American Journal of Bioethics
HESC and Equitable Residues Gopal Sreenivasan, Duke University Preda and Voigt (2015) do an admirable job of clarifying and scrutinizing the influential “health equity through social change” model (HESC). In particular, they helpfully identify a number of cases where the model’s claims or assumptions stand in need of greater defense. I shall focus on some important questions they raise about the model’s central normative claim. As Preda and Voigt formulate it, HESC’s central normative claim is that an inequality in health’s being avoidable is both necessary and sufficient for its being unjust. Against this, they go on to suggest that “‘avoidability,’ as understood in this framework, is neither necessary nor sufficient” (28). In a spirit of respectful engagement, I shall criticize Preda and Voigt’s treatment of HESC’s claim, taking its two halves separately. For each half, I first argue that their interpretation leaves room for improvement, and then argue that, better understood, HESC’s normative claim is actually reasonably defensible, contrary to what they suggest. Let us start with the necessity half. We can be brief here, since there is less philosophical substance at stake. Preda and Voigt usefully distinguish several different things that might be meant by saying that a given inequality in health is “avoidable.” One option is that the inequality can be prevented (i.e., avoided ahead of time); another is that it can be remedied (i.e., a deficit in function occurs, but it can be made good by medical or other means after the fact—hence its persistence can be avoided); and a final option is that the inequality can be compensated (i.e., a deficit in function occurs and persists, but its impact on wellbeing can be made good after the fact, e.g., by a financial payment). It was not clear to me whether Preda and Voigt mean to claim that the compensation option should be treated on a par with the other two here. But in my view, it should not be. To begin with, the immediate context is the interpretation of “avoidability,” as it applies to inequalities in health, and it is simply false that compensation allows us to avoid the persistence of an inequality in health (as opposed to the persistence of its impact on well-being). Furthermore, while the option of compensation is significant, it muddies the analytic waters to bring it in at this point, as we can appreciate when the issue recurs later in this commentary. Thus, for the sake of both simplicity and charity, I shall read Preda and Voigt as (properly) treating compensation separately here. Having distinguished these senses, Preda and Voigt then introduce “amenability to intervention” to cover the
first two senses, that is, health inequalities that are either preventable or remediable. Subject to one caveat, they concede that “it is plausible to regard ‘amenability’ as a necessary condition for unfairness” (30). However, they still reject HESC’s necessity claim because they construe its use of “avoidability” very narrowly, as meaning only preventability (as distinct from remediability). So construed, preventability is clearly not a necessary condition of unfairness. But I fail to see why “avoidability” in HESC should not be interpreted exactly along the lines of their own “amenability” (cf. their note 8). Read that way, HESC’s necessity claim would be, precisely, plausible. (Their caveat reflects an acknowledgment that some philosophers regard injustice as applicable even in cases where nothing can be or could have been changed at all. But this dispute can be cabined by distinguishing “natural” from “social” justice, where “amenability” [to borrow their term] is defined as a necessary condition of the latter, but not of the former. See Sreenivasan [2014]. HESC’s normative claims are easily restricted to social justice.) Turning now to the sufficiency half of HESC’s normative claim, the first thing to say is that the proposition that an inequality in health’s being avoidable is, strictly speaking, a sufficient condition of its being unjust makes no sense. This proposition may be logically equivalent to something that HESC does affirm, namely, that all avoidable inequalities in health are unjust. But the truly sufficient conditions for their injustice must at least include a principle of equality (or something like it). Of course, principles of equality themselves also stand in need of some defense, as does the choice of any particular principle of equality rather than another. Still, appeals to equality do have a certain plausibility. Preda and Voigt appear to hold that direct appeals to equality are somehow suspect in this context. I discern two grounds for suspicion in what they say. As I shall try to explain, both strike me as confused. But we need three pieces of apparatus to appreciate why that is. The first is the notion of a “residual” health inequality, which Preda and Voigt also invoke. A residual health inequality is an avoidable (i.e., “amenable”) inequality in health, the causes of which are otherwise fair. It is not controversial—indeed, Preda and Voigt themselves accept— that avoidable health inequalities resulting from an independently unjust cause (e.g., racial discrimination) are also and therefore unjust. Restricting our attention to residual health inequalities allows us to set these uncontroversial cases aside, and thereby to concentrate on the remainder.
