“I’m tired of paying for everyone else’s stupidity,” is a comment I read on the Internet last week after the health care bill was passed. It summed up the views of many Americans worried about shelling out higher premiums and taxes to cover the uninsured. Why should we pick up the tab when so much disease in our country stems from unhealthy behavior like smoking and overeating?

In fact, the majority of Americans say it is fair to ask people with unhealthy lifestyles to pay more for health insurance. We believe in the concept of personal responsibility. You hear it in doctors’ lounges and in coffee shops, among the white collar and blue collar alike. Even President Obama has said, “We’ve got to have the American people doing something about their own care.”

But personal responsibility is a complex notion, especially when it comes to health. Individual choices always take place within a broader, messy context. When people advocate the need for personal accountability, they presuppose more control over health and sickness than really exists.

Unhealthy habits are one factor in disease, but so are social status, income, family dynamics, education and genetics. Patient noncompliance with medical recommendations undoubtedly contributes to poor health, but it is as much a function of poor communication, medication costs and side effects, cultural barriers and inadequate resources as it is of willful disregard of a doctor’s advice.