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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
The Social Determinants of Health: Why We Should Care a
Audrey R. Chapman a
University of Connecticut Health Center Published online: 18 Mar 2015.
Click for updates To cite this article: Audrey R. Chapman (2015) The Social Determinants of Health: Why We Should Care, The American Journal of Bioethics, 15:3, 46-47, DOI: 10.1080/15265161.2014.998375 To link to this article: http://dx.doi.org/10.1080/15265161.2014.998375
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
The Social Determinants of Health: Why We Should Care
Downloaded by [University of Alberta] at 21:46 25 April 2015
Audrey R. Chapman, University of Connecticut Health Center Adina Preda and Kristin Voigt (2015) have written a provocative article that seeks to challenge major aspects of the current consensus on the significant role social determinants play in shaping population health outcomes and in contributing to inequalities in health outcome across social groups. They argue that the normative underpinnings of the framework they label as the “health equity through social change model” (HESC) are not sufficiently supported and lack a solid philosophical argument (Preda and Voigt 2015), possibly because of their lack of familiarity with the ethical and philosophical literature addressing issues related to the social determinants of health. Preda and Voigt also take issue with normative judgments about the injustice of health inequalities based on the social determinants of health and the policy recommendations based on this analysis. This OPC will critically assess three of the points they raise: (1) that avoidability or preventability of socially controllable factors does not offer an adequate grounding to consider inequalities of health to be unfair; (2) that differences within groups undermine the importance of the social determinants in shaping health outcomes across social groups; and (3) that there is not a sufficient basis to argue that inequalities in health are problematic or unjust in themselves. A major issue Preda and Voigt address is when and whether inequalities in health between social groups should be considered to be unfair and thereby to constitute an injustice. Much of the work on the social determinants of health follows the Whitehead–Dahlgren analysis that health inequalities count as inequities when they are avoidable, unnecessary, and unfair (Dahlgren and Whitehead 1991; Whitehead 1992). Norman Daniels (2008, 23, 27) offers a slightly different formulation, that the inequalities that affect population health and its distribution and that result from socially controllable factors are unfair. Preda and Voigt argue that avoidability as understood in the HESC framework is neither a necessary nor a sufficient basis to claim that health inequalities are unfair or unjust. They point out that inequality can be avoided in two ways: It can either be prevented from occurring or it can be redressed. But why this should affect the validity of avoidability as a foundation for injustice is unclear. For some unexplained reason they also seem to believe that even if avoidability is a necessary condition for unfairness,
we still need a further reason to accept that all avoidable inequalities are unfair. Part of their critique relates to their concerns about natural inequalities in health that may be unfair. They claim that the HESC model assumes that differences among social groups must have social causes whereas differences within these groups reflect natural, biological variation. They point out that inequalities in average health outcomes between different social groups may also have nonsocial causes, such as average differences in life expectancies between females and males. However Daniels and other HESC proponents have noted the role of biological differences rooted in gender, age, race, and ethnic differences in shaping health outcomes (Daniels 2008, 90– 91). Many HESC proponents would also consider biologically based differences in health outcomes to be unjust when they can be prevented or ameliorated but the government is not doing so (Daniels 2008, 90). Preda and Voigt take issue with the focus in the HESC model on differences among social groups rather than an analysis of individual differences. The analysis by groups has the advantage of helping to explain how these differences might have been generated. It also enables us to identify groups that suffer poor health or are at risk of doing so and to target them to try to effect health improvements. The goal is to identify groups which have suffered disadvantages in access to vital social determinants of health such as basic education, health care, affordable housing, and clean water and sanitation, as well as those needing protection from unsafe living and working conditions. In many cases these group inequalities are more likely to derive from social rather than natural factors and therefore may be amenable to public intervention (Anand 2004, 19). Other analysts have noted that the focus on social groups is more consistent with equity and human rights considerations (Braveman and Gruskin 2003; Chapman 2010). However, Preda and Voigt seem to consider groupbased measures to be less adequate because they average out differences among individuals within the groups, thereby obscuring outcomes for individuals. Moreover, they apparently consider individuals to be the appropriate ultimate locus of moral concern. Their discomfort with the group-level focus may also reflect a concern that it reduces individual responsibility for health behaviors. This issue is
