roles they inherit. Important among these facts is socio-economic position since it determines much of behaviour and resulting health status. Many people who are poor and lack education also suffer from poor health. To blame their poor health on their behaviour is to blame people already victimized by their circumstances. The relationships of these two models to health promotion are explored. Though conflicting in theory, some justice can be done to each model in the practical world of health promotion by appealing to the freedom in individuals in health education and to the facts that shape individuals in other health promotion and health care contexts.
Public health officials, industrial leaders, and insurance companies early in this century optimistically advocated the potential for improved health and productivity through regular physical examinations. Doctors and the public, fed both by the exigencies of war and the experience of new technology, later joined the pursuit of protection from hazard--physical, social, and economic. But these very technologies--newer and more "mechanistic"--changed interest in the annual checkup into a fervor for "mass screening." By the 1970's the quarrel shifted from affective questions to matters of effectiveness and efficiency. Has progress been real?
The rhetoric of the new administration's national health policy reflects a shift in priorities that could have a profound impact on the lives and health of Americans by the end of the decade. It is a move away from what has been a heavy economic investment in disease treatment and toward a greater emphasis on health promotion and disease prevention. So far, the new emphasis has been limited to budget cuts in old health programs rather than new investments or initiatives. Two principal reasons are offered for the change in policy. The first is that medical care is widely perceived . . .
1979, individual responsibility and health politics in the 1970s
- R Crawford
Crawford, R.: 1979, individual responsibility and health politics in the 1970s', in S. Reverby and D. Rosner (eds.), Health Care in America, Temple Univer-sity Press, Philadelphia, pp. 247-268.
http://jmp.oxfordjournals.org/ Downloaded from Galen: 1951, A Translation of Galen's Hygiene, R. M. Green (trans.), Charles C. Thomas, Springfield, Illinois. Hippocrates: 1959a, 'Ancient medicine Hippocrates: 1959b, The sacred disease
- H Emerson
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- J D Knowles
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Landmarks in the History of HygieneMirrors of health and treasures of poor men: The use of the vernacular medical literature in Tudor EnglandMedical advice books: the search for the healthy body
- H Sigerist
- London
- P Slack
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- J A Tobey
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The social meaning of personal health: The ladies physiological institute of Boston and vicinity in the 185O's
- M H Verbrugge
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