This article was downloaded by: [University of Victoria] On: 25 April 2015, At: 21:50 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Just Deserts or Icing on the Cake? Addressing the Social Determinants of Health a
a
b
Mark D. Fox , Michael R. Gomez & Ricky T. Munoz a
University of Oklahoma School of Community Medicine
b
University of Oklahoma–Tulsa Published online: 18 Mar 2015.
Click for updates To cite this article: Mark D. Fox, Michael R. Gomez & Ricky T. Munoz (2015) Just Deserts or Icing on the Cake? Addressing the Social Determinants of Health, The American Journal of Bioethics, 15:3, 42-44, DOI: 10.1080/15265161.2014.998383 To link to this article: http://dx.doi.org/10.1080/15265161.2014.998383
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
American Journal of Bioethics
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In the end, this line of thought can count as further evidence for Voigt and Preda’s insistence that we have to examine the situation more carefully, and that the reports are themselves not sufficiently careful, but it does seem that Marmot’s view should not be characterized as advocating something so extreme. Finally, a comment on Preda and Voigt’s claim that there are “straightforward” social justice reasons for altering the social factors that concern resource inequality, so that perhaps it’s odd, unnecessary, or counterproductive to approach this in terms of health. This is certainly an important heuristic toward taking seriously that we should not jump to a particular policy too quickly. But the following is also a reasonable and important consideration: Yes, we should be doing something about these things simply on grounds of social justice, but of course we do not tend
to do so (or we tend not to do nearly enough). And this is causing damage to health (causing inequality of health, as well as poor health), which is uncontroversially serious, and which plays a role in whether there is equality of opportunity in our society. The sense in which connection to health adds urgency is quite important and appropriate. Again, all of this is consistent with an endorsement of Voigt and Preda’s view that we must address these questions of how to characterize the SDH and think about their implications for policy much more carefully than we have. & REFERENCE Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36.
Just Deserts or Icing on the Cake? Addressing the Social Determinants of Health Mark D. Fox, University of Oklahoma School of Community Medicine Michael R. Gomez, University of Oklahoma School of Community Medicine Ricky T. Munoz, University of Oklahoma–Tulsa Preda and Voigt (2015) raise the provocative question, “Why should we care about the social determinants of health?” Despite a careful, stepwise analysis of the implications and obligations arising from social and health inequalities versus inequities, their analysis ultimately loses sight of its initial focus, that is, the social determinants of health per se. Although the authors assert their endorsement of certain policies that have led to “improvements to people’s living conditions and reductions of inequalities in wealth and power,” these are required as a matter of social justice, not because of any perceived health inequality or even because of any impact on health outcomes. Specifically, the authors argue that health disparities arising from social inequalities (resulting from “natural” differences and not deemed unfair) ought not to be the target of intervention via social change. Ultimately, we think the authors belabor a distinction with little relevance, while dodging the issue purportedly framing their inquiry. Their commitment to social justice, irrespective of health outcomes, seems curiously dogmatic, given the careful parsing of claims regarding avoidable versus amenable health disparities and natural social
inequalities. Interestingly, a physician’s commitment to social justice is one of the striking features codified in the Physician Charter on Medical Professionalism (ABIM Foundation, American Board of Internal Medicine; ACPASIM Foundation, American College of Physicians–American Society of Internal Medicine; and European Federation of Internal Medicine 2002). This commitment is articulated, however, in a clinically circumscribed way. Specifically, it calls upon physicians to “promote justice in the health care system,” through fair distribution of scarce resources and the elimination of discrimination (presumably in clinical care). Thus, the charter advocates for, at best, a limited notion of social justice, focused on the provision of health care, not on the elimination of health inequities. Rather than arguing the merits of pursuing health equity through social change, we take at face value the authors’ query regarding why social determinants of health merit attention. As clinicians, we take as one of our central commitments an obligation to seek to improve the health of our patients. However, we also recognize that our actual clinical care has at best a modest impact in
Address correspondence to Mark D. Fox, University of Oklahoma School of Community Medicine, 4502 E. 41st Street, Tulsa, OK 74135, USA. E-mail: [email protected]
42 ajob
March, Volume 15, Number 3, 2015
Downloaded by [University of Victoria] at 21:50 25 April 2015
Caring About Social Determinants of Health
