Much of the philosophical literature on health inequalities seeks to establish the superiority of one or another conception of luck egalitarianism. In recent years, however, an increasing number of self-avowed egalitarian philosophers have proposed replacing luck egalitarianism with alternatives that stress the moral relevance of distinct relationships, rather than the moral relevance of good or bad luck. After briefly explaining why I am not attracted to luck egalitarianism, I seek in this chapter to distinguish and clarify three views that (...) have been characterized in the philosophical literature as forms of relational egalitarianism. I call these three relational views equality of treatment, equality of concern, and social egalitarianism. I will explain why each claims to be a form of egalitarianism and why these three views should not be seen as competitors. I will argue that each brand of relational egalitarianism describes a plausible plank of distributive justice that bears on the evaluation of health inequalities and on the political institutions that create, sustain, or exacerbate them. To illustrate this pluralistic relational egalitarian approach, I will draw on a case study by Horton and Barker (this volume) to discuss how each of the three planks might be brought to bear on the evaluation of oral health disparities among the children of migrant Latino farmworkers in California. (shrink)

In this paper I argue that certain ways in which the relationship among discrimination, emotions and health is presented can undermine equity. I identify a model of this relationship the discrimination-emotion-health model - and claim that while the model is important for understanding the detrimental impact that discrimination and oppression can have on emotions and health, certain implications of the model are troubling. I identify six critiques of the model, and show that equity could be undermined, for (...) example, when stereotypes of the oppressed are reinforced and the experiences of the privileged are normalized. I then assess the implications of my analysis of the model and its critique for a framework of health equity, demonstrating what such a framework would need to look like in order for it to best represent discrimination as a psychosocial determinant of health. (shrink)

An estimated 700,000 people in the United States have "long COVID," that is, symptoms of COVID-19 persisting beyond three weeks. COVID-19 and its long-term sequelae are strongly influenced by social determinants such as poverty and by structural inequalities such as racism and discrimination. Primary care providers are in a unique position to provide and coordinate care for vulnerable patients with long COVID. Policy measures should include strengthening primary care, optimizing data quality, and addressing the multiple nested domains of inequity.

I outline and defend two egalitarian theories, which yield distinctive and, I argue, complementary answers to why health-related inequalities matter: a brute luck egalitarian view, according to which inequalities due to unchosen, differential luck are bad because unfair, and a social egalitarian view, according to which inequalities are bad when and because they undermine people’s status as equal citizens. These views identify different objects of egalitarian concern: the brute luck egalitarian view directs attention to health-related well-being, while social (...) egalitarianism focuses on health-related capabilities that are central to a person’s status as a citizen. I argue that both views are correct and should jointly guide priority-setting in health. (shrink)

Child health inequalities violate children’s rights to optimal wellbeing. Different issues worldwide affect children’s physical and mental health as well as their development, influencing their future as adults. Inequities are avoidable inequalities. Despite improvements in the past two decades, the ambitious goals of global agendas have, for the most part, remained as expectations with regard to childhood rights, social justice, and health equity in practice. The concept of social determinants of health has become part of the (...) common language in certain settings, but this is still too little to improve health in practice on a global scale, particularly for underprivileged subgroups of the community, as children and adolescents often are. Pediatric health professionals and their organizations are also responsible for guaranteeing children’s and adolescents’ right to health and better wellbeing, helping to reduce health inequalities. (shrink)

The paper discusses the possibility that the benefits of pharmacogenomics will not be distributed equally and will create orphan populations. I argue that since these inequalities are not substantially different from those produced by ‘traditional’ drugs and are not generated with the intention to discriminate, their production needs not be unethical. Still, the final result is going against deep-seated moral feelings and intuitions, as well as broadly accepted principles of just distribution of health outcomes and healthcare. I thus propose (...) two provisos that would prevent the most offensive outcomes and moderate the scope of the produced inequalities. The first proviso rejects pharmacogenomics innovations that worsen existing group inequalities and aggravate the disadvantage of communities with a history of discrimination. The second proviso requires that there is a strategy in place to even out as much as possible the distribution of benefits in the future and that a system of compensations is in place for pharmacogenomic orphans. Given that only one moral problem generated by pharmacogenomics has been tackled, the list of provisos might be expanded when other issues are considered. (shrink)

Chile has achieved great success in terms of growth and development. However, growing inequalities exist in relation to income and health status. The previous Chilean government began to reform the healthcare system with the aim of reducing health inequities. What is meant by “equity” in this context? What is the extent of the equity aimed for? A normative framework is required for public policy-makers to consider ideas about fairness in their decisions about healthcare reform. This paper aims to (...) discuss the main features of the Chilean healthcare reform and their implications for such a normative framework. (shrink)