Address correspondence to Gopal Sreenivasan, Duke University, Philosophy Department, Box 90743, Durham, NC 27708, USA. E-mail: [email protected]
54 ajob
March, Volume 15, Number 3, 2015
Caring About Social Determinants of Health
As our next piece of apparatus, we should distinguish two fundamentally different approaches to bringing principles of justice to bear on evaluating inequalities in health (see Sreenivasan 2009; 2014). On the freestanding approach, the primary locus of evaluation is (the justice of) avoidable health inequalities themselves. The simplest version applies a general principle of equality directly to the case of health (e.g., Culyer and Wagstaff 1993). Like HESC, it entails that any avoidable (and, a fortiori, any residual) inequality in health is unjust. On the derivative approach, the primary locus of evaluation is (the justice of) the socially controllable causes of health inequalities. Here the injustice of a cause of an avoidable health inequality functions as a sufficient condition of the injustice of its effect. In this way, the injustice of an unjust health inequality derives from the injustice of its cause(s). No version of the derivative approach entails that any residual health inequality is unjust. Each approach offers no more than sufficient conditions for the injustice of an avoidable inequality in health. Hence, each is entirely consistent with the other. Yet this also means that no version of the derivative approach entails that any residual health inequality is just either. Since that would contradict Culyer and Wagstaff (1993), for example, it requires a separate argument. After all, “not entail unjust” is different from “entails not unjust.” Preda and Voigt are skeptical whether there is “any theoretical framework that can support the claim that [residual] inequalities are unjust” (30). Since freestanding approaches purport to do exactly that, their puzzle seems to be how any version of this approach could be correct. My puzzle is what the obstacles are supposed to be. I discern two possibilities. On the one hand, Preda and Voigt do “not find much support” (31) for the freestanding approach in the literature, while two “major types of theory” conclude that residual inequalities are “not unfair.” This overlooks the example of Culyer and Wagstaff (1993). More importantly, the most prominent example they adduce is confused precisely on this point: Daniels (2008) certainly concludes that residual inequalities are “just.” However, his theory follows the derivative approach (see Sreenivasan 2009) and thus fails, as explained earlier, to license this conclusion. Moreover, he signally fails to offer any separate argument against any freestanding approach or even to recognize that he needs one. Daniels therefore makes a poor authority on this point. On the other hand, Preda and Voigt contend that theories of justice “are usually concerned with ‘overall’ inequalities” (31) and that this militates against HESC’s sufficiency claim. Here we need our final piece of apparatus, which is the distinction between “pro tanto” and “overall” injustice. An inequality is pro tanto unjust when it is unjust, other things equal. Culyer and Wagstaff (1993), for example, only claim that avoidable inequalities in health are unjust, other things equal; and no sensible freestanding approach will claim more. There is no tension whatsoever between this claim and the idea that justice is
March, Volume 15, Number 3, 2015
concerned with overall inequalities. Likewise, there is no obstacle here to accepting HESC’s sufficiency claim, similarly understood. (This confusion is parallel to the one that afflicts the argument in Hausman [2013], which I examine in Sreenivasan [2014], to which readers are referred for more detail than present space permits). To see this, say that the overall inequalities with which justice is concerned are inequalities in well-being (and assume that avoidability is satisfied throughout). Inequalities in health contribute, other things equal, to inequalities in well-being; and inequalities in well-being contribute, other things equal, to injustice. Since these relations are transitive, inequalities in health still contribute, other things equal, to injustice. In other words, they are pro tanto unjust, as HESC claims. Of course, other things may not be equal. An inequality in health may be consistent with equality in well-being—for example, if it is compensated by a complementary inequality in some nonhealth contributor to well-being (friendship, say). In that case, it will not result in any overall injustice. But