determining the health of our patients. Although estimates vary, the impact of health care on health pales in comparison to health behaviors and social and economic factors. A working paper from the University of Wisconsin Population Health Institute assesses various weighting schemes, but all place the impact of clinical care in the 10–20% range among determinants of health. (Booske et al. 2010). Meanwhile, health behaviors account for 25– 57% of health determinants, and social and economic factors represent 21–55%. No matter how one slices it, factors beyond the exam room, beyond the clinician’s competence, and beyond the reach of a prescription pad have a vastly greater impact on our patients’ health and the health of a community. Thus, no matter where one may fall on the political spectrum or in the commitment to social justice, clinicians are compelled to attend to social determinants of health in order to fulfill their commitment to optimize patients’ health. One challenge, however, is that physicians may often feel ill-equipped to address the social determinants of health, let alone to effect social change. For most of us, advocacy was not a topic covered in our medical school curricula, and may not have been a part of our clinical training. Physicians may feel they lack the content expertise to address the social determinants, the “causes of causes,” in a meaningful way. Further, clinicians may lack the “influencing skills” needed to advocate effectively for social change (van de Wiele et al. 2014). We contend, therefore, that advocacy is an essential skill for physicians to develop in order to maintain fidelity to their obligation to promote health, which in turn requires a commitment to addressing the social determinants of health. How, then, can one fulfill a commitment to an objective for which one feels largely ill prepared? There are countless examples of how clinicians advocate on behalf of individual patients. Likewise, the physicians’ advocacy role within health care systems is likely familiar (Earnest, Wong, and Federico 2010), and consistent with the social justice role contemplated in the Physician Charter. However, to be most effective in advocating for social change to address determinants of health, physicians may best lend their professional and technical expertise in collaboration with other professionals such as social workers, educators, policy makers, and others. This role may not feel immediately comfortable, reaching beyond the realm of the exam room, hospital, or health system. John Snow likely did not appreciate that he was shaping the discipline of epidemiology during London’s cholera outbreaks of the 1800s (Hempel 2007). He may also have felt ill equipped to address the Board of Guardians in 1854. But his scientifically organized inquiry, directed by his clinical observations and commitment to improve health, not only profoundly influenced modern epidemiology, but also dramatically effected social change. A more recent, but similarly profound, social change inspired by health concerns is seen in the work of child health advocates in promoting the removal of lead from both paint and gasoline. These efforts have led to a dramatic decline
March, Volume 15, Number 3, 2015
in lead toxicity among children in the United States (Pirkle 1994). Preda and Voight (2014) take issue with the notion that we ought to redress health inequities, except as they might incidentally be addressed by a social justice commitment undertaken for obligations irrespective of health concerns. Indeed, they seem to suggest both that health inequalities arise from “natural” individual differences, which ought not be addressed by corrective action, and further that finding effective policy approaches is too difficult. However, if the fundamental commitment of health care professionals is to improve health, then attention to root causes of, and factors contributing to, poor health is needed. The focus of that attention, then, falls on both health behavior and the social and economic determinants of health. While we embrace a commitment to social justice, particularly the view that “Where systematic differences in health are judged to be avoidable by reasonable action. . .they are, quite simply, unfair” (Commission on the Social Determinants of Health 2008, 29), we contend that attending to the social determinants is a challenge and opportunity for quality health care. We recognize that, as articulated, this commitment extends far beyond the clinically constrained commitment to social justice envisaged in the Physician Charter. Nevertheless, if our efforts to improve health, by seeking to address the social determinants of health, incidentally serve to promote social justice, well, that is icing on the cake. &
REFERENCES ABIM Foundation, American Board of Internal Medicine; ACPASIM Foundation, American College of Physicians–American Society of Internal Medicine; and European Federation of Internal Medicine. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136: 243–246. Booske, B. C., J. K. Athens, D. A. Kindig, H. Park, and P. L. Remington. 2010. Different perspectives for assigning weights to determinants of health. University of Wisconsin Population Health Institute, County Health Rankings Working Paper. Available at: http://www.countyhealthrankings.org/sites/default/files/differ entPerspectivesForAssigningWeightsToDeterminantsOfHealth. pdf Commission on the Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization. Earnest, M. A., S. L. Wong, and S. G. Federico. 2010. Physician advocacy: What is it and how do we do it? Academic Medicine 85 : 63–67. Available at: http://dx.doi.org/10.1097/ACM.0b013e3181c40d40 Hempel, S. 2007. The strange case of the Broad Street pump: John Snow and the mystery of cholera. Berkeley, CA: University of California Press. Pirkle, J. L., D. J. Brody, E. W. Gunter, et al. 1994. The decline in blood lead levels in the United States: The National Health and Nutrition Examination Surveys (NHANES II, 1976 to 1980 and NHANES III, 1988 to 1991). Journal of the American Medical
ajob 43
American Journal of Bioethics
Association 272: 284–291. Available at: http://dx.doi.org/10.1001/ jama.1994.03520040046039 Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36.