The application of Artificial Intelligence (AI) in healthcare and epidemiology undoubtedly has many benefits for the population. However, due to its environmental impact, the use of AI can produce social inequalities and long-term environmental damages that may not be thoroughly contemplated. In this paper, we propose to consider the impacts of AI applications in medical care from the One Health paradigm and long-term global health. From health and environmental justice, rather than settling for a short and fleeting (...) green honeymoon between health and sustainability caused by AI, it should aim for a lasting marriage. To this end, we conclude by proposing that, in the upcoming years, it could be valuable and necessary to promote more interconnected health, call for environmental cost transparency, and increase green responsibility. (shrink)

There are a number of important links and similarities between public health and safety. In this extended essay, Gregg D. Caruso defends and expands his public health-quarantine model, which is a non-retributive alternative for addressing criminal behavior that draws on the public health framework and prioritizes prevention and social justice. In developing his account, he explores the relationship between public health and safety, focusing on how social inequalities and systemic injustices affect health outcomes and crime (...) rates, how poverty affects brain development, how offenders often have pre-existing medical conditions (especially mental health issues), how involvement in the criminal justice system itself can lead to or worsen health and cognitive problems, how treatment and rehabilitation methods can best be employed to reduce recidivism and reintegrate offenders back into society, and how a public health approach could be successfully applied within the criminal justice system. Caruso's approach draws on research from the health sciences, social sciences, public policy, law, psychiatry, medical ethics, neuroscience, and philosophy, and he delivers a set of ethically defensible and practically workable proposals for implementing the public health-quarantine model. The essay begins by discussing recent empirical findings in psychology, neuroscience, and the social sciences that provide us with an increased understanding of the social and neurological determinants of health and criminal behavior. It then turns to Caruso's public health-quarantine model and argues that the model provides the most justified, humane, and effective approach for addressing criminal behavior. Caruso concludes by proposing a capability approach to social justice grounded in six key features of human well-being. He argues that we cannot successfully address concerns over public health and safety without simultaneously addressing issues of social justice—including the social determinants of health (SDH) and the social determinants of criminal behavior (SDCB)—and he recommends eight general policy proposals consistent with his model. (shrink)

This review article of Shlomi Segall's Health, Luck, and Justice (Princeton University Press, 2010) addresses three issues: first, Segall’s claim that luck egalitarianism, properly construed, does not object to brute luck equality; second, Segall’s claim that brute luck is properly construed as the outcome of actions that it would have been unreasonable to expect the agent to avoid; and third, Segall’s account of healthcare and criticism of rival views. On the first two issues, a more conventional form of luck (...) egalitarianism – that is, one which objects to brute luck even if it creates equality, and which construes brute luck as the inverse of agent responsibility – is defended. On the third issue, strengths and weaknesses in Segall’s criticism of Rawlsian, democratic egalitarian, and all-luck egalitarian approaches to healthcare, and in his own luck egalitarian approach, are identified. (shrink)

As COVID-19 spread, clinicians warned of mental illness epidemics within the coronavirus pandemic. Funding for digital mental health is surging and researchers are calling for widespread adoption to address the mental health sequalae of COVID-19. -/- We consider whether these technologies improve mental health outcomes and whether they exacerbate existing health inequalities laid bare by the pandemic. We argue the evidence for efficacy is weak and the likelihood of increasing inequalities is high. -/- First, we review (...) recent trends in digital mental health. Next, we turn to the clinical literature to show that many technologies proposed as a response to COVID-19 are unlikely to improve outcomes. Then, we argue that even evidence-based technologies run the risk of increasing health disparities. We conclude by suggesting that policymakers should not allocate limited resources to the development of many digital mental health tools and should focus instead on evidence-based solutions to address mental health inequalities. (shrink)

Recently, there has been a concerted effort to shift bioethics’ traditional focus from clinical and research settings to more robustly engage with issues of justice and health equity. This broader bioethics agenda seeks to embed health related issues in wider institutional and cultural contexts and to help develop fair policies. In this paper, we argue that bioethicists who ascribe to the broader bioethics’ agenda could gain valuable insights from the interdisciplinary field of environmental justice and transportation justice, in (...) particular. We then proceed to demonstrate the importance of adopting an intersectional approach to transportation and health. The paper concludes with the argument that intersectional gender inequality is of particular importance when studying both health equity and the unequal distribution of burdens associated with transportation systems in local contexts. This essay is meant to be the beginning of a robust conversation concerning health equity, transportation justice, and intersectional distributions of both benefits and burdens. (shrink)