the same is true of inequalities in overall well-being. They may not result in any overall injustice either, for example, if their contribution is neutralized by considerations of individual choice. That does not make either category suspect. In its simplest version, then, HESC should be read as entailing that residual health inequalities are pro tanto unjust. This strikes me as much less problematic than Preda and Voigt make out. All the same, this kind of pro tanto injustice is rather fragile. There are many ways in which it can fail to result in overall injustice. Thus, Preda and Voigt are still on strong ground in emphasizing that a lot of work remains to be done before moving from HESC’s front-line normative assessments to its policy prescriptions; and this quite apart from attending to any of the difficulties with causation they also rightly flag. &
REFERENCES Culyer, A. and A. Wagstaff. 1993. Equity and equality in health and health care. Journal of Health Economics 12: 431–457. Available at: http://dx.doi.org/10.1016/0167-6296(93)90004-X Daniels, N. 2008. Just health. New York, NY: Cambridge University Press. Hausman, D. 2013. Egalitarian critiques of health inequalities. In Inequalities in health: Concepts, measure, and ethics. ed. N. Eyal, S. Hurst, O.F. Norheim, and D. Wikler, 95–112. Oxford, UK: Oxford University Press. Preda, A. and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36. Sreenivasan, G. 2009. Ethics and epidemiology: Residual health inequalities. Public Health Ethics 2(3): 244–249. Available at: http://dx.doi.org/10.1093/phe/php030 Sreenivasan, G. 2014. Justice, inequality, and health. In Stanford Encyclopedia of Philosophy. Available at: http://plato.stanford. edu/archives/fall2014/entries/justice-inequality-health
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Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
HESC and Equitable Residues Gopal Sreenivasan, Duke University Preda and Voigt (2015) do an admirable job of clarifying and scrutinizing the influential “health equity through social change” model (HESC). In particular, they helpfully identify a number of cases where the model’s claims or assumptions stand in need of greater defense. I shall focus on some important questions they raise about the model’s central normative claim. As Preda and Voigt formulate it, HESC’s central normative claim is that an inequality in health’s being avoidable is both necessary and sufficient for its being unjust. Against this, they go on to suggest that “‘avoidability,’ as understood in this framework, is neither necessary nor sufficient” (28). In a spirit of respectful engagement, I shall criticize Preda and Voigt’s treatment of HESC’s claim, taking its two halves separately. For each half, I first argue that their interpretation leaves room for improvement, and then argue that, better understood, HESC’s normative claim is actually reasonably defensible, contrary to what they suggest. Let us start with the necessity half. We can be brief here, since there is less philosophical substance at stake. Preda and Voigt usefully distinguish several different things that might be meant by saying that a given inequality in health is “avoidable.” One option is that the inequality can be prevented (i.e., avoided ahead of time); another is that it can be remedied (i.e., a deficit in function occurs, but it can be made good by medical or other means after the fact—hence its persistence can be avoided); and a final option is that the inequality can be compensated (i.e., a deficit in function occurs and persists, but its impact on wellbeing can be made good after the fact, e.g., by a financial payment). It was not clear to me whether Preda and Voigt mean to claim that the compensation option should be treated on a par with the other two here. But in my view, it should not be. To begin with, the immediate context is the interpretation of “avoidability,” as it applies to inequalities in health, and it is simply false that compensation allows us to avoid the persistence of an inequality in health (as opposed to the persistence of its impact on well-being). Furthermore, while the option of compensation is significant, it muddies the analytic waters to bring it in at this point, as we can appreciate when the issue recurs later in this commentary. Thus, for the sake of both simplicity and charity, I shall read Preda and Voigt as (properly) treating compensation separately here. Having distinguished these senses, Preda and Voigt then introduce “amenability to intervention” to cover the