van de Wiele, J., M. Davison, S. Ijams, et al. 2014. Strengths Finder profiles of physician assistant students: Implications for admissions. Presentation at the Physician Assistant Education Association 2014 Annual Education Forum, Philadelphia, PA, October 17.
Noncomparative Justice Regarding Health and Its Social Determinants
Downloaded by [University of Victoria] at 21:50 25 April 2015
Thomas Schramme, Hamburg University Adina Preda and Kristin Voigt (2015) provide a very clear and systematic overview of the many pitfalls that surround normative claims regarding health inequalities. There are numerous methodological problems in establishing health inequalities, as well as philosophical problems in developing a convincing account of health justice. Indeed, occasionally public health theorists and practitioners seem to be far too quick in drawing normative conclusions or simply taking certain viewpoints for granted. Since I am in agreement with Preda and Voigt’s analysis, I would like to hint at a possible way forward in the debate on health justice and health inequality. I do so by introducing the notion of noncomparative justice. Preda and Voigt make clear that the plain fact that health is distributed unequally between socioeconomic groups does not suffice to call it an instance of injustice, even where it is coupled with a criterion of avoidability. Inequalities in health might be deserved in the sense of being based on voluntary choices, or health inequalities might simply be the outcome of circumstances that cannot plausibly be deemed unjust for other reasons. In other words, inequality in health as such does not carry any normative weight. This applies to both interpersonal and group relations: The fact that a person or group of people is healthier (in some respect) than another person or group, as such, is neutral from a perspective of justice. We might find out that the less healthy person or group is in such a disadvantaged position due to discrimination or an avoidable health threat—but then the normatively relevant issue is to be found in relation to, say, the working conditions that pose health threats, not the interpersonal relation. It is true, of course, that an unequal health status might be the starting point of normative considerations. When people end up in different health conditions we might assume that something unfair has happened to them along the way. So inequality—an interpersonal or intergroup relation—might be a “symptom” of injustice, but inequality as such is not the “disease,” that is, the normative problem.
The claim that avoidable health inequalities are unjust has a certain initial plausibility, because social epidemiology can show correlations of socioeconomic status and health status. The very notion of social determinants of health even suggests a causal relation between social conditions and health, and indeed, it seems fairly clear that the social conditions we live in have an impact on our health. The plausibility of the mentioned normative claim therefore stems from the established correlations between social status and health status in combination with the fact that belonging to a certain socioeconomic group is not (completely) up to us—it is not our choice. Thus, belonging to a group that is in a worse state of health than another seems to be a bit like suffering from discrimination or a preventable health threat. But such a verdict would mean jumping to conclusions; it cannot be more than a piece of evidence in a normative puzzle. It is true, of course, that we tend to think that unchosen (and avoidable) disadvantages are always due to injustices, but such a simple claim is not convincing, if only because we also tend to believe that some such disadvantages do not matter or are part and parcel of generally preferred living conditions. Thus, we still have to make a normative case for which unchosen disadvantages are unfair. It is true that evidence concerning unequal health might be the starting point for raising normative concerns about the underlying conditions, but merely pointing at inequalities is not the answer to our normative concerns. I believe a way forward here can be to introduce philosophical terminology that stems from Joel Feinberg’s distinction between comparative and noncomparative justice. Egalitarianism, at least in the way it is presented in the public health literature, is an account of comparative justice. From this perspective, what is due to persons or groups of persons is at least partially determined by comparing them to others. Thus, when some people are unequal in their health status and it is not due to their own choice and avoidable, there is a case for saying it is an unjust situation, according to a comparative account of
Address correspondence to Thomas Schramme, Hamburg University, Philosophy, Von-Melle-Park 6, Hamburg 20146, Germany. E-mail: [email protected]
44 ajob
March, Volume 15, Number 3, 2015
The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
Just Deserts or Icing on the Cake? Addressing the Social Determinants of Health a
a
b
Mark D. Fox , Michael R. Gomez & Ricky T. Munoz a
University of Oklahoma School of Community Medicine
b
University of Oklahoma–Tulsa Published online: 18 Mar 2015.
