Considerations of autonomy and independence, properly understood, support strictly egalitarian provision of necessary medical treatment. If the financially better-off can purchase access to necessary medical treatments that the financially less well-off cannot purchase without help, then their discretionary power to give or to withhold monetary gifts indirectly gives them the power to make life-and-death or sickness-and-health decisions for others. To prevent private citizens from having this objectionable form of power, government must ensure that citizens’ finances do not affect their access (...) to medical treatments that significantly prolong life, relieve suffering, or cure or mitigate disabilities. Government should ensure this even if doing so involves leveling down and even if it is unclear whether egalitarian provision of necessary treatment would provide better care to the poor than a less egalitarian health care system would. (shrink)

I critically examine a common liberal egalitarian view about the justification for, and proper content of, mandatory health insurance. This view holds that a mandate is justified because it is the best way to ensure that those in poor health gain health insurance on equitable terms. It also holds that a government should mandate what a representative prudent individual would purchase for themselves if they were placed in fair conditions of choice. I argue that this common justification for a mandate (...) is incomplete. A further reason for mandated insurance is that it helps secure social egalitarian public goods that would be underprovided if insurance were optional. I also argue that rather than mandating what a representative individual would choose for themselves, we should design the mandatory package by appealing to a pluralistic egalitarian view, which cares about improving people’s well-being, reducing unfair inequality, and maintaining egalitarian social relations. (shrink)

Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health care justice, and outlines a new approach that can (...) justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services. (shrink)

A growing body of research emphasises the role of ‘social determinants of health’ in generating inequalities in health outcomes. How, if at all, should primary care providers respond? In this paper, I want to shed light on this issue by focusing on the role that ‘big data’ might play in allowing primary care providers to respond to the social determinants that affect individual patients’ health. The general idea has been proposed and endorsed by the Institute of Medicine, and the idea (...) has been developed in more detail by Bazemore et al.. In Bazemore et al.’s proposal, patients’ addresses are used to generate information about the patients’ neighbourhood; this information is then included in patients’ health care records and made available to providers. This allows primary care providers to take this information into account when interacting with, and providing care to, patients. I explore three issues arising from this proposal. First, while questions of privacy have been central to discussions about big data, Bazemore et al.’s proposal also allows us to see that there might be costs to not making certain information available. Second, I consider some of the questions arising for primary care from the influence of social factors on health outcomes: given that we know these factors to be significant contributors to social inequalities in health, what precisely should be done about this in the primary care context? Finally, I address problems arising from the use of population level data when dealing with individuals. (shrink)

This paper problematizes the precision medicine approach embraced by the All of Us Research Program (US) and by Genomics England (UK) in terms of benefits distribution, by arguing that current “diversity and inclusion” efforts do not prevent exclusiveness, unless the framing and scope of the projects are revisited in public health terms. Grounded on document analysis and fieldwork interviews, this paper analyzes efforts to address potential patterns of exclusion upstream (from participating in precision medicine research) and downstream (from benefitting from (...) precision medicine outputs). It argues that efforts for inclusion upstream are not corresponded downstream, and this unbalance jeopardizes the equitable capacities of the projects. It concludes that enhanced focus on socio-environmental determinants of health and aligned public health interventions as precision medicine outputs would be to the benefit of all and especially of those who are most at risk of (upstream as well as downstream) exclusion. (shrink)

Gopal Sreenivasan, 201 West Duke Building, Box 90743, Durham NC USA 27708. Email: gopal.sreenivasan{at}duke.edu ' + u + '@ ' + d + ' '/ /- ->This paper reviews the epidemiological debate between the relative income hypothesis and the absolute income hypothesis. The dispute between these rival hypotheses has to do with whether an adequate account of the relationship between income and life expectancy requires the definition of ‘income’ to include any comparative element. I discuss the evidence offered for the (...) relative hypothesis, as well as two important criticisms that have been levelled against this evidence. I also offer some critical reflections on the debate from a philosophical standpoint concerned with the ethics of population health. Both hypotheses agree that a redistribution of income towards the worst off will improve their life expectancy. CiteULike Connotea Del.icio.us What's this? (shrink)