Recent years have seen growing public concern about the effects of persuasive digital technologies on public mental health and well-being. As the draws on our attention reach such staggering scales and as our ability to focus our attention on our own considered ends erodes ever further, the need to understand and articulate what is at stake has become pressing. In this ethical viewpoint, we explore the concept of attentional harms and emphasize their potential seriousness. We further argue that the (...) acknowledgment of these harms has relevance for evolving debates on digital inequalities. An underdiscussed aspect of web-based inequality concerns the persuasions, and even the manipulations, that help to generate sustained attentional loss. These inequalities are poised to grow, and as they do, so will concerns about justice with regard to the psychological and self-regulatory burdens of web-based participation for different internet users. In line with calls for multidimensional approaches to digital inequalities, it is important to recognize these potential harms as well as to empower internet users against them even while expanding high-quality access. (shrink)

This thesis under the title “Public Health Policy in Resource Allocation: the Role of Ubuntu Ethics in Redressing Resource Disparity between Public and Private Healthcare in South Africa” explores health care disparities pertaining to resource allocation between public and private sector. It is of relevance and importance in South Africa where 54% of the population live on less than US$3 per day. Although the government has instituted certain changes aimed at transforming the public health care system, the (...) resource allocation gap between the two persists and remains wide. The research gives special attention to the role that Ubuntu ethics can play in redressing the resource allocation disparities between public and private health care sectors in South Africa, pointing out the existing gap in financing, as well as human resource between public and private health care sectors, which leads to poor health outcomes in public sector. Therefore, the problem is the prevalent inequality of resource allocation between private and public health care sectors. The analysis of policy gaps, as well as evaluating the cause of disparities in the health system is the goal of this research. The study endeavours to redress the disparities within the context of Ubuntu ethical principles and proposes a change in public policy so as to enhance healthcare for the benefit of the people. The study is philosophical and ethical, so the methodology used is discursive in nature, majorly focusing on critically reviewing existing literature, that is, the philosophical resources on Ubuntu ethics and justice theories as well as a range of government resources inclusive of public health policy documents. Social determinants of health and their impact in a South African context are discussed with the implication that health is not merely freedom from disease and or incapacity, but rather being well mentally, physically and socially. The attainment of a healthy status goes beyond ability to access healthcare services, and incorporates social determinants including but not limited to conditions in which people have been born into, stay, establish career and grow old in. It also includes the arrangements put in place to deal with illness and determine health. Issues of revenue, literacy, communal safety networks, vocation and conditions under-which vocation is undertaken, lack of work and vocation insecurity, early stages of human development, gender, cultural group, dietary insecurity, housing communal exclusion and disability all come into the picture as factors that determine health. But there is also discussion of the socio-economic status as contributors to health inequity wherein alcohol abuse, sugar intake, and smoking are identified as behavioural factors that complicate public health. One outstanding feature of this research is that it establishes a link between Ubuntu and public health policy. The researcher establishes that Ubuntu ethics is appropriate for not only discussing public morality, but also for formulating public policy that is morally tenable for South Africa, especially for the public health sector. This thesis calls for an application of Ubuntu in a proper context in order to enhance societal well-being for the benefit of many, if not all. The research proposes the fundamental principle of Ubuntu ethics in which the good of the community is as important as the good of every member of the community. Since Ubuntu ethics does not merely seek to fulfil what benefits the majority, as would be the case in a utilitarian society, the researcher advocates for the building of consensus on the common good, which should be understood to imply not just what is good for everyone in the community, but also what is good for the continued well-being of the community as a single unit. In this regard, the research finds it important that deliberate effort be made to integrate Ubuntu ethics into policies, citing the example of the National Health Insurance (NHI). The good health of all the members of a community is an assurance of the well-being and continuity of the whole national community. The research concludes that public health policy should integrate Ubuntu ethical values such as community, sharing, care, solidarity, identity, harmony, respect, and dignity into policy documents and legislation. (shrink)

