This article was downloaded by: [University of Victoria] On: 25 April 2015, At: 21:52 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
Why We Should Care About the Social Determinants of Health Norman Daniels
a
a
Harvard School of Public Health Published online: 18 Mar 2015.
Click for updates To cite this article: Norman Daniels (2015) Why We Should Care About the Social Determinants of Health, The American Journal of Bioethics, 15:3, 37-38, DOI: 10.1080/15265161.2015.1000062 To link to this article: http://dx.doi.org/10.1080/15265161.2015.1000062
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
The American Journal of Bioethics, 15(3): 37–62, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2015.1000062
Open Peer Commentaries
Why We Should Care About the Social Determinants of Health
Downloaded by [University of Victoria] at 21:52 25 April 2015
Norman Daniels, Harvard School of Public Health I agree with some of the key points in the article by Preda and Voigt (2015), yet I disagree with the main point of the article as I understand it. Specifically, I agree that avoidability is neither a necessary nor a sufficient condition for a health inequality to count as unfair (in any case, it is neither a necessary nor a sufficient condition for our having obligations to meet a health need). Thus, I agree with some of the key claims that Preda and Voigt make about the ethical underpinnings of the importance of the social determinants in producing observable health inequalities. I also agree (although I am not a social epidemiologist) with the widely held empirical findings that they do not challenge. However, I disagree with what I take to be their central claim, that we should not see unjust health inequalities as giving us additional reasons for redistributing the social determinants of health in a more just arrangement. Rather, they argue that we should redistribute those determinants because social justice requires it independently of any implication for population health. By implication, however, I agree that their health effects are not the only reasons for redistributing those determinants of health. I proceed next from points of agreement to points of disagreement. First, consider the claim about avoidability. Some health conditions are the result of genetic disorders and fit clearly into Whitehead’s (1991) category of nonavoidable disorders. Health inequalities that derive from such conditions do not count as inequities. As Preda and Voigt point out, we can still treat such conditions, if we know how. My extension to health of Rawls’s general theory of justice (Daniels 2008) claims that we have obligations of justice to remedy these “natural” conditions, even if we do not view them as “unfair.” Some other theories, such as luck egalitarianism, view these unchosen conditions as bad brute luck and thus as unfair. On both views of the fairness of these “natural” conditions, we have obligations of justice to address the health needs that result. In one interpretation of the notion of avoidability, it is clearly not a necessary condition of our having obligations
to meet those health needs. Suppose a condition is avoidable, but at such great cost that we would be unable to meet a greater set of health needs (or even to assure people with comparable needs of equal chances of having those needs met). We arguably would be justified in concluding that it is not unfair to leave unmet the needs created by this costly condition to avoid (provided we meet the less costly but comparably serious needs instead). In one of the passages quoted by Preda and Voigt, the modifier “reasonable” is used with “avoidable.” I interpret this to mean that if it is reasonably avoidable to eliminate a health inequality, then it is unfair. Does the example of the condition that it is too costly to avoid mean that avoiding it is unreasonable? If so, there is no counterexample here to the claim of necessity. Nevertheless, Preda and Voigt are right that the “redressability” of even unavoidable conditions means that avoidability is not a necessary condition of our having obligations to meet relevant health needs. As used by Preda and Voigt, redressability means only that a condition is amenable to an intervention, which may be either treatment or compensation. They correctly point out that many conditions that we cannot prevent can still have their effects mitigated through treatment. I am less persuaded by the claim that even if we lack treatment for a condition that we cannot prevent, we should compensate people for having it. Still, Preda and Voigt are correct that avoidability is not a necessary condition for our having obligations to meet the relevant health needs. In my view, we have obligations to meet health needs (to protect fair equality of opportunity) even if a condition is unavoidable; my view does not require these obligations to be aimed only at “unfair” inequalities, for I do not agree that a genetic disorder is “unfair,” although it is unfortunate. We have social obligations to meet those needs anyway. What is the point of the article by Preda and Voigt? They make it clear that they are not disagreeing with the central empirical claim of social epidemiologists (that there are social determinants of health that explain a significant part of the health inequalities that people find problematic
Address correspondence to Norman Daniels, Mary B. Saltonstall Professor, Professor of Ethics and Population Health, Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Building I, Room 1210D, Boston, MA 02115, USA. E-mail: [email protected]
ajob 37
Downloaded by [University of Victoria] at 21:52 25 April 2015
American Journal of Bioethics