Click for updates To cite this article: Mark D. Fox, Michael R. Gomez & Ricky T. Munoz (2015) Just Deserts or Icing on the Cake? Addressing the Social Determinants of Health, The American Journal of Bioethics, 15:3, 42-44, DOI: 10.1080/15265161.2014.998383 To link to this article: http://dx.doi.org/10.1080/15265161.2014.998383
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
American Journal of Bioethics
Downloaded by [University of Victoria] at 21:50 25 April 2015
In the end, this line of thought can count as further evidence for Voigt and Preda’s insistence that we have to examine the situation more carefully, and that the reports are themselves not sufficiently careful, but it does seem that Marmot’s view should not be characterized as advocating something so extreme. Finally, a comment on Preda and Voigt’s claim that there are “straightforward” social justice reasons for altering the social factors that concern resource inequality, so that perhaps it’s odd, unnecessary, or counterproductive to approach this in terms of health. This is certainly an important heuristic toward taking seriously that we should not jump to a particular policy too quickly. But the following is also a reasonable and important consideration: Yes, we should be doing something about these things simply on grounds of social justice, but of course we do not tend
to do so (or we tend not to do nearly enough). And this is causing damage to health (causing inequality of health, as well as poor health), which is uncontroversially serious, and which plays a role in whether there is equality of opportunity in our society. The sense in which connection to health adds urgency is quite important and appropriate. Again, all of this is consistent with an endorsement of Voigt and Preda’s view that we must address these questions of how to characterize the SDH and think about their implications for policy much more carefully than we have. & REFERENCE Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36.
Just Deserts or Icing on the Cake? Addressing the Social Determinants of Health Mark D. Fox, University of Oklahoma School of Community Medicine Michael R. Gomez, University of Oklahoma School of Community Medicine Ricky T. Munoz, University of Oklahoma–Tulsa Preda and Voigt (2015) raise the provocative question, “Why should we care about the social determinants of health?” Despite a careful, stepwise analysis of the implications and obligations arising from social and health inequalities versus inequities, their analysis ultimately loses sight of its initial focus, that is, the social determinants of health per se. Although the authors assert their endorsement of certain policies that have led to “improvements to people’s living conditions and reductions of inequalities in wealth and power,” these are required as a matter of social justice, not because of any perceived health inequality or even because of any impact on health outcomes. Specifically, the authors argue that health disparities arising from social inequalities (resulting from “natural” differences and not deemed unfair) ought not to be the target of intervention via social change. Ultimately, we think the authors belabor a distinction with little relevance, while dodging the issue purportedly framing their inquiry. Their commitment to social justice, irrespective of health outcomes, seems curiously dogmatic, given the careful parsing of claims regarding avoidable versus amenable health disparities and natural social
inequalities. Interestingly, a physician’s commitment to social justice is one of the striking features codified in the Physician Charter on Medical Professionalism (ABIM Foundation, American Board of Internal Medicine; ACPASIM Foundation, American College of Physicians–American Society of Internal Medicine; and European Federation of Internal Medicine 2002). This commitment is articulated, however, in a clinically circumscribed way. Specifically, it calls upon physicians to “promote justice in the health care system,” through fair distribution of scarce resources and the elimination of discrimination (presumably in clinical care). Thus, the charter advocates for, at best, a limited notion of social justice, focused on the provision of health care, not on the elimination of health inequities. Rather than arguing the merits of pursuing health equity through social change, we take at face value the authors’ query regarding why social determinants of health merit attention. As clinicians, we take as one of our central commitments an obligation to seek to improve the health of our patients. However, we also recognize that our actual clinical care has at best a modest impact in
Address correspondence to Mark D. Fox, University of Oklahoma School of Community Medicine, 4502 E. 41st Street, Tulsa, OK 74135, USA. E-mail: [email protected]
42 ajob
March, Volume 15, Number 3, 2015
Downloaded by [University of Victoria] at 21:50 25 April 2015
Caring About Social Determinants of Health