Address correspondence to Audrey R. Chapman, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030, USA. E-mail: [email protected]
46 ajob
March, Volume 15, Number 3, 2015
Downloaded by [University of Alberta] at 21:46 25 April 2015
Caring About Social Determinants of Health
mentioned at various points in their article but does not receive an integrated exposition. At one point they argue that a portion of the social differences in health is attributable to individual behaviors and that proponents of the HESC model must therefore show that these individual behaviors are determined by social and economic status. However, as they themselves recognize, some risky behaviors, such as smoking, tend to be more prevalent in lower than higher income groups because of social factors, such as tobacco advertising targeting poor neighborhoods. Preda and Voigt raise the question that if inequalities in the distribution of social factors such as income or status are unjust, why should we focus on health inequality rather than on social inequality more broadly? They argue that social inequalities ought to be redressed because justice requires it, rather than because of their effects on health (Preda and Voigt 2015). In making this claim, they do not take into account the literature on the special moral importance of health. Norman Daniels’s work links the special moral importance of health with its impact on the range of opportunities open to us and the social obligation to protect equality of opportunity. According to Daniels, the socially controllable factors that promote health—medical services, traditional public health, and the distribution of the broader social determinants of health—in turn derive special importance from their role in protecting opportunities (Daniels 2008, 27, chapter 2). Other thinkers have put forward similar views on why health is a special social good. Sudhir Anand (2004) explains that health is so important because (1) it is directly constitutive of a person’s well-being and (2) it enables a person to function as an agent and thereby to pursue the various goals and projects that the person has reason to value. Thus, inequalities in health constitute inequalities in people’s capacity to function or, more generally, in their positive freedom. Hence inequalities in health amount to a denial of equality of opportunity (Anand 2004, 17–18). Amartya Sen (2004, 23) characterizes health as among the most important conditions of human life and a critically significant constituent of human capabilities. Health equity is also important because it is central to our understanding of social justice (Sen 2004, 22). Social
March, Volume 15, Number 3, 2015
inequalities in health often reflect injustices in the basic structure of society that disadvantage the worse off to benefit better-off groups. Fabienne Peter (2004) argues that social inequalities in health are wrong not simply because they deviate from a fair pattern of health outcomes but also because they are the expression and product of unjust economic, social, and political institutions. Conversely, she believes that an understanding of social inequalities in health and the mechanisms by which they are produced may illuminate something important about how the institutions of society operate and thereby inform our assessment of the justice of those institutions (Peter 2004, 94– 95). & REFERENCES Anand, S. 2004. The concern for equity in health. In Public health, ethics, and equity, ed. S. Anand, F. Peter, and A. Sen. 15–20. Oxford, UK: Oxford University Press. Braveman, P. and S. Gruskin. 2003. Poverty, equity, human rights, and health. Bulletin of the World Health Organization 81: 539–545. Chapman, A. 2010. The social determinants of health, health equity, and human rights. Health and Human Rights 12(2): 17–30. Dahlgren, G., and M. Whitehead. 1991. Policies and strategies to promote social equity in health. Stockholm, Sweden: Institute of Future Studies. Daniels, N. 2008. Just health: Meeting health needs fairly. New York, NY: Cambridge University Press. Peter, F. 2004. Health equity and social justice. In Public health, ethics, and equity, ed. S. Anand, F. Peter, and A. Sen, 93–106. 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. Sen, A. 2004. Why health equity? In Public health, ethics, and equity ed. S. Anand, F. Peter, and A. Sen, 21–33. Oxford, UK: Oxford University Press. Whitehead, M. 1992. The concepts and principles of equity in health. International Journal of Health Services 22: 429–425. Available at: http://dx.doi.org/10.2190/986L-LHQ6-2VTE-YRRN
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The American Journal of Bioethics Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/uajb20
The Social Determinants of Health: Why We Should Care a
Audrey R. Chapman a
University of Connecticut Health Center Published online: 18 Mar 2015.
