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The distribution of scarce healthcare resources is an increasingly important issue due to factors such as expensive 'high tech' medicine, longer life expectancies and the rising prevalence of chronic illness. Part of the healthcare resource allocation debate centres on the question of whether individual patient characteristics should be considered in decision-making. 1 Characteristics proposed to be relevant include: (1) an individual's relationship to others (eg, the individual is a criminal, has dependents or rare skills); (2) an individual's personal attributes (eg, gender or cultural background); and (3) an individual's relationship to their illness (eg, the individual's disease is due to genetic, environmental, or lifestyle factors). 1
Characteristic three, the individual's relationship to their illness, is particularly pertinent to the current healthcare context in which lifestyle-related factors such as high blood pressure, tobacco use and obesity are believed to contribute significantly to the global burden of disease and individual behaviour is seen as a responsible for many health problems. 2 3 As such, this paper focuses on an ongoing debate in the academic literature regarding the role of responsibility for illness in healthcare resource allocation: should patients with self-caused illness receive lower priority in access to healthcare resources?
This debate began in earnest during 1991 with the publication of opposing papers by Moss and Siegler 4 and Cohen and Benjamin 5 in the Journal of the American Medical Association . Moss and Siegler 4 argued that patients with alcohol-related liver disease should have lower priority in access to liver transplantation, while Cohen and Benjamin 5 argued the contrary. In 1993, the debate gained momentum with the publication of two further papers in the British Medical Journal for 6 and against 7 a lower priority for smokers in access to coronary artery bypass surgery. These articles prompted numerous letters to the editor in subsequent issues of the British Medical Journal . 8-24 Currently, the debate remains unresolved and new articles continue to emerge (eg, Ho 2008, 25 Feiring 2008, 26 Glannon 2009 27 ). One factor hindering the progression of the lower priority debate is the lack of an overall description or 'map' detailing the nature of the arguments and their relationships. Therefore, the primary purpose of this article is to present a comprehensible and comprehensive...