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Caring About the Social Determinants of Health a

Peter Sheehan & Mark Sheehan a

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Victoria University

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University of Oxford Published online: 18 Mar 2015.

Click for updates To cite this article: Peter Sheehan & Mark Sheehan (2015) Caring About the Social Determinants of Health, The American Journal of Bioethics, 15:3, 48-50, DOI: 10.1080/15265161.2014.999172 To link to this article: http://dx.doi.org/10.1080/15265161.2014.999172

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American Journal of Bioethics

Caring About the Social Determinants of Health

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Peter Sheehan, Victoria University Mark Sheehan, University of Oxford Preda and Voigt (2015) discuss two issues about what they call the “health equity through social change model” (HESC), namely, the normative judgments and assumptions about the unfairness of particular health inequalities and the policy recommendations that follow from the model. They argue that the normative underpinnings of the HESC are not sufficient supported and that the policy recommendations do not follow from the arguments offered, and may be inconsistent. Following much of the literature, they use “health inequalities” to refer to differences in health outcomes and “health inequities” to such outcomes that are judged to be unfair or unjust.

WHEN ARE HEALTH INEQUALITIES UNJUST? This is a central question that Preda and Voigt discuss. They touch on, but do not clearly distinguish, two relevant approaches to this issue. One is the view taken by Marmot and the various commissions that he has chaired (Marmot et al. 2008; 2013; World Health Organization [WHO] Commission on the Social Determinants of Health 2008; WHO 2014), that health inequalities are unfair if they can be avoided by reasonable means. The World Health Organization (WHO) Commission on the Social Determinants of Health (2008) said that “where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair.” On this view, health inequalities are unfair in themselves if they can be reasonably avoided. The alternative view is that health inequalities are not unfair in themselves, but they are unfair if their causes are unfair. For example, Whitehead (1990) argues that “in order to judge a certain situation as inequitable, the cause has to be examined and judged to be unfair in the context of what is going on in the rest of society” (Whitehead 1990). Daniels (2008) also argues that a set of health outcomes are unjust when they derive from an unjust distribution socially controllable determinants. In our reading, the recent official literature underpinning the HESC model is clearly in the first camp, but Preda and Voigt’s discussion treats these as two options for the HESC model, without clearly separating out the views of the participants. This makes their argument difficult to discern at times.

Turning first to the view that health inequalities are unjust because their determinants are unjust, the question then arises as to what determinants are to be deemed unjust. Are inequalities arising from genetic variation or from freely chosen risky behavior unjust? In the HESC model the distinguishing factor is avoidability, and this is consistent with the idea that natural inequalities (being unavoidable) are not unjust. But Preda and Voigt rightly point out that an inequality can be prevented in two ways: It can be prevented from occurring or it can be redressed. But they then argue that this allows some inequalities arising from natural causes to be unjust, as they can be redressed, contrary to the HESC view. In our view these useful clarifications pose no serious problems for the HESC model. Inequities arising from natural causes are never per se unjust; it is the failure to take reasonable action to avoid them that may be unjust. And while the social determinants of health (SDH) literature sets out to focus attention on the social determinants of health, there is no reason for excluding individual inequalities, or those arising from natural causes, as unjust to the extent to which they reflect a failure to take reasonable action to prevent or redress them. The second view, which we suggest is the main view in the recent official SDH literature being discussed, is that some health inequalities are unjust in their own right. Here Preda and Voigt (2015) are concerned with residual inequalities, cases in which health inequalities are judged unfair even when they arise from a fair but unequal distribution of social goods. These are avoidable health inequalities, the causes of which are otherwise fair. If some health inequalities are unjust in the own right rather than because they derive from unjust causes, residual inequalities must be possible. Preda and Voigt point out that few theories of justice have addressed the issue of residual inequalities, with perhaps the only one being luck egalitarianism (Segall 2009). Luck egalitarianism argues that health inequalities are problematic if they do not reflect people’s choices. On this view, if the causes of the health inequalities reflected people’s choices they would not be unfair, but if they did not reflect those choices they would be unfair. Preda and Voigt conclude that there is little support in the existing philosophical literature for residual inequalities.