first two senses, that is, health inequalities that are either preventable or remediable. Subject to one caveat, they concede that “it is plausible to regard ‘amenability’ as a necessary condition for unfairness” (30). However, they still reject HESC’s necessity claim because they construe its use of “avoidability” very narrowly, as meaning only preventability (as distinct from remediability). So construed, preventability is clearly not a necessary condition of unfairness. But I fail to see why “avoidability” in HESC should not be interpreted exactly along the lines of their own “amenability” (cf. their note 8). Read that way, HESC’s necessity claim would be, precisely, plausible. (Their caveat reflects an acknowledgment that some philosophers regard injustice as applicable even in cases where nothing can be or could have been changed at all. But this dispute can be cabined by distinguishing “natural” from “social” justice, where “amenability” [to borrow their term] is defined as a necessary condition of the latter, but not of the former. See Sreenivasan [2014]. HESC’s normative claims are easily restricted to social justice.) Turning now to the sufficiency half of HESC’s normative claim, the first thing to say is that the proposition that an inequality in health’s being avoidable is, strictly speaking, a sufficient condition of its being unjust makes no sense. This proposition may be logically equivalent to something that HESC does affirm, namely, that all avoidable inequalities in health are unjust. But the truly sufficient conditions for their injustice must at least include a principle of equality (or something like it). Of course, principles of equality themselves also stand in need of some defense, as does the choice of any particular principle of equality rather than another. Still, appeals to equality do have a certain plausibility. Preda and Voigt appear to hold that direct appeals to equality are somehow suspect in this context. I discern two grounds for suspicion in what they say. As I shall try to explain, both strike me as confused. But we need three pieces of apparatus to appreciate why that is. The first is the notion of a “residual” health inequality, which Preda and Voigt also invoke. A residual health inequality is an avoidable (i.e., “amenable”) inequality in health, the causes of which are otherwise fair. It is not controversial—indeed, Preda and Voigt themselves accept— that avoidable health inequalities resulting from an independently unjust cause (e.g., racial discrimination) are also and therefore unjust. Restricting our attention to residual health inequalities allows us to set these uncontroversial cases aside, and thereby to concentrate on the remainder.
Address correspondence to Gopal Sreenivasan, Duke University, Philosophy Department, Box 90743, Durham, NC 27708, USA. E-mail: [email protected]
54 ajob
March, Volume 15, Number 3, 2015
Caring About Social Determinants of Health
As our next piece of apparatus, we should distinguish two fundamentally different approaches to bringing principles of justice to bear on evaluating inequalities in health (see Sreenivasan 2009; 2014). On the freestanding approach, the primary locus of evaluation is (the justice of) avoidable health inequalities themselves. The simplest version applies a general principle of equality directly to the case of health (e.g., Culyer and Wagstaff 1993). Like HESC, it entails that any avoidable (and, a fortiori, any residual) inequality in health is unjust. On the derivative approach, the primary locus of evaluation is (the justice of) the socially controllable causes of health inequalities. Here the injustice of a cause of an avoidable health inequality functions as a sufficient condition of the injustice of its effect. In this way, the injustice of an unjust health inequality derives from the injustice of its cause(s). No version of the derivative approach entails that any residual health inequality is unjust. Each approach offers no more than sufficient conditions for the injustice of an avoidable inequality in health. Hence, each is entirely consistent with the other. Yet this also means that no version of the derivative approach entails that any residual health inequality is just either. Since that would contradict Culyer and Wagstaff (1993), for example, it requires a separate argument. After all, “not entail unjust” is different from “entails not unjust.” Preda and Voigt are skeptical whether there is “any theoretical framework that can support the claim that [residual] inequalities are unjust” (30). Since freestanding approaches purport to do exactly that, their puzzle seems