How do you count accountability?

The way people are throwing around the word, one would think the world has just discovered “accountability.” It is being used everywhere: in politics, business, medicine and education. Probably the word’s popularity is increasing because so much seems to be going wrong. We want action. We want heads to roll. We want accountability.

The term is used a lot in health-care circles in part due to the newly minted ACOs, Accountable Care Organizations. These are embryonic or more appropriately still-the-glimmer-in-someone’s-eye creations that the health-care reform law recognizes. On paper, they are groups of doctors, other clinicians, hospitals and insurance companies that come together bearing some financial risk to provide care for a population of people. The ACO will be held accountable for standards of care at a set budget. There is that word again.

Doctors also talk about patient accountability. The concept is commonly employed with someone who smokes, uses drugs, is overweight, has diabetes, hypertension, watches a lot of TV or feels depressed. Accountability advocates imply such conditions are a choice. Therefore, if the person is suffering from these lifestyle disorders, they must somehow pay the consequences; as if being obese, sad, unemployed with diabetes and addicted are not punishments enough.

Don’t get me wrong. I’m all in favor of accountability. But I am interested in what it means to different people. Based on the angry tone of some voices, accountability means punishment. One never holds a do-gooder accountable. It is the criminal who is accountable for his crimes. It is the teacher who is accountable for her student’s test scores. It is the poor who are held accountable for their station in life.

It sounds as if they are saying: “Being accountable means you better be good because I am watching you.” It is putting the accent on the count. “I am counting your every move; I am counting on you failing.” “Then I’m going to count the number of lashes you deserve.”

There is, among many, an underlying assumption that all outcomes in life fall from a conscious choice. Yet, we all know that bad things happen to good people. If anyone has any doubt about cruel randomness, just pick any child inflicted with a bad disease, abuse or poor nutrition. Chromosomes are not choices. Parents aren’t picked. Small children don’t buy junk food. Babies don’t raise their hands in favor of being yelled at or being a punching bag.