Address correspondence to Mark Sheehan, University of Oxford, The Ethox Centre, Department of Public Health, Badenock Building, Old Road Campus, Headington, Oxford, OX3 7LF, United Kingdom. E-mail: [email protected]

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Nevertheless, it seems clear that residual health inequalities are quite possible. If modest inequalities in income and other social goods, deemed to be fair, gave rise to massive but avoidable differences in health and life expectancy, these health inequalities would clearly be deemed to be inequitable if they were not addressed. To take another example, if in an otherwise equal society people living on different sides of the river had quite different health outcomes, these would surely be regarded as inequitable if they could be but were not addressed. Given Preda and Voigt’s clarifications, we suggest that the recent SDH view could be summarized as follows: All serious health inequalities that can be avoided by reasonable actions, in the sense of being prevented or redressed, are unjust. This applies to social or individual inequalities, whether arising from social, genetic or other natural causes, with the unfairness arising from the failure to take action to avoid the inequality rather than from the nature of the cause. Of these health inequities the most important type by far is those arising from social causes.

COMPLEX INTERLINKS BETWEEN HEALTH AND SOCIOECONOMIC FACTORS The central thrust of the SDH literature is to draw attention to the fact that the distribution of health outcomes in most societies is systematically linked to broader economic and social patterns. But there is no clear detailed specification in the literature of the content of the social determinants of health. For example, WHO (2008) says that the SDH are “the circumstances in which people are born, grow up, live, work and age, and the systems put in place to deal with illness,” which circumstances are in turn shaped by wider economic, social, and political forces. While there is a general appeal to powerful economic and social forces, there is no clearly specified model of what the SDH are and how they specifically relate to health. In fact, much of the recent empirical literature makes clear that there is a complex web of interacting causal factors, including health, which shape patterns of inequality in most societies and the way these develop over the life course. For example, maternal and early childhood health is influenced by mother’s education, income, diet, and other factors, and in turn influences the child’s learning activities, health, and future income. Parental income and health, as well as education and living conditions during childhood and adolescence, influence adult income, occupation, and health. These and other factors influence both health and well-being in later life. Elsewhere we have given an initial sketch of what we termed “the social reality of health” (Sheehan and Sheehan 2002). By this we meant that a person’s health cannot be understood in purely individual terms, but is the outcome of complex social and individual factors. An individual’s health is strongly influenced by inherited biological characteristics and patterns of behavior, as well as by social circumstances, activities, and expectations. The social reality

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of health stands as a negative claim: It guards against oversimplification of the social influences on health outcomes in our theories of justice in health care, and it guards against complacency in our methods of addressing health inequalities within society (Sheehan 2006). It is not adequate to convey this complexity in terms of a set of SDH that determine, in part, the distribution of health outcomes, as much of the SDH literature does and as Preda and Voigt do. Nor is it adequate to frame the normative issue in terms of whether or not a set of health inequalities is unjust because its causes are unjust. Income, health, education, and living conditions mutually interact at many stages of the life course to shape the evolution of diverging paths of well-being and capability over the life course. One limitation of the SDH literature is that it has offered us a too simple causal model of this complex process.

POLICY ISSUES Finally, Preda and Voigt turn to the policy recommendations of the HESC model, which they characterize as “the idea that social inequalities in health can only be addressed through actions on the social determinants of health” (32), and say that these must be addressed as a matter of justice. That they can only be addressed through action on the SDH is, in our view, a misleading statement of the HESC view. For example, the WHO (2014) report (cited by Preda and Voigt) proposes three types of action: universal coverage of health care, action to change individual behavior, and addressing the SDH. But certainly a major focus is on action to address the “causes of the causes.” Preda and Voigt have several concerns with giving primacy to addressing the SDH. Even if social factors cause health inequalities, it does not follow that addressing the causal factors will be the most effective way to reduce them. They note that our knowledge of the impact of specific social factors, and of their causal pathways, remains limited. In some countries in Europe social inequalities in health have widened even as the welfare state has reduced inequalities in income and wealth. Certain key health behaviors, such as tobacco smoking, seem to be relatively resistant to social measures. While the SDH literature has made a major contribution in emphasizing the importance of social and economic factors in shaping health, in our view these points from Preda and Voigt about a quick move to policy measures are well made. The task now, in which many are engaged, is to find effective points of intervention in the complex web of economic and social factors, including health, that shapes the evolution of welfare over the life course. &

REFERENCES Daniels, N. 2008. Just health: Meeting health needs fairly. Cambridge, UK: Cambridge University Press. Marmot, M. 2013. Fair society healthy lives. In Inequalities in health: Concepts, measures, and ethics, ed. N. Eyal, S. Hurst, O. F.