Previous research has shown that women are disproportionately negatively affected by a variety of socio-economic hardships, many of which COVID-19 is making worse. In particular, because of gender roles, and because women’s jobs tend to be given lower priority than men’s (since they are more likely to be part-time, lower-income, and less secure), women assume the obligations of increased caregiving needs at a much higher rate. This unfairly renders women especially susceptible to short- and long-term economic insecurity and decreases in (...) wellbeing. Single-parent households, the majority of which are headed by single mothers, face even greater risks. These vulnerabilities are further compounded along the dimensions of race, ethnicity, class, and geography. Drawing upon the philosophical literature on political responsibility and structural injustice (specifically, the work of Iris Marion Young), I argue that while the state may not have had either foresight into, or control over, the disproportionate effect the pandemic would have on women, it can nonetheless be held responsible for mitigating these effects. In order to do so, it must first recognize the ways in which women have been affected by the outbreak. Specifically, policies must take into account the unpaid labor of care that falls on women. Moreover, given that this labor is particularly vital during a global health pandemic, the state ought to immediately prioritize the value of this work by providing financial stimuli directly to families, requiring employers to provide both sick leave and parental leave for at least as long as schools and daycares are inoperational, and providing subsidized emergency childcare. (shrink)

The purpose of cultural competence education for medical professionals is to ensure respectful care and reduce health disparities. Yet as Berger and Miller (2021) show, the cultural competence framework is dated, confused, and self-defeating. They argue that the framework ignores the primary driver of health disparities—systemic racism—and is apt to exacerbate rather than mitigate bias and ethnocentrism. They propose replacing cultural competence with a framework that attends to two social aspects of structural inequality: health and social (...) policy, and institutional-system activity; and two psychological aspects of structural inequality: the clinical encounter, and the epistemic. -/- We agree with the structural approach. To that end, we think it would be fruitful to include attention to physical contributors to structural inequality, namely the material artifacts used in medicine. Devices, tools, and technologies can materialize biases, perpetuate oppression, and contribute to health disparities. Granted, not everything that interests philosophers can be squeezed into medical education. Nevertheless, there are compelling reasons for including the study of material artifacts in education designed to reduce health disparities. First, devices and tools often carry forward biases from the past, and keep biases hidden from plain sight. Second, by studying these artifacts, future clinicians can begin to see themselves as part of a larger sociotechnical system. Finally, as medicine becomes increasingly tech-laden, it’s important for clinicians to see how material artifacts (including algorithms) connect individuals to structures. This will help to undermine oversimplified narratives according to which objective tools and technologies can correct for the bias and subjectivity of flawed human beings. (shrink)

Well before the COVID-19 pandemic, proponents of digital psychiatry were touting the promise of various digital tools and techniques to revolutionize mental healthcare. As social distancing and its knock-on effects have strained existing mental health infrastructures, calls have grown louder for implementing various digital mental health solutions at scale. Decisions made today will shape the future of mental healthcare for the foreseeable future. We argue that bioethicists are uniquely positioned to cut through the hype surrounding digital mental (...) class='Hi'>health, which can obscure crucial ethical and epistemic gaps that ought to be considered by policymakers before committing to a digital psychiatric future. Here, we describe four such gaps: The evidence gap, the inequality gap, the prediction-intervention gap, and the safety gap. (shrink)

Many social gradients in health appear steeper for men than for women. I refer to this as the “Steepness Puzzle.” This paper explores the ethical implications of this Puzzle. First, it identifies potential explanations for the Steepness Puzzle, including methodological problems. Second, it highlights two harms associated with the methodological explanation: the consequences of biased epistemic practices and the marginalization of women. It also demonstrates how attempts to flatten the gradients in health could disproportionately favor men or reinforce (...) troubling gendered norms. Finally, I suggest ways to address the methodological problems underlying the Puzzle. (shrink)

New biotechnologies have the potential to both dramatically improve human well-being and dramatically widen inequalities in well-being. This paper addresses a question that lies squarely on the fault line of these two claims: When as a matter of justice are societies obligated to include a new biotechnology in a national healthcare system? This question is approached from the standpoint of a twin aim theory of justice, in which social structures, including nation-states, have double-barreled theoretical objectives with regard to human well-being. (...) The first aim is to achieve a sufficient level of well-being in each of six core dimensions. In the special case of healthcare systems, this aim is focally but not exclusively attentive to achieving health sufficiency as one of the core dimensions. The second aim is to combat the emergence and persistence of densely woven patterns of systematic disadvantage that tend to undermine the achievement of a sufficient level of health and the other core elements of well-being of some persons and groups. Judgments about entitlements to health related resources, including new biotechnologies, are made in light of a threshold notion of health sufficiency. What is enough or sufficient health? The answer that is defended here is that sufficient health is enough health for a decent human life, understood as enough health to live a full life course without preventable, significant functional disability or decrement in health, or treatable pain or suffering. When a state must include a new biotechnology in its national healthcare system is also influenced by ancillary concerns about the connection between health and other core dimensions of well-being. What counts as a significant functional impairment or health decrement is thus explicated, in part, in relation to the theory’s sufficiency aim for the other essential dimensions of well-being, and thus for a decent life, overall. Those elements of health that play a critical role in the experience of sufficient reasoning, affiliation, security, respect and self determination are especially important; any loss of health function or capacity that threatens the individual’s prospects for sufficiency in these other dimensions, including the relational egalitiarian concerns they entail, constitutes a significant functional impairment. Within national borders, individuals are thus entitled to those health-related goods and services that are essential for a sufficiency of each of the dimensions of well-being; with regard to self determination and respect, what is sufficient by way of guaranteed access to specific goods and services is going to depend on the implications of such access for where an individual stands in relation to her co-nationals. The content of any entitlement to health-related goods and services is also necessarily dynamic. What can be done for health and the other core dimensions of well-being as a function of technological innovation and diffusion is in constant flux. The paper concludes by considering the implications of this analysis for the conditions under which states are obligated to include access in their healthcare systems to one biotechnology, deep brain stimulation. (shrink)

