The Fallacy of Relying on Personal Responsibility as a Pandemic Management Strategy
We cannot effectively change or maintain health behaviour — certainly not on the scale of fighting a pandemic — with a ‘personal responsibility’ narrative.
As a lens through which to view, understand, and change health behaviour, ‘personal responsibility’ is one-dimensional, deeply flawed (theoretically and practically), and is not aligned with the extant evidence.
A personal responsibility narrative takes little to no account of the environment within which we behave, the situations in which people live or find themselves, or the myriad of psychological and social influences on behaviour.
A personal responsibility narrative or framework responsibilizes the individual for everything. Responsibilization is a process whereby individuals are held responsible for actions, risks, and outcomes which would otherwise fall within the remit of another (i.e. the state), or would not have previously been considered a responsibility. Yes, of course we all make decisions in our lives. And being responsibile is all fine and well. That is the level of the apple. What about the barrel — the environment? And the barrel-makers or barrel making — policy decisions?
Even at the apple level, there are countless psychological influences on behaviour: cognition (informed decision making, ability, distraction, effects of stress, cognitive biases (intrinsically human)); emotion; anxiety; attitudes; personality; self-efficacy; competing motivations; perceived social support; and the list goes on.
Each of these may warrant differential inclusion in a health behaviour model or health behaviour messaging, depending on the particular problem, depending on whether we want to influence, for example a protective behaviour (like social distancing, hand washing) or a screening behaviour (like testing). And messages may need to be tailored according to sociodemographic characteristics. It’s a complex science. A complex science that cannot be boiled down to ‘personal responsibility’.
To fully understand health behaviour, we can look at different categories of influence, through the COM-B model, developed by Michie, van Stralen, and West (2011): capability, opportunity, and motivation.
Capability: Can we do it? Do we have the physical capability? Do we have the cognitive abilities and requisite knowledge?
Opportunity: Are we enabled by the environment to do it? Opportunity is everything outside the individual, everything in the ecosystem, everything in the physical, social, economic, and political environment. Opportunity can be broken down into physical opportunity and social opportunity.
Motivation: Are we motivated to do it? Are we motivated on an intrinsic, automatic, or habitual level, or in terms of emotional responding? Are we motivated upon reflection, according to our social role, or in terms of analytical decision making?
Each of these influences (capability, opportunity, motivation) operates within an interactive system with behaviour. Opportunity influences motivation. Behaviour influences the COM factors, and feeds back to them.
This is much more comprehensive and complex than a ‘personal responsibility’ framework.
A key component of the model on which we need to redouble our focus is opportunity. How are people being enabled to change and maintain health behaviour? Are people getting what they need? For example, are people getting clear information, appropriate health messaging, and social supports (welfare, income, preserved opportunity)? Is the social environment, as shaped by health messaging, conducive to adherence to clear guidelines?
But, at a deeper, more fundamental level, what do people’s employment opportunities look like if they adhere to the messaging? Are they in precarious employment, and at risk of unemployment if they adhere to social isolation rules? Do they have sick leave? Does the employer pressure employees not to take sick leave? Is there a safety net so that the person can afford to isolate? Do people have housing that enables them to isolate? Is public transport capacity sufficient? Are businesses and other organisations supported to remain closed temporarily? Do people have the connectivity to reliably work from home?
Distal decisions and policies must also be identified. Decisions about health system capacity, whether in acute care or rehabilitation, are affecting how we can deal with pandemics and other public health problems. As does insufficient health and social care integration and structural problems. Delays in the National Broadband Plan are causing lost opportunity in education and ability to work from home. Income and wealth inequality means that some people can afford to self-isolate and have the physical and social opportunity. Others are in precarious employment or crowded or damp housing.
We see now how COVID-19 is both a microcosm and an exploded example of how the environment may be shaped to either enable or hold people back. We can isolate and criticise proximal policy decisions, like the focus on personal responsibility and the refusal to implement an elimination/#ZeroCovid strategy.
Is there a terrible irony to the responsibilization of individuals to stop COVID? Is personal responsibility thus the lens through which to view and understand Government and media (many, influential) eschewing health advice and evidence and chasing false economies? No. Whether it’s you, me, a Cabinet member, senior civil servant, or op-ed writer, we all live within an environment, with personal histories, with myriad psychological, social, and environmental influences, and the intrinsic human bias toward proximal threats, and a difficulty weighing the distal.
I get the sense that eyes often glaze over at the mention of neoliberalism, but our socioeconomic system and governance is an ideological framework. There is a sense that the way we do things is determined by the invisible hand of the free market, and woe betide those who interfere. But, it’s simply not the only way things can be. (And to be clear, I understand that while neoliberalism is a very strong prevailing influence on policy, true neoliberalism is substantially more laissez-faire than actual policy implementation in Ireland).
A look at the successes of Vietnam, South Korea, Australia, New Zealand, some Canadian states tells us that. Vietnam “very quickly acted in ways which seemed to be quite extreme at the time but were subsequently shown to be rather sensible”: travel restrictions, border monitoring and closure, implementation of health assessments at high risk physical locations, school closures (January to May), contact tracing, and 14-day quarantine for inward travel and confirmed contacts. And no, we don’t have to adopt Vietnam’s economic model to deal with the pandemic. New Zealand’s successes are well publicised, and its economic model is much, much closer to our own.
Neoliberalism, or more generally laissez-faire economics, has, I think, been one of the roots of arguments for false economies, like opening high risk environments just prior to Christmas. And the prioritisation of certain economic factors over public health — another false economy. Yet, and acknowledging that GDP is but one, blunt measure of economic impact, there seems to be a pretty clear relationship between higher COVID-related mortality and greater loss of GDP.
I don’t think we needed to even wait for that data. If half the population is sick with COVID, what sort of economic activity will they be engaged in?! How would confidence and demand be affected by highly prevalent coronavirus? What are the long-term costs of overwhelmed hospitals, high morbidity, and chronic morbidity and associated health service and rehabilitation need? What are the costs relating to health and social service interruption from uncontrolled spread of the virus? These were considered by science, academia, and the general public. There are though, none so blind as those who will not see.
We should consider neoliberalism as an environmental influence on thinking, decisions, behaviour, and policy. This prevailing ideology — a huge part of the environment within which we operate — is a tremendous barrier to dealing with the pandemic.
We cannot simply tell people to ‘be responsible’ and grow our way out of this one. We need an elimination strategy.
