American Journal of Bioethics
children have shut themselves in their bedrooms, and even your dog turns its back on you. You find yourself some food, which you microwave and eat standing, looking out of the kitchen window, where you see the neighboring family sitting down to a cheerful meal, talking excitedly about their days, with their dog lying under the table wagging its tail. One thought you may have is, “It is so unfair that they have a life like that when I have my life.” This thought, Frankfurt seems to think, displays a problematically envious character. But another possible thought is: “My neighbors are showing me what life has to offer.” This, we might say, is an epistemological use of the notion of inequality. Comparing yourself with others gives you a sense of what is possible. It is something you might have learned from a film or a novel, but in this case you learned it, or at least were reminded, through observation. And it is this that goes along with the sense of the “tragic” or the “unnecessary.” It is also resistant to the idea of leveling down, which is pointless because it does not solve the identified problems. There is a difference between regarding the poorer health prospects of some groups as unjust and regarding these prospects as unnecessary. The idea of inequality can be used as an argument about justice, but it can also be used as argument about what is possible for human beings. If the wealthy in Glasgow can have an average life expectancy of 82, then it must surely be possible for the poor to do better than 54. Looking at the lives of the rich may help us understand what has to change if the poor are to do better, or, at least, for their children or grandchildren. By defining health inequity in terms of what is “avoidable,” the Whitehead approach comes dangerously
close to treating the justice and the epistemological issues as the same thing. Whether an inequality is unjust surely cannot turn on the question of whether we can do anything about it (although that will be relevant to the question of whether anyone can be blamed for it, and how much point there is in complaining about the situation). But whether an inequality (or, better, an adverse health condition or prospect) is avoidable must be relevant to the question of what is possible. In this way, considerations about possibility are inadvertently merged into considerations about justice. And both of these issues are distinct from the question of how to maximize total health gain, which, as the authors point out, will often increase health inequalities. In conclusion, the authors are to be thanked for the clarity with which they have brought out some difficulties in the philosophical and policy discussions surrounding the epidemiological evidence on the social determinants of health. Their work will help us keep distinct ideas apart and help us concentrate on what does and does not matter, and what stands a chance of working to resolve health inequalities and what may not. I hope that they will develop these themes at greater length in the future. &
REFERENCES Frankfurt, H. 1997. Equality as a moral ideal. Ethics 98(1): 21–43. Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36. Wolff, J. 2007. Equality: The recent history of an idea. Journal of Moral Philosophy 4(1): 125–136.
Nondistributive Social Factors, Noneconomic Distributive Factors Fred Gifford, Michigan State University There has been, in recent years, an increasing appreciation of the social determinants of health (SDH). Important questions emerge concerning how to utilize these facts in judging appropriate responses, and a certain movement in this regard can be identified in an important series of reports, including that of the World Health Organization. Preda and Voigt (2015) see this movement to argue for policy change in the name of social justice related to health as not properly grounded. They elucidate a number of very significant points that must be addressed in moving forward concerning the significance of the social
determinants of health. There is much of value in their analysis, most of which I will have to leave aside here. Preda and Voigt are certainly right to insist on the importance of a critical examination of the assumptions underlying the position, and to note that some of the discussion in the reports is not sufficiently careful. What counts as social, and what counts as the responsibility of the state to alter, is quite contentious. But taking proper care here also requires a close attention to some other matters of how we are to conceptualize the claims at issue. I worry that the authors go too quickly,
Address correspondence to Fred Gifford, Department of Philosophy, Michigan State University, 503 S. Kedzie, East Lansing, MI 48824, USA. E-mail: [email protected]
40 ajob
March, Volume 15, Number 3, 2015
Caring About Social Determinants of Health
