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“Smokers and obese people ‘soft targets’ for NHS savings, say surgeons.”1
The rationing of medical services to patients with so-called lifestyle diseases remains a controversial proposition worthy of newspaper headlines—like the one above from The Guardian, reporting on findings from a study commissioned in 2015 by the Royal College of Surgeons.2 Such headlines tend to prompt lavish commentary from readers, and opinions tend to be highly polarised. Even at the highest levels, public debate on these issues often appears trapped in a stark alternative between blaming individuals for their behavioural ‘choices’, or appealing to forms of determinism—whether biological or environmental—in order to excuse them. In the face of ageing populations and a growing prevalence of chronic conditions, there has long been a general consensus about the need to shift the focus of healthcare policy and practice towards prevention. Yet, everyday vocabularies of prevention rarely reflect what we know about the complexity of such diseases and of the behaviours associated with them. ‘Both folk psychology and practical reasoning in the clinic,’ write Kirmayer and Gómez-Carrillo in their contribution to this special issue, ‘tend to employ simpler, often dichotomous models’ that are not necessarily helpful, or indeed that may be counterproductive, potentially to the point of harm.3
Against the backdrop of this broad social and cultural context, this collection of articles aims to enrich the repertoire of discussion around questions of agency, responsibility, motivation and self-management. In recent years, these concepts have become explicitly central to the ambitions of a ‘participatory’ model of healthcare where patients are expected to ‘shift from being mere passengers to responsible drivers of their health’.4 Interrogating them both critically and creatively appears particularly important and urgent today, at a time when the marked resurgence of an individualist political rhetoric opposes …
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