The strong correlation between people’s socioeconomic position and health within high income countries is a well-documented fact. A person’s occupation, income and education level tell us a lot about that person’s prospects on a long and healthy life, such that we can speak of a ‘social gradient in health’, or a ‘socioeconomic health gap’. This association is often perceived to be unjust. Therefore, it is generally thought that governments should aim to reduce socioeconomic health inequalities. However, this idea needs ethical (...) justification, for it is not evident if and why exactly these inequalities are unjust. For instance, are inequalities in health unjust per se? Or because the underlying socioeconomic inequalities are unjust? And does justice require equal health levels, or a minimum level of health? What complicates the issue, is that the width of the health gap, or the steepness of the social gradient, depends on what health measures are used. Overall, the more subjective the measure, the greater the inequalities appear to be. But are all these measures equally morally relevant? This dissertation aims to give a better understanding of these philosophical questions. It does so by investigating the question of what we should understand by health in the first part, after which it addresses the question of how to evaluate socioeconomic health inequalities in the light of justice. The introduction begins with a description of the phenomenon of socioeconomic health inequalities, and how it has been addressed by politicians, epidemiologists and philosophers in the past and today. The chapter continues by formulating the central question of the dissertation – that of which health inequalities should be focused in the light of a concern with social justice. It explicates how this dissertation contributes to answering that question, by discussing the potential relation between the conceptualisation of health and justice evaluations, and by discussing which questions are addressed in each of the following chapters. The chapter 2 addresses the question of how health is conceptualised in the philosophical and public heath literature, and how theoretical concepts of health differ. It proposes to approach health concepts as a Wittgensteinian family of thick concepts and argues that while theories on health generally argue in favour of one specific concept, a comparison of concepts shows that we may need different concepts of health given the variety of health practices. By explicating the differences between five concepts of health, this chapter argues that each captures aspects of health that all seem relevant when we talk and think about health. Classifying these concepts based on their distinctions reveals them as members of a conceptual family: each of the discussed concepts differs from the others in at least one respect and resembles the others in several respects. Moreover, the discussion of the concepts shows that ‘health’ always both describes a condition and values that condition at the same time. Having both descriptive and evaluative dimensions, we can see health concepts as ‘thick concepts’. Given this evaluative dimension, it is important to reflect on the question of what understanding of health guides specific practices. Moreover, the distinctions revealed by the classification can serve as a conceptual toolbox for reflection on the assumptions and purposes of health practices. How such reflection could work is illustrated by a brief exploration of what health aspects are focused upon in three specific health practices. Chapter 3 presents a study into the question of how health is conceptualised by ordinary citizens and to what extent conceptualisations of health differ between socioeconomic groups. By making use of the method of concept mapping, this study analyses how different socioeconomic groups formulate their own answers regarding the question ‘what does health mean to you?’. It presents concept maps of health for three different socioeconomic groups living in the city of Utrecht that reveal that all groups have a multidimensional understanding of health. An interpretation of the concept maps reveals nuanced differences between groups. The multiple aspects of health were also ranked by importance. It appears that each group assigned most importance to mental health. All in all, the study shows that people in lower socioeconomic groups are more likely to show a conceptualisation of health that refers to 1) the absence of health threats, 2) a person within his/her circumstances, 3) the value of functional notions, and 4) an accepting attitude towards life. Chapter 4 addresses the question of what the theoretical and empirical study to concepts of health could imply for health equity practices. It does so by exploring further the suggestions made in chapters 2 and 3. Regarding the question of which health aspects should guide health equity policies, this chapter discusses the question of whether we should primarily look at subjective or objective health measures, and whether a universal or relative standard of health should be central. While justice-related concerns of impartiality and equal treatment may seem to favour an objective perspective and a universal health standard, it appears that we have good reason to account for the subjective perspective as well. It is also argued that a concern for recognition and participatory parity gives room for relative health standards. Th room for relative health standards confronts us with the question of how to deal with mechanisms like adaptive preferences that the concept maps reveal. It proposes a way out, by arguing for society-relative health standards. Chapter 5 examines the question of whether inequalities in health should be evaluated ‘directly’, thus independently of a distribution of their social determinants. It proposes a sufficientarian perspective, such that the central question of evaluation is that of whether everyone is – or can be – healthy enough. By discussing two