making misleading claims and characterizing the HESC proponents in too simple a manner. Preda and Voigt describe a central assumption of the proponents as “if we are to address social inequalities in health, we must go beyond medical and behavioral approaches and include strategies that redistribute income and wealth and make societies more egalitarian.” One representative ambiguity here is whether the claim (whether that by Marmot, or that by Preda and Voigt) is that no progress can be made without this, or only that our success will not be complete without it. But there are other issues. The discovery that socioeconomic status (SES) is a deep causal factor concerning health and disease might lead one to the conclusion that we must erase those differences in income or SES, and that “the response” will simply be the redistribution of income and wealth. But this may seem too extreme and unwarranted. One aspect here is the idea that it requires “complete erasure” (which they might worry about given the insight of the “social gradient”: even getting rid of poverty won’t be enough); another is that the solution is characterized as using as the causal levers the modification of incomes. But an alternative conclusion would see the insight as being that low income (or differences in income) is a distal causal factor (rather than a proximal one—one might be tempted to call it “ultimate,” but that may mislead), but one that then operates through particular mechanisms, and we can use this knowledge as a way to help us use those mechanisms as causal levers—not (or not only) by altering income but by modifying social practices so that income would not have such a large impact on health. For example, we might endeavor to make it the case that no neighborhoods are toxic, or food deserts, rather than giving everyone enough money that they can in effect move out of such neighborhoods. This is especially important because the recommendations (1) to (5) from the Marmot Review listed in Preda and Voigt are in fact not really a matter of redistribution of incomes, or really even a “redistribution” of social determinants of health. There is an interesting question of exactly what would count as this. But these recommendations (such as “create and develop healthy and sustainable places and communities”) surely do not seem so to count. (Of course, the intervention will cost money, and this may come from a progressive tax system, but I assume this is not Preda and Voigt’s complaint here.) More generally, the following features need to be kept in mind if we are going to make progress on this topic: This discussion of SDH inevitably involves dealing with a number of statements that can be interpreted in more or less strict ways, and their strict interpretation will almost never be reasonable. For instance, a claim about the appropriateness of social intervention could be viewed as the claim that “changing income” (or some such social change) is the one thing we should do. Alternatively, it could be put as “one thing that could be used” or that it “should be used more than it is now.”
March, Volume 15, Number 3, 2015
Further, recommendations to proceed at the social level are ambiguous because the social determinants of health are comprised of a wide spectrum of factors beyond the usual biomedical ones, a complex set of factors not all of the same sort or at the same level. The idea is noted of the various more proximal social factors, and then the “causes of the causes” beyond that. But it is not as though there are precisely two levels, and in addition, there will be causal interaction between the levels. Finally, some relevant social factors have to do with redistribution of resources or income; others do not. Thus, a good deal of what needs to be clarified here is how strong and exclusive the claims are meant to be, or should be taken as being. Preda and Voigt’s analysis focuses throughout on the redistribution of the social factors. They say that if the social factors themselves are unfairly distributed, calling for their redistribution for reasons of health may detract from important social justice concerns. Addressing inequalities in income and wealth, for instance, is an important justice concern, regardless of its effects on health or health inequalities. But it may be damaging for health to suggest that only farreaching societal changes can lead to improvements in this area (34).
To say “only” here makes it sound as though our efforts should be exclusively there, but there are more significant issues here. Not all ways of addressing systematic social determinants of health are a matter of redistributing income and wealth, as we can address things for which SES is one causal factor, as in the case of addressing the unhealthiness of particular neighborhoods in terms of such things as crime and the lack of availability of nutritious food. And not all ways of addressing systematic social determinants of health are a matter of redistributing either income and wealth themselves or factors that are specifically caused by those. After all, one especially important set of such causal factors involves racism. Saying that action is needed across the society does not refer only to the reduction of economic inequality. In fact, it’s hard to imagine that any general claim or set of rules about how best to intervene in these complex cases will get it right. What is needed is the generation of a broader and more developed understanding of the various sorts of social, psychological, behavioral, economic, and cultural and other environmental inputs that are contributory toward health. One will then inevitably need to examine much more of the context in order to decide what to do—whether to intervene and via which causal path. (Consider by analogy the situation when we identify genetic causes. It hardly follows that the preferred means of intervention should be at the genetic level [whether this is always, or most often, or whether it’s “mostly”], even when knowledge of genetic causes helps us to locate nongenetic causal levers.) I believe that we will also have to be attentive to these other matters in order to see ourselves to a clear position concerning the SDH.
ajob 41
American Journal of Bioethics
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
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.