both nationally and globally). Nor are they disagreeing with many of the policy recommendations that are made in light of those empirical claims, namely for reducing inequalities in income, wealth, political power, and education, viewed as social determinants of health. Rather, the problem they focus on is the normative link that leading proponents of these empirical and policy claims make between these policy claims and the health inequalities that the distribution of the social determinants of health in part creates, which they refer to as the “health equity through social change model” or HESC model. Why, they argue, should these health inequalities be a reason for doing what we have plenty of reason for doing in the name of social justice. After all, social justice requires us— health aside—to distribute these social determinants of health more fairly, so attending to the health inequalities they in large part create is a mistake. Is it a mistake? I do not think so. I believe the fact that a fairer distribution of the determinants of health would reduce many intergroup health inequalities significantly gives us an additional reason to redistribute those determinants more fairly. To show that there is an additional reason, notice that we would have a serious problem if social injustice worked in a different way. If the link between these determinants and their health effects is empirical, as it is, then there is nothing conceptually confused about supposing the opposite finding. Suppose that increasing economic and educational inequality in society actually reduced health inequalities, contrary to what we observe. Then the fact that we have reasons of social justice to reduce existing inequalities in income, wealth, political power, and education would fight against the (hypothetical) empirical observation that health inequalities are decreased by social inequality. Social justice would lead to greater health inequality, not less inequality. This empirical fact would, I think, give us some reason to doubt our views about social justice. In short, it is a very welcome finding that more social justice decreases health inequality, for we are likely to find the opposite relationship very hard to take. Why think there is something unjust about the health inequalities that are actually caused by the unjust distribution of income, wealth, political power, and education? One important reason to think the health inequalities that result from the unjust distribution of these social determinants of health are themselves unjust is the impact which they have on the opportunities people can reasonably exercise (to use my terminology—Daniels [2010]), or the capabilities to do or be things (to use Sen’s terminology— Sen [1992]). The health inequalities that are caused by the unjust distribution of the social determinants of health are therefore viewed as unjust for good reason, and not just because they are caused by the unjust distribution of these social determinants. This good reason gives us additional reason for seeking social justice in the distribution of the social determinants of health.
38 ajob
Marmot (2010) and others are therefore not wrong to emphasize the creation of health inequalities as an additional reason for seeking social justice in the distribution of income, wealth, political power, and education, among other key social determinants of health. I do not believe they ever say that these health inequalities are the only reason to redistribute the social determinants. The effects on health add to the reasons for seeking social justice and are not redundant or irrelevant. Thus, the effect of the social determinants on health (and health inequality) does give us a reason to care about their distribution—not the only reason, but a relevant reason. Much of the reasoning that Preda and Voigt give (in their fourth section) for thinking that the measures recommended by the proponents of the HESD model do not turn on the ethical reasoning they find problematic. Rather, these measures are criticized for having little effect where they have been tried. Preda and Voigt thus suggest we do not have a well-thought-out set of measures that can reduce observed health inequalities. But these points (if they cannot be adequately explained while retaining the HESD model) either challenge the empirical findings, contrary to what these authors claim, or challenge the policy implications of those findings, again contrary to the authors’ claim. The problem with these measures does not derive from the faulty ethical underpinnings upon which the authors focused. In short, if the point of their article is to answer the question “Why should we care about the distribution of the social determinants of health?,” then the answer the authors give seems wrong. They seem to think that we should care only about the non-health-related reasons of social justice. My view is that the social determinants of population health and its distribution give us an additional reason of social justice for redistributing these determinants of health in a fairer way. & REFERENCES Daniels, N. 2008. Just health: Meeting health needs fairly. New York, NY: Cambridge University Press. Daniels, N. 2010. Capabilities, opportunity, and health. In Measuring justice: Primary goods and capabilities, ed. H. Brighouse and I. Robeyns, 131–49. New York, NY: Cambridge University Press. Marmot, M. 2010. Fair society, healthy lives—The Marmot review. Strategic review of health inequalities in England post-2010. London, UK: Marmot Review. Available at: http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review 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..K. 1992. Inequality reexamined. Cambridge, MA: Harvard University Press. Whitehead, M. 1991. The concepts and principles of equity and health. Health Promotion International 6: 217–28. http://dx.doi.org/ 10.1093/heapro/6.3.217
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
Why We Should Care About the Social Determinants of Health Norman Daniels
a
a
Harvard School of Public Health Published online: 18 Mar 2015.