Click for updates To cite this article: Audrey R. Chapman (2015) The Social Determinants of Health: Why We Should Care, The American Journal of Bioethics, 15:3, 46-47, DOI: 10.1080/15265161.2014.998375 To link to this article: http://dx.doi.org/10.1080/15265161.2014.998375
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
The Social Determinants of Health: Why We Should Care
Downloaded by [University of Alberta] at 21:46 25 April 2015
Audrey R. Chapman, University of Connecticut Health Center Adina Preda and Kristin Voigt (2015) have written a provocative article that seeks to challenge major aspects of the current consensus on the significant role social determinants play in shaping population health outcomes and in contributing to inequalities in health outcome across social groups. They argue that the normative underpinnings of the framework they label as the “health equity through social change model” (HESC) are not sufficiently supported and lack a solid philosophical argument (Preda and Voigt 2015), possibly because of their lack of familiarity with the ethical and philosophical literature addressing issues related to the social determinants of health. Preda and Voigt also take issue with normative judgments about the injustice of health inequalities based on the social determinants of health and the policy recommendations based on this analysis. This OPC will critically assess three of the points they raise: (1) that avoidability or preventability of socially controllable factors does not offer an adequate grounding to consider inequalities of health to be unfair; (2) that differences within groups undermine the importance of the social determinants in shaping health outcomes across social groups; and (3) that there is not a sufficient basis to argue that inequalities in health are problematic or unjust in themselves. A major issue Preda and Voigt address is when and whether inequalities in health between social groups should be considered to be unfair and thereby to constitute an injustice. Much of the work on the social determinants of health follows the Whitehead–Dahlgren analysis that health inequalities count as inequities when they are avoidable, unnecessary, and unfair (Dahlgren and Whitehead 1991; Whitehead 1992). Norman Daniels (2008, 23, 27) offers a slightly different formulation, that the inequalities that affect population health and its distribution and that result from socially controllable factors are unfair. Preda and Voigt argue that avoidability as understood in the HESC framework is neither a necessary nor a sufficient basis to claim that health inequalities are unfair or unjust. They point out that inequality can be avoided in two ways: It can either be prevented from occurring or it can be redressed. But why this should affect the validity of avoidability as a foundation for injustice is unclear. For some unexplained reason they also seem to believe that even if avoidability is a necessary condition for unfairness,
we still need a further reason to accept that all avoidable inequalities are unfair. Part of their critique relates to their concerns about natural inequalities in health that may be unfair. They claim that the HESC model assumes that differences among social groups must have social causes whereas differences within these groups reflect natural, biological variation. They point out that inequalities in average health outcomes between different social groups may also have nonsocial causes, such as average differences in life expectancies between females and males. However Daniels and other HESC proponents have noted the role of biological differences rooted in gender, age, race, and ethnic differences in shaping health outcomes (Daniels 2008, 90– 91). Many HESC proponents would also consider biologically based differences in health outcomes to be unjust when they can be prevented or ameliorated but the government is not doing so (Daniels 2008, 90). Preda and Voigt take issue with the focus in the HESC model on differences among social groups rather than an analysis of individual differences. The analysis by groups has the advantage of helping to explain how these differences might have been generated. It also enables us to identify groups that suffer poor health or are at risk of doing so and to target them to try to effect health improvements. The goal is to identify groups which have suffered disadvantages in access to vital social determinants of health such as basic education, health care, affordable housing, and clean water and sanitation, as well as those needing protection from unsafe living and working conditions. In many cases these group inequalities are more likely to derive from social rather than natural factors and therefore may be amenable to public intervention (Anand 2004, 19). Other analysts have noted that the focus on social groups is more consistent with equity and human rights considerations (Braveman and Gruskin 2003; Chapman 2010). However, Preda and Voigt seem to consider groupbased measures to be less adequate because they average out differences among individuals within the groups, thereby obscuring outcomes for individuals. Moreover, they apparently consider individuals to be the appropriate ultimate locus of moral concern. Their discomfort with the group-level focus may also reflect a concern that it reduces individual responsibility for health behaviors. This issue is