children have shut themselves in their bedrooms, and even your dog turns its back on you. You find yourself some food, which you microwave and eat standing, looking out of the kitchen window, where you see the neighboring family sitting down to a cheerful meal, talking excitedly about their days, with their dog lying under the table wagging its tail. One thought you may have is, “It is so unfair that they have a life like that when I have my life.” This thought, Frankfurt seems to think, displays a problematically envious character. But another possible thought is: “My neighbors are showing me what life has to offer.” This, we might say, is an epistemological use of the notion of inequality. Comparing yourself with others gives you a sense of what is possible. It is something you might have learned from a film or a novel, but in this case you learned it, or at least were reminded, through observation. And it is this that goes along with the sense of the “tragic” or the “unnecessary.” It is also resistant to the idea of leveling down, which is pointless because it does not solve the identified problems. There is a difference between regarding the poorer health prospects of some groups as unjust and regarding these prospects as unnecessary. The idea of inequality can be used as an argument about justice, but it can also be used as argument about what is possible for human beings. If the wealthy in Glasgow can have an average life expectancy of 82, then it must surely be possible for the poor to do better than 54. Looking at the lives of the rich may help us understand what has to change if the poor are to do better, or, at least, for their children or grandchildren. By defining health inequity in terms of what is “avoidable,” the Whitehead approach comes dangerously
close to treating the justice and the epistemological issues as the same thing. Whether an inequality is unjust surely cannot turn on the question of whether we can do anything about it (although that will be relevant to the question of whether anyone can be blamed for it, and how much point there is in complaining about the situation). But whether an inequality (or, better, an adverse health condition or prospect) is avoidable must be relevant to the question of what is possible. In this way, considerations about possibility are inadvertently merged into considerations about justice. And both of these issues are distinct from the question of how to maximize total health gain, which, as the authors point out, will often increase health inequalities. In conclusion, the authors are to be thanked for the clarity with which they have brought out some difficulties in the philosophical and policy discussions surrounding the epidemiological evidence on the social determinants of health. Their work will help us keep distinct ideas apart and help us concentrate on what does and does not matter, and what stands a chance of working to resolve health inequalities and what may not. I hope that they will develop these themes at greater length in the future. &
REFERENCES Frankfurt, H. 1997. Equality as a moral ideal. Ethics 98(1): 21–43. Preda, A., and K. Voigt. 2015. The social determinants of health: Why should we care? American Journal of Bioethics 15(3): 25–36. Wolff, J. 2007. Equality: The recent history of an idea. Journal of Moral Philosophy 4(1): 125–136.
Nondistributive Social Factors, Noneconomic Distributive Factors Fred Gifford, Michigan State University There has been, in recent years, an increasing appreciation of the social determinants of health (SDH). Important questions emerge concerning how to utilize these facts in judging appropriate responses, and a certain movement in this regard can be identified in an important series of reports, including that of the World Health Organization. Preda and Voigt (2015) see this movement to argue for policy change in the name of social justice related to health as not properly grounded. They elucidate a number of very significant points that must be addressed in moving forward concerning the significance of the social
determinants of health. There is much of value in their analysis, most of which I will have to leave aside here. Preda and Voigt are certainly right to insist on the importance of a critical examination of the assumptions underlying the position, and to note that some of the discussion in the reports is not sufficiently careful. What counts as social, and what counts as the responsibility of the state to alter, is quite contentious. But taking proper care here also requires a close attention to some other matters of how we are to conceptualize the claims at issue. I worry that the authors go too quickly,
Address correspondence to Fred Gifford, Department of Philosophy, Michigan State University, 503 S. Kedzie, East Lansing, MI 48824, USA. E-mail: [email protected]
40 ajob
March, Volume 15, Number 3, 2015
Caring About Social Determinants of Health