to be how any version of this approach could be correct. My puzzle is what the obstacles are supposed to be. I discern two possibilities. On the one hand, Preda and Voigt do “not find much support” (31) for the freestanding approach in the literature, while two “major types of theory” conclude that residual inequalities are “not unfair.” This overlooks the example of Culyer and Wagstaff (1993). More importantly, the most prominent example they adduce is confused precisely on this point: Daniels (2008) certainly concludes that residual inequalities are “just.” However, his theory follows the derivative approach (see Sreenivasan 2009) and thus fails, as explained earlier, to license this conclusion. Moreover, he signally fails to offer any separate argument against any freestanding approach or even to recognize that he needs one. Daniels therefore makes a poor authority on this point. On the other hand, Preda and Voigt contend that theories of justice “are usually concerned with ‘overall’ inequalities” (31) and that this militates against HESC’s sufficiency claim. Here we need our final piece of apparatus, which is the distinction between “pro tanto” and “overall” injustice. An inequality is pro tanto unjust when it is unjust, other things equal. Culyer and Wagstaff (1993), for example, only claim that avoidable inequalities in health are unjust, other things equal; and no sensible freestanding approach will claim more. There is no tension whatsoever between this claim and the idea that justice is
March, Volume 15, Number 3, 2015
concerned with overall inequalities. Likewise, there is no obstacle here to accepting HESC’s sufficiency claim, similarly understood. (This confusion is parallel to the one that afflicts the argument in Hausman [2013], which I examine in Sreenivasan [2014], to which readers are referred for more detail than present space permits). To see this, say that the overall inequalities with which justice is concerned are inequalities in well-being (and assume that avoidability is satisfied throughout). Inequalities in health contribute, other things equal, to inequalities in well-being; and inequalities in well-being contribute, other things equal, to injustice. Since these relations are transitive, inequalities in health still contribute, other things equal, to injustice. In other words, they are pro tanto unjust, as HESC claims. Of course, other things may not be equal. An inequality in health may be consistent with equality in well-being—for example, if it is compensated by a complementary inequality in some nonhealth contributor to well-being (friendship, say). In that case, it will not result in any overall injustice. But the same is true of inequalities in overall well-being. They may not result in any overall injustice either, for example, if their contribution is neutralized by considerations of individual choice. That does not make either category suspect. In its simplest version, then, HESC should be read as entailing that residual health inequalities are pro tanto unjust. This strikes me as much less problematic than Preda and Voigt make out. All the same, this kind of pro tanto injustice is rather fragile. There are many ways in which it can fail to result in overall injustice. Thus, Preda and Voigt are still on strong ground in emphasizing that a lot of work remains to be done before moving from HESC’s front-line normative assessments to its policy prescriptions; and this quite apart from attending to any of the difficulties with causation they also rightly flag. &
REFERENCES Culyer, A. and A. Wagstaff. 1993. Equity and equality in health and health care. Journal of Health Economics 12: 431–457. Available at: http://dx.doi.org/10.1016/0167-6296(93)90004-X Daniels, N. 2008. Just health. New York, NY: Cambridge University Press. Hausman, D. 2013. Egalitarian critiques of health inequalities. In Inequalities in health: Concepts, measure, and ethics. ed. N. Eyal, S. Hurst, O.F. Norheim, and D. Wikler, 95–112. Oxford, UK: Oxford University Press. Preda, A. and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36. Sreenivasan, G. 2009. Ethics and epidemiology: Residual health inequalities. Public Health Ethics 2(3): 244–249. Available at: http://dx.doi.org/10.1093/phe/php030 Sreenivasan, G. 2014. Justice, inequality, and health. In Stanford Encyclopedia of Philosophy. Available at: http://plato.stanford. edu/archives/fall2014/entries/justice-inequality-health
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Copyright of American Journal of Bioethics is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
