The premise that individuals have a personal responsibility to protect and promote health has been debated throughout public health history. This notion gained a special place in country agendas and political discourse in 1978, when it was included in the Declaration of Alma-Ata, which also posed health as a fundamental human right and primary health care as essential to achieve it.[¹1. World Health Organization. Declaration of Alma-Ata [Internet]. Geneva: World Health Organization; 1978 Sep [cited 2012 Mar 29]. Available from: http://new.paho.org/hq/dmdocuments/2010/PHC_Alma_Ata-Declaration-1978.pdf
http://new.paho.org/hq/dmdocuments/2010/... ]

Undoubtedly personal responsibility was one of the original underpinnings of primary health care, although the term was never defined. Nearly four decades later, the idea that individuals have a responsibility for their own and their community’s health has not been fully articulated theoretically or explored empirically. It is always accompanied by polemics emerging from a) inexact translations of the term (in our case, between English and Spanish); b) lack of consensus on the concept itself; and c) multiple health strategies adopted in the late 20th century by various countries, using personal responsibility for their neoliberal rationale and theoretical foundation.

The Spanish–English conundrum derives from the original Alma-Ata document, which twice refers to the Spanish autorresponsabilidad as self-reliance in English. The two are not equivalent by any linguistic standards, with the closest English being personal responsibility. To this, add the general confusion generated in scientific and other literature by the indistinct use of self-care, self-management, self-help and self-sufficiency, among others, as substitutes for personal responsibility, despite clear differences in meaning.

In a previous article I proposed a conceptual definition of personal responsibility for health: the understanding that our actions have consequences for individual and collective health. It implies that, ethically and morally, we have a civic duty to act in daily life in such a way that our behavior is not harmful to our own wellbeing or that of others. The ethical foundation of this approach is that a claim to any right should necessarily be accompanied by fulfillment of a duty.[²2. Luis Gonzalvez IP, Martinez Calvo S, Alvarez Pérez AG. Community Engagement, Personal Responsibility and Self Help in Cuba’s Health System Reform. MEDICC Rev [Internet]. 2012 Oct [cited 2013 Jan 13];14(4):44–7. Available from: http://www.medicc.org/mediccreview/index.php?issue=22&id=279&a=va
http://www.medicc.org/mediccreview/index... ]

Acceptance and application of this definition implies that personal responsibility for health is not only reactive, but rather proactive. It does not mean simply practicing healthy behaviors, but rather adopting these behaviors as a result of individual reflection leading to a personal moral commitment. Thus, personal responsibility would apply not only to fulfillment of duties prescribed by law (civil, criminal, environmental), but also to moral ones, not necessarily contemplated in law.

At the same time, this definition incorporates the theory of health as a human right, as it recognizes the intimate relationship between right and duty. Such a duty as personal responsibility for protecting health cannot be demanded unless countries have previously guaranteed their populations the possibility of exercising this right, offering individuals, families and communities universal health through health systems with accessible, comprehensive, quality and inclusive care. Thus, personal responsibility cannot be imposed without considering the influence of health’s social determinants.

This definition does NOT mean that personal responsibility is used to justify privatizing medical services, creating basic or specific-care packages, or to prioritize medical services for those who demonstrate healthy behaviors while discriminating against those whose behavior is deemed irresponsible. None of these can be justified under the definition proposed, since they have been shown to damage the right to health and increase disparities. Nor does this proposal use illness or risk as a moral yardstick to judge individuals, but rather it is a means to mobilize them to reflect on and commit to protecting and promoting both their own and their community’s health through more informed, genuine participation.

Still unresolved is how to pinpoint, concretely and practically, the spot where personal responsibility ends and social responsibility begins. This requires collective deliberation, relying on opinions from multiple actors, to assure validation and social legitimization of conclusions. Tools such as those offered by UNESCO’s Universal Declaration on Bioethics and Human Rights can be useful in this regard.

In Cuba, the Constitution establishes citizens’ rights to health care and protection, as well as state responsibility to provide these free of charge.[³3. National Assembly of People’s Power (CU). Constitution of the Republic of Cuba. Havana: National Assembly of People’s Power (CU); 1992 Aug 1. Article 50. p. 24. Spanish, English.] This is reflected in a single national, universal health system. The Constitution also notes public cooperation is key to these efforts, offering a point of departure to consider fresh ways to implement personal responsibility as conceptualized here. In fact, our society—highly organized, with a well-educated population and strong social cohesion—has the opportunity to reconstruct the meaning of personal responsibility for health.

Despite economic limitations that do affect individuals, families and the whole country, we can practice a vision of personal responsibility far removed from neoliberal discourse that negates the fundamental role of government in protecting health and often blames the sick for their predicament. Rather, we can commit to further empowering individuals and their communities to actively build health, contributing to a shared responsibility with the state in which conscious citizen participation also counters paternalistic notions of health care as the province of health professionals alone.

What’s more, such personal responsibility is essential to ensure economic sustainability of our health system (as reminders in community polyclinics read: Health care is free, but it costs!); as well as to promote intersectoral actions for health in all policies to address social determinants. The ethical principles of beneficence, protection, solidarity and social justice should be our guide.

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