making misleading claims and characterizing the HESC proponents in too simple a manner. Preda and Voigt describe a central assumption of the proponents as “if we are to address social inequalities in health, we must go beyond medical and behavioral approaches and include strategies that redistribute income and wealth and make societies more egalitarian.” One representative ambiguity here is whether the claim (whether that by Marmot, or that by Preda and Voigt) is that no progress can be made without this, or only that our success will not be complete without it. But there are other issues. The discovery that socioeconomic status (SES) is a deep causal factor concerning health and disease might lead one to the conclusion that we must erase those differences in income or SES, and that “the response” will simply be the redistribution of income and wealth. But this may seem too extreme and unwarranted. One aspect here is the idea that it requires “complete erasure” (which they might worry about given the insight of the “social gradient”: even getting rid of poverty won’t be enough); another is that the solution is characterized as using as the causal levers the modification of incomes. But an alternative conclusion would see the insight as being that low income (or differences in income) is a distal causal factor (rather than a proximal one—one might be tempted to call it “ultimate,” but that may mislead), but one that then operates through particular mechanisms, and we can use this knowledge as a way to help us use those mechanisms as causal levers—not (or not only) by altering income but by modifying social practices so that income would not have such a large impact on health. For example, we might endeavor to make it the case that no neighborhoods are toxic, or food deserts, rather than giving everyone enough money that they can in effect move out of such neighborhoods. This is especially important because the recommendations (1) to (5) from the Marmot Review listed in Preda and Voigt are in fact not really a matter of redistribution of incomes, or really even a “redistribution” of social determinants of health. There is an interesting question of exactly what would count as this. But these recommendations (such as “create and develop healthy and sustainable places and communities”) surely do not seem so to count. (Of course, the intervention will cost money, and this may come from a progressive tax system, but I assume this is not Preda and Voigt’s complaint here.) More generally, the following features need to be kept in mind if we are going to make progress on this topic: This discussion of SDH inevitably involves dealing with a number of statements that can be interpreted in more or less strict ways, and their strict interpretation will almost never be reasonable. For instance, a claim about the appropriateness of social intervention could be viewed as the claim that “changing income” (or some such social change) is the one thing we should do. Alternatively, it could be put as “one thing that could be used” or that it “should be used more than it is now.”
March, Volume 15, Number 3, 2015
Further, recommendations to proceed at the social level are ambiguous because the social determinants of health are comprised of a wide spectrum of factors beyond the usual biomedical ones, a complex set of factors not all of the same sort or at the same level. The idea is noted of the various more proximal social factors, and then the “causes of the causes” beyond that. But it is not as though there are precisely two levels, and in addition, there will be causal interaction between the levels. Finally, some relevant social factors have to do with redistribution of resources or income; others do not. Thus, a good deal of what needs to be clarified here is how strong and exclusive the claims are meant to be, or should be taken as being. Preda and Voigt’s analysis focuses throughout on the redistribution of the social factors. They say that if the social factors themselves are unfairly distributed, calling for their redistribution for reasons of health may detract from important social justice concerns. Addressing inequalities in income and wealth, for instance, is an important justice concern, regardless of its effects on health or health inequalities. But it may be damaging for health to suggest that only farreaching societal changes can lead to improvements in this area (34).
To say “only” here makes it sound as though our efforts should be exclusively there, but there are more significant issues here. Not all ways of addressing systematic social determinants of health are a matter of redistributing income and wealth, as we can address things for which SES is one causal factor, as in the case of addressing the unhealthiness of particular neighborhoods in terms of such things as crime and the lack of availability of nutritious food. And not all ways of addressing systematic social determinants of health are a matter of redistributing either income and wealth themselves or factors that are specifically caused by those. After all, one especially important set of such causal factors involves racism. Saying that action is needed across the society does not refer only to the reduction of economic inequality. In fact, it’s hard to imagine that any general claim or set of rules about how best to intervene in these complex cases will get it right. What is needed is the generation of a broader and more developed understanding of the various sorts of social, psychological, behavioral, economic, and cultural and other environmental inputs that are contributory toward health. One will then inevitably need to examine much more of the context in order to decide what to do—whether to intervene and via which causal path. (Consider by analogy the situation when we identify genetic causes. It hardly follows that the preferred means of intervention should be at the genetic level [whether this is always, or most often, or whether it’s “mostly”], even when knowledge of genetic causes helps us to locate nongenetic causal levers.) I believe that we will also have to be attentive to these other matters in order to see ourselves to a clear position concerning the SDH.
ajob 41
American Journal of Bioethics
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
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.