determining the health of our patients. Although estimates vary, the impact of health care on health pales in comparison to health behaviors and social and economic factors. A working paper from the University of Wisconsin Population Health Institute assesses various weighting schemes, but all place the impact of clinical care in the 10–20% range among determinants of health. (Booske et al. 2010). Meanwhile, health behaviors account for 25– 57% of health determinants, and social and economic factors represent 21–55%. No matter how one slices it, factors beyond the exam room, beyond the clinician’s competence, and beyond the reach of a prescription pad have a vastly greater impact on our patients’ health and the health of a community. Thus, no matter where one may fall on the political spectrum or in the commitment to social justice, clinicians are compelled to attend to social determinants of health in order to fulfill their commitment to optimize patients’ health. One challenge, however, is that physicians may often feel ill-equipped to address the social determinants of health, let alone to effect social change. For most of us, advocacy was not a topic covered in our medical school curricula, and may not have been a part of our clinical training. Physicians may feel they lack the content expertise to address the social determinants, the “causes of causes,” in a meaningful way. Further, clinicians may lack the “influencing skills” needed to advocate effectively for social change (van de Wiele et al. 2014). We contend, therefore, that advocacy is an essential skill for physicians to develop in order to maintain fidelity to their obligation to promote health, which in turn requires a commitment to addressing the social determinants of health. How, then, can one fulfill a commitment to an objective for which one feels largely ill prepared? There are countless examples of how clinicians advocate on behalf of individual patients. Likewise, the physicians’ advocacy role within health care systems is likely familiar (Earnest, Wong, and Federico 2010), and consistent with the social justice role contemplated in the Physician Charter. However, to be most effective in advocating for social change to address determinants of health, physicians may best lend their professional and technical expertise in collaboration with other professionals such as social workers, educators, policy makers, and others. This role may not feel immediately comfortable, reaching beyond the realm of the exam room, hospital, or health system. John Snow likely did not appreciate that he was shaping the discipline of epidemiology during London’s cholera outbreaks of the 1800s (Hempel 2007). He may also have felt ill equipped to address the Board of Guardians in 1854. But his scientifically organized inquiry, directed by his clinical observations and commitment to improve health, not only profoundly influenced modern epidemiology, but also dramatically effected social change. A more recent, but similarly profound, social change inspired by health concerns is seen in the work of child health advocates in promoting the removal of lead from both paint and gasoline. These efforts have led to a dramatic decline
March, Volume 15, Number 3, 2015
in lead toxicity among children in the United States (Pirkle 1994). Preda and Voight (2014) take issue with the notion that we ought to redress health inequities, except as they might incidentally be addressed by a social justice commitment undertaken for obligations irrespective of health concerns. Indeed, they seem to suggest both that health inequalities arise from “natural” individual differences, which ought not be addressed by corrective action, and further that finding effective policy approaches is too difficult. However, if the fundamental commitment of health care professionals is to improve health, then attention to root causes of, and factors contributing to, poor health is needed. The focus of that attention, then, falls on both health behavior and the social and economic determinants of health. While we embrace a commitment to social justice, particularly the view that “Where systematic differences in health are judged to be avoidable by reasonable action. . .they are, quite simply, unfair” (Commission on the Social Determinants of Health 2008, 29), we contend that attending to the social determinants is a challenge and opportunity for quality health care. We recognize that, as articulated, this commitment extends far beyond the clinically constrained commitment to social justice envisaged in the Physician Charter. Nevertheless, if our efforts to improve health, by seeking to address the social determinants of health, incidentally serve to promote social justice, well, that is icing on the cake. &
REFERENCES ABIM Foundation, American Board of Internal Medicine; ACPASIM Foundation, American College of Physicians–American Society of Internal Medicine; and European Federation of Internal Medicine. 2002. Medical professionalism in the new millennium: A physician charter. Annals of Internal Medicine 136: 243–246. Booske, B. C., J. K. Athens, D. A. Kindig, H. Park, and P. L. Remington. 2010. Different perspectives for assigning weights to determinants of health. University of Wisconsin Population Health Institute, County Health Rankings Working Paper. Available at: http://www.countyhealthrankings.org/sites/default/files/differ entPerspectivesForAssigningWeightsToDeterminantsOfHealth. pdf Commission on the Social Determinants of Health. 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: World Health Organization. Earnest, M. A., S. L. Wong, and S. G. Federico. 2010. Physician advocacy: What is it and how do we do it? Academic Medicine 85 : 63–67. Available at: http://dx.doi.org/10.1097/ACM.0b013e3181c40d40 Hempel, S. 2007. The strange case of the Broad Street pump: John Snow and the mystery of cholera. Berkeley, CA: University of California Press. Pirkle, J. L., D. J. Brody, E. W. Gunter, et al. 1994. The decline in blood lead levels in the United States: The National Health and Nutrition Examination Surveys (NHANES II, 1976 to 1980 and NHANES III, 1988 to 1991). Journal of the American Medical
ajob 43
American Journal of Bioethics
Association 272: 284–291. Available at: http://dx.doi.org/10.1001/ jama.1994.03520040046039 Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36.