Click for updates To cite this article: Norman Daniels (2015) Why We Should Care About the Social Determinants of Health, The American Journal of Bioethics, 15:3, 37-38, DOI: 10.1080/15265161.2015.1000062 To link to this article: http://dx.doi.org/10.1080/15265161.2015.1000062
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
The American Journal of Bioethics, 15(3): 37–62, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1526-5161 print / 1536-0075 online DOI: 10.1080/15265161.2015.1000062
Open Peer Commentaries
Why We Should Care About the Social Determinants of Health
Downloaded by [University of Victoria] at 21:52 25 April 2015
Norman Daniels, Harvard School of Public Health I agree with some of the key points in the article by Preda and Voigt (2015), yet I disagree with the main point of the article as I understand it. Specifically, I agree that avoidability is neither a necessary nor a sufficient condition for a health inequality to count as unfair (in any case, it is neither a necessary nor a sufficient condition for our having obligations to meet a health need). Thus, I agree with some of the key claims that Preda and Voigt make about the ethical underpinnings of the importance of the social determinants in producing observable health inequalities. I also agree (although I am not a social epidemiologist) with the widely held empirical findings that they do not challenge. However, I disagree with what I take to be their central claim, that we should not see unjust health inequalities as giving us additional reasons for redistributing the social determinants of health in a more just arrangement. Rather, they argue that we should redistribute those determinants because social justice requires it independently of any implication for population health. By implication, however, I agree that their health effects are not the only reasons for redistributing those determinants of health. I proceed next from points of agreement to points of disagreement. First, consider the claim about avoidability. Some health conditions are the result of genetic disorders and fit clearly into Whitehead’s (1991) category of nonavoidable disorders. Health inequalities that derive from such conditions do not count as inequities. As Preda and Voigt point out, we can still treat such conditions, if we know how. My extension to health of Rawls’s general theory of justice (Daniels 2008) claims that we have obligations of justice to remedy these “natural” conditions, even if we do not view them as “unfair.” Some other theories, such as luck egalitarianism, view these unchosen conditions as bad brute luck and thus as unfair. On both views of the fairness of these “natural” conditions, we have obligations of justice to address the health needs that result. In one interpretation of the notion of avoidability, it is clearly not a necessary condition of our having obligations
to meet those health needs. Suppose a condition is avoidable, but at such great cost that we would be unable to meet a greater set of health needs (or even to assure people with comparable needs of equal chances of having those needs met). We arguably would be justified in concluding that it is not unfair to leave unmet the needs created by this costly condition to avoid (provided we meet the less costly but comparably serious needs instead). In one of the passages quoted by Preda and Voigt, the modifier “reasonable” is used with “avoidable.” I interpret this to mean that if it is reasonably avoidable to eliminate a health inequality, then it is unfair. Does the example of the condition that it is too costly to avoid mean that avoiding it is unreasonable? If so, there is no counterexample here to the claim of necessity. Nevertheless, Preda and Voigt are right that the “redressability” of even unavoidable conditions means that avoidability is not a necessary condition of our having obligations to meet relevant health needs. As used by Preda and Voigt, redressability means only that a condition is amenable to an intervention, which may be either treatment or compensation. They correctly point out that many conditions that we cannot prevent can still have their effects mitigated through treatment. I am less persuaded by the claim that even if we lack treatment for a condition that we cannot prevent, we should compensate people for having it. Still, Preda and Voigt are correct that avoidability is not a necessary condition for our having obligations to meet the relevant health needs. In my view, we have obligations to meet health needs (to protect fair equality of opportunity) even if a condition is unavoidable; my view does not require these obligations to be aimed only at “unfair” inequalities, for I do not agree that a genetic disorder is “unfair,” although it is unfortunate. We have social obligations to meet those needs anyway. What is the point of the article by Preda and Voigt? They make it clear that they are not disagreeing with the central empirical claim of social epidemiologists (that there are social determinants of health that explain a significant part of the health inequalities that people find problematic
Address correspondence to Norman Daniels, Mary B. Saltonstall Professor, Professor of Ethics and Population Health, Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Building I, Room 1210D, Boston, MA 02115, USA. E-mail: [email protected]
ajob 37
Downloaded by [University of Victoria] at 21:52 25 April 2015
American Journal of Bioethics