sufficientarian approaches to health and social justice – by Powers & Faden and by Nussbaum – this chapter distinguishes two ways of setting a threshold level for health. Both approaches appear to provide an unsatisfactory basis for justice evaluations and lead us away from direct evaluation if we try to settle health minima that are less arbitrary. In anticipation to chapters 6 and 7, it is argued that the perspective of sufficient health for relational equality escapes this arbitrariness: compared to that of a decent human life, it better helps to answer both the question of what socioeconomic health inequalities a society is due to avoid, and the question of when socioeconomic health inequalities are unjust considering their consequences. Chapter 6 discusses to what extent Daniels’s theory of health justice provides a satisfactory answer to the question of what health inequalities a society is due to avoid. Daniels proposes an indirect evaluative approach by arguing that we should evaluate socioeconomic health inequalities in the light of Rawls’s principles of justice as fairness. That is, if socioeconomic inequalities are in accordance with fair equality of opportunity and with the difference principle, the corresponding health inequalities would be just. It is shown that the suggestion that Rawls’s principles regulate the social determinants of health neglects that not all social determinants of health belong to society’s basic structure as conceived of by Rawls and are thereby not subjected to the principles of justice. To acknowledge the social mechanisms leading to socioeconomic health inequalities in their full complexity, it is argued that we should broaden our understanding of society’s structure in accordance with Young’s notion of social structural processes. This renders the question of what health inequalities a society is due to avoid into a question of what we can expect from the side of the various actors that uphold the social structures that produce socioeconomic health inequalities. Lastly, it is discussed how a shift to Young’s theory completes the shift to non-ideal theorising that seem already initiated by Daniels, and that with this, the distinction between direct and indirect evaluation dissolves. Chapter 7 discusses to what extent equality in health is of instrumental value for a society of free and equals. It thus takes up the idea proposed in chapter 5, that an evaluation of the consequences of health inequalities is also due. Taking relational equality as an evaluative framework reveals three ways in which inequalities in life expectancy threaten this ideal. That is, via unequal risks to stigmatisation, unequal risks to unemployment and the risk of unequal pension enjoyments. It is thereby shown that these risks are especially great for those lower down the socioeconomic strata. It thus concludes that equality in health is of instrumental value to relational equality. The chapter continues to argue that our instrumental approach opens a new perspective: to mitigate the identified injustices by changing society, rather than by reducing inequalities in health. This is argued to be an advantage in the light of the realistic assumption that of the socioeconomic health inequalities will persist. The paper thus offers a complementary approach to both the evaluation and the mitigation of the injustice of socioeconomic inequalities in health. The discussion chapter summarises the central findings of the analyses of health concepts and discusses questions regarding the philosophical and practical merits of comparing theoretical health concepts, the need for developing new health measures or concepts and the importance or nonsense of studying citizen’s views on health. Repeating this for the dissertation’s second part, the central findings of the chapters on justice evaluation are summarised and followed by a discussion of questions and issues that have remained unaddressed so far. Here, central points of discussion are my take on rules of distribution, the distinction of direct and indirect evaluation, the role of ideal and non-ideal theory, the idea of relational equality, and personal responsibility for health. The chapter concludes by noting that also in the light of justice evaluations, all commonly used health measures are relevant for justice. Therefore, my recommendations for policy and further research entail that inequalities in each of these measures deserve attention by both policymakers and researchers. Specifically, policymakers and researchers should give attention to how exactly each of these health inequalities come about, in such a way that a discussion about the question of who can be assigned responsibility to alleviate them is well-informed; and both should give attention to the effects of health inequalities on the opportunities for people to live on equal standing, in such a way that when these opportunities are diminished, actions can be considered to aim to restore relational equality. (shrink)

The role (if any) that principles of global health ethics play in the formulation of global and national level policies remains poorly understood. In this article we examine the status and trajectory of India, as a prototype low-middle income country that is on track to meet some important health targets set by the Sustainable Development Goals, with a view to assessing how relevant the global goals are to achieving equitable health care and health outcomes in India. We define the principles (...) of global health ethics relevant to our discussion and then examine some critical aspects of Indian healthcare policy through this lens. We demonstrate various areas where principles of global health ethics have been overlooked in planning and resulted in serious flaws in the healthcare system. It is our position that explicit attention should be given to the principles of global health ethics while framing policy at the national as well as the global level to ensure just health care outcomes in the future. (shrink)