van de Wiele, J., M. Davison, S. Ijams, et al. 2014. Strengths Finder profiles of physician assistant students: Implications for admissions. Presentation at the Physician Assistant Education Association 2014 Annual Education Forum, Philadelphia, PA, October 17.
Noncomparative Justice Regarding Health and Its Social Determinants
Downloaded by [University of Victoria] at 21:50 25 April 2015
Thomas Schramme, Hamburg University Adina Preda and Kristin Voigt (2015) provide a very clear and systematic overview of the many pitfalls that surround normative claims regarding health inequalities. There are numerous methodological problems in establishing health inequalities, as well as philosophical problems in developing a convincing account of health justice. Indeed, occasionally public health theorists and practitioners seem to be far too quick in drawing normative conclusions or simply taking certain viewpoints for granted. Since I am in agreement with Preda and Voigt’s analysis, I would like to hint at a possible way forward in the debate on health justice and health inequality. I do so by introducing the notion of noncomparative justice. Preda and Voigt make clear that the plain fact that health is distributed unequally between socioeconomic groups does not suffice to call it an instance of injustice, even where it is coupled with a criterion of avoidability. Inequalities in health might be deserved in the sense of being based on voluntary choices, or health inequalities might simply be the outcome of circumstances that cannot plausibly be deemed unjust for other reasons. In other words, inequality in health as such does not carry any normative weight. This applies to both interpersonal and group relations: The fact that a person or group of people is healthier (in some respect) than another person or group, as such, is neutral from a perspective of justice. We might find out that the less healthy person or group is in such a disadvantaged position due to discrimination or an avoidable health threat—but then the normatively relevant issue is to be found in relation to, say, the working conditions that pose health threats, not the interpersonal relation. It is true, of course, that an unequal health status might be the starting point of normative considerations. When people end up in different health conditions we might assume that something unfair has happened to them along the way. So inequality—an interpersonal or intergroup relation—might be a “symptom” of injustice, but inequality as such is not the “disease,” that is, the normative problem.
The claim that avoidable health inequalities are unjust has a certain initial plausibility, because social epidemiology can show correlations of socioeconomic status and health status. The very notion of social determinants of health even suggests a causal relation between social conditions and health, and indeed, it seems fairly clear that the social conditions we live in have an impact on our health. The plausibility of the mentioned normative claim therefore stems from the established correlations between social status and health status in combination with the fact that belonging to a certain socioeconomic group is not (completely) up to us—it is not our choice. Thus, belonging to a group that is in a worse state of health than another seems to be a bit like suffering from discrimination or a preventable health threat. But such a verdict would mean jumping to conclusions; it cannot be more than a piece of evidence in a normative puzzle. It is true, of course, that we tend to think that unchosen (and avoidable) disadvantages are always due to injustices, but such a simple claim is not convincing, if only because we also tend to believe that some such disadvantages do not matter or are part and parcel of generally preferred living conditions. Thus, we still have to make a normative case for which unchosen disadvantages are unfair. It is true that evidence concerning unequal health might be the starting point for raising normative concerns about the underlying conditions, but merely pointing at inequalities is not the answer to our normative concerns. I believe a way forward here can be to introduce philosophical terminology that stems from Joel Feinberg’s distinction between comparative and noncomparative justice. Egalitarianism, at least in the way it is presented in the public health literature, is an account of comparative justice. From this perspective, what is due to persons or groups of persons is at least partially determined by comparing them to others. Thus, when some people are unequal in their health status and it is not due to their own choice and avoidable, there is a case for saying it is an unjust situation, according to a comparative account of
Address correspondence to Thomas Schramme, Hamburg University, Philosophy, Von-Melle-Park 6, Hamburg 20146, Germany. E-mail: [email protected]
44 ajob
March, Volume 15, Number 3, 2015