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Norheim, and D. Wikler, 282–298. Oxford, UK: Oxford University Press Marmot, M., S. Friel, R. Bell, T. A. J. Houweling, and S. Taylor 2008. Closing the gap in a generation: Health equity through action on the social determinants of health. Lancet 372: 1661–1669. Available at: http://dx.doi.org/10.1016/S0140-6736(08)61690-6 Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36. Segall, S. 2009. Health, luck, and justice. Princeton, NJ: Princeton University Press.

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Sheehan, M. 2006. The social reality of health. In Global knowledge economy and society: Strategic economic studies in honour of Peter J. Sheehan, ed. B. Grewal and M. Kumnick, 262–279. Melbourne, Australia: Melbourne University Press.

Sheehan, M., and P. Sheehan. 2002. Justice and the social reality of health: The case of Australia. In Medicine and social justice: Essays on the distribution of jealth care, ed. R. Rhodes, M. Battin, and A. Silvers, 169–182. New York, NY: Oxford University Press. Whitehead, M. 1990. The concepts and principles of equity in health. Copenhagen, Denmark: World Health Organization. World Health Organization. 2014. Review of social determinants and the health divide in the WHO European Region: Final report. Regional Office for Europe. World Health Organization 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. Available at: http://whqlibdoc. who.int/publications/2008/9789241563703_eng.pdf?ua=1

Evaluating Health Inequalities: Residual Worries J. Paul Kelleher, University of Wisconsin–Madison Adina Preda and Kristin Voigt (2015) should be commended for bridging the gap between moral philosophy and health policy. While I am convinced by much of their analysis of what they call the health equity as social change (HESC) model, I am not certain they are correct to claim that “in the HESC model, ‘avoidability’ appears as both a necessary and sufficient condition for health inequity” (28). I next explain my hesitation, and then explain some further qualms about Preda and Voigt’s arguments concerning the evaluation of health inequalities. To start, I want to flag one claim that HESC proponents make that I think is mistaken but that Preda and Voigt seem to accept. This is the claim that whatever is unfair is unjust. Early in their article, Preda and Voigt quote the Commission on the Social Determinants of Health as saying, “Where systematic differences in health are judged to be avoidable by reasonable action they are, quite simply, unfair. It is this that we label health inequity. Putting right these inequities . . . is a matter of social justice.” This in turn suggests that unfair health inequalities are perforce unjust. Preda and Voigt seem to accept this. For example, after asking whether “health inequalities are unfair when they result from a fair albeit unequal distribution of social goods,” they go on to restate this question as, “Is there any theoretical framework that can support the claim that these inequalities are unjust?” By contrast, I would prefer a conceptual scheme in which inequalities can be unfair but nevertheless just. (By calling an unfair situation just I mean

that there is no pressing social duty to rectify the unfairness.) For example, consider a society that must choose between restoring the mobility of a few people and treating nondebilitating arthritis in a great many others. I believe it can be right to treat arthritis as long as the group that suffers it is large enough. But I also believe this is unfair to the person with the mobility impairment, since she is (let us assume) worse off than anyone suffering from arthritis. So this strikes me as an unfairness that is nevertheless just. Likewise, I would urge Preda and Voigt to consider adopting this conceptual scheme more generally, for it permits one to acknowledge that inequalities can have demonstrable moral downsides even while a society is not unjust for allowing them. (I return to this point later.) Although I do not detect much evidence for the ascription in their article, Preda and Voigt claim that the HESC model holds that an inequality in health must be avoidable in order to be unjust. I fully agree with their argument against this claim. They explain that even when it is impossible to prevent or eliminate an impairment in health, it may be possible to “address its negative effects.” For example, even if it were impossible to eliminate my severe near-sightedness, eyeglasses could still eliminate its severe effects on my life. In light of this, it would be a mistake to foreclose questions of health justice simply because impairments themselves cannot be eliminated. This suggests that HESC should focus on what Preda and Voigt call the “amenability” of health impairments, rather than

Address correspondence to J. Paul Kelleher, Department of Medical History & Bioethics, University of Wisconsin–Madison, 1300 University Ave., Rm. 1430, Madison, WI, 53705, USA. E-mail: [email protected]

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