Address correspondence to Audrey R. Chapman, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030, USA. E-mail: [email protected]
46 ajob
March, Volume 15, Number 3, 2015
Downloaded by [University of Alberta] at 21:46 25 April 2015
Caring About Social Determinants of Health
mentioned at various points in their article but does not receive an integrated exposition. At one point they argue that a portion of the social differences in health is attributable to individual behaviors and that proponents of the HESC model must therefore show that these individual behaviors are determined by social and economic status. However, as they themselves recognize, some risky behaviors, such as smoking, tend to be more prevalent in lower than higher income groups because of social factors, such as tobacco advertising targeting poor neighborhoods. Preda and Voigt raise the question that if inequalities in the distribution of social factors such as income or status are unjust, why should we focus on health inequality rather than on social inequality more broadly? They argue that social inequalities ought to be redressed because justice requires it, rather than because of their effects on health (Preda and Voigt 2015). In making this claim, they do not take into account the literature on the special moral importance of health. Norman Daniels’s work links the special moral importance of health with its impact on the range of opportunities open to us and the social obligation to protect equality of opportunity. According to Daniels, the socially controllable factors that promote health—medical services, traditional public health, and the distribution of the broader social determinants of health—in turn derive special importance from their role in protecting opportunities (Daniels 2008, 27, chapter 2). Other thinkers have put forward similar views on why health is a special social good. Sudhir Anand (2004) explains that health is so important because (1) it is directly constitutive of a person’s well-being and (2) it enables a person to function as an agent and thereby to pursue the various goals and projects that the person has reason to value. Thus, inequalities in health constitute inequalities in people’s capacity to function or, more generally, in their positive freedom. Hence inequalities in health amount to a denial of equality of opportunity (Anand 2004, 17–18). Amartya Sen (2004, 23) characterizes health as among the most important conditions of human life and a critically significant constituent of human capabilities. Health equity is also important because it is central to our understanding of social justice (Sen 2004, 22). Social
March, Volume 15, Number 3, 2015
inequalities in health often reflect injustices in the basic structure of society that disadvantage the worse off to benefit better-off groups. Fabienne Peter (2004) argues that social inequalities in health are wrong not simply because they deviate from a fair pattern of health outcomes but also because they are the expression and product of unjust economic, social, and political institutions. Conversely, she believes that an understanding of social inequalities in health and the mechanisms by which they are produced may illuminate something important about how the institutions of society operate and thereby inform our assessment of the justice of those institutions (Peter 2004, 94– 95). & REFERENCES Anand, S. 2004. The concern for equity in health. In Public health, ethics, and equity, ed. S. Anand, F. Peter, and A. Sen. 15–20. Oxford, UK: Oxford University Press. Braveman, P. and S. Gruskin. 2003. Poverty, equity, human rights, and health. Bulletin of the World Health Organization 81: 539–545. Chapman, A. 2010. The social determinants of health, health equity, and human rights. Health and Human Rights 12(2): 17–30. Dahlgren, G., and M. Whitehead. 1991. Policies and strategies to promote social equity in health. Stockholm, Sweden: Institute of Future Studies. Daniels, N. 2008. Just health: Meeting health needs fairly. New York, NY: Cambridge University Press. Peter, F. 2004. Health equity and social justice. In Public health, ethics, and equity, ed. S. Anand, F. Peter, and A. Sen, 93–106. 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. Sen, A. 2004. Why health equity? In Public health, ethics, and equity ed. S. Anand, F. Peter, and A. Sen, 21–33. Oxford, UK: Oxford University Press. Whitehead, M. 1992. The concepts and principles of equity in health. International Journal of Health Services 22: 429–425. Available at: http://dx.doi.org/10.2190/986L-LHQ6-2VTE-YRRN
ajob 47