both nationally and globally). Nor are they disagreeing with many of the policy recommendations that are made in light of those empirical claims, namely for reducing inequalities in income, wealth, political power, and education, viewed as social determinants of health. Rather, the problem they focus on is the normative link that leading proponents of these empirical and policy claims make between these policy claims and the health inequalities that the distribution of the social determinants of health in part creates, which they refer to as the “health equity through social change model” or HESC model. Why, they argue, should these health inequalities be a reason for doing what we have plenty of reason for doing in the name of social justice. After all, social justice requires us— health aside—to distribute these social determinants of health more fairly, so attending to the health inequalities they in large part create is a mistake. Is it a mistake? I do not think so. I believe the fact that a fairer distribution of the determinants of health would reduce many intergroup health inequalities significantly gives us an additional reason to redistribute those determinants more fairly. To show that there is an additional reason, notice that we would have a serious problem if social injustice worked in a different way. If the link between these determinants and their health effects is empirical, as it is, then there is nothing conceptually confused about supposing the opposite finding. Suppose that increasing economic and educational inequality in society actually reduced health inequalities, contrary to what we observe. Then the fact that we have reasons of social justice to reduce existing inequalities in income, wealth, political power, and education would fight against the (hypothetical) empirical observation that health inequalities are decreased by social inequality. Social justice would lead to greater health inequality, not less inequality. This empirical fact would, I think, give us some reason to doubt our views about social justice. In short, it is a very welcome finding that more social justice decreases health inequality, for we are likely to find the opposite relationship very hard to take. Why think there is something unjust about the health inequalities that are actually caused by the unjust distribution of income, wealth, political power, and education? One important reason to think the health inequalities that result from the unjust distribution of these social determinants of health are themselves unjust is the impact which they have on the opportunities people can reasonably exercise (to use my terminology—Daniels [2010]), or the capabilities to do or be things (to use Sen’s terminology— Sen [1992]). The health inequalities that are caused by the unjust distribution of the social determinants of health are therefore viewed as unjust for good reason, and not just because they are caused by the unjust distribution of these social determinants. This good reason gives us additional reason for seeking social justice in the distribution of the social determinants of health.
38 ajob
Marmot (2010) and others are therefore not wrong to emphasize the creation of health inequalities as an additional reason for seeking social justice in the distribution of income, wealth, political power, and education, among other key social determinants of health. I do not believe they ever say that these health inequalities are the only reason to redistribute the social determinants. The effects on health add to the reasons for seeking social justice and are not redundant or irrelevant. Thus, the effect of the social determinants on health (and health inequality) does give us a reason to care about their distribution—not the only reason, but a relevant reason. Much of the reasoning that Preda and Voigt give (in their fourth section) for thinking that the measures recommended by the proponents of the HESD model do not turn on the ethical reasoning they find problematic. Rather, these measures are criticized for having little effect where they have been tried. Preda and Voigt thus suggest we do not have a well-thought-out set of measures that can reduce observed health inequalities. But these points (if they cannot be adequately explained while retaining the HESD model) either challenge the empirical findings, contrary to what these authors claim, or challenge the policy implications of those findings, again contrary to the authors’ claim. The problem with these measures does not derive from the faulty ethical underpinnings upon which the authors focused. In short, if the point of their article is to answer the question “Why should we care about the distribution of the social determinants of health?,” then the answer the authors give seems wrong. They seem to think that we should care only about the non-health-related reasons of social justice. My view is that the social determinants of population health and its distribution give us an additional reason of social justice for redistributing these determinants of health in a fairer way. & REFERENCES Daniels, N. 2008. Just health: Meeting health needs fairly. New York, NY: Cambridge University Press. Daniels, N. 2010. Capabilities, opportunity, and health. In Measuring justice: Primary goods and capabilities, ed. H. Brighouse and I. Robeyns, 131–49. New York, NY: Cambridge University Press. Marmot, M. 2010. Fair society, healthy lives—The Marmot review. Strategic review of health inequalities in England post-2010. London, UK: Marmot Review. Available at: http://www.instituteofhealthequity.org/projects/fair-society-healthy-lives-the-marmot-review 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..K. 1992. Inequality reexamined. Cambridge, MA: Harvard University Press. Whitehead, M. 1991. The concepts and principles of equity and health. Health Promotion International 6: 217–28. http://dx.doi.org/ 10.1093/heapro/6.3.217
March, Volume 15, Number 3, 2015