The context of international health research involving human subjects, and this should appear obvious, is the human community. As such, basic questions of how human beings should be treated by other human beings, particularly in situations of unequal power – e.g., in the form of control, choice, or opportunity – lay at the foundations of related ethical discourse when ethics are discussed at all. I trace a narrative that follows upon a recent revision process of international guidelines for biomedical (...) research involving human subjects. I focus in particular upon the issue of a standard of care. In the second section, I draw upon philosophers John Rawls, Claudia Card, and Allen Buchanan to discuss concerns regarding the 'least advantaged members of society' in the context of global inequality. The paper includes reflections upon pedagogy in courses focused upon international health research involving human subjects. (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)

The increased complexity of health information management sows the seeds of inequalities between health care stakeholders involved in the production and use of health information. Patients may thus be more vulnerable to use of their data without their consent and breaches in confidentiality. Health care providers can also be the victims of a health information system that they do not fully master. Yet, despite its possible drawbacks, the management of health information is indispensable for (...) advancing science, medical care and public health. Therefore, the central question addressed by this paper is how to manage health information ethically? This article argues that Paul Ricœur’s ‘‘little ethics’’, based on his work on hermeneutics and narrative identity, provides a suitable ethical framework to this end. This ethical theory has the merit of helping to harmonise self-esteem and solicitude amongst patients and healthcare providers, and at the same time provides an ethics of justice in public health. A matrix, derived from Ricœur’s ethics, has been developed as a solution to overcoming possible conflicts between privacy interests and the common good in the management of health information. (shrink)

That there is a positive correlation between healthy populations and socio-economic and human development is not in dispute. It is in countries’ interests, therefore, to aim to have healthy, productive citizens. A strong, well-functioning public health care system would go some way to realising this. In sub-Saharan Africa, the issue of how to finance health care and make it accessible to the majority of citizens is an ongoing challenge. While the overall intention behind The Structural Adjustment Programmes (SAPs) (...) of the 1980s and 1990s was to assist development, the inadvertent result in many African countries that subscribed to SAPs was, in fact, the deepening of poverty and inequality. (shrink)

This paper aims to recover the history of health concept evolution from its birth in Ancient Greece to the contemporary days, drawing an overview of the firsts philosophical thoughts about health in distinctive historical periods, analyzing how this concept has been impacted by knowledge improvement and both research and technological discoveries over time. In order to understand the persistence of Neglected Tropical Diseases which causes physical disabilities and social discrimination, this paper will focus on Leprosy and Cutaneous Leishmaniasis (...) and its relation to social inequality mainly in developing countries. These approaches on the understanding of the health-disease binomial are necessary to reflect on health in the course of human history and, from there, to promote joint actions both in the area of scientific research and health education. (shrink)

Community resilience, a system’s ability to maintain its essential functions despite disturbance, is a cornerstone of public health preparedness. However, as currently practiced, community resilience generally focuses on defined neighborhood characteristics to describe factors such as vulnerability or social capital. This ignores the way that residents of some neighborhoods (as ‘essential workers’’) were required during the COVID-19 pandemic to sacrifice their wellbeing for the sake of others staying at home in more affluent neighborhoods. Using the global care chain theory, (...) we analyze the way that the resilience of affluent neighborhoods depends on siphoning off the labor of other, less affluent neighborhoods, creating what we call the parasitic nature of resilience. We argue that understanding this neighborhood interdependence—and accounting for its parasitic nature— should be prioritized by public health authorities to prevent unintentional harm in future pandemics. Otherwise, any public health emergency response that relies on this labor (as did the COVID-19 pandemic response) depends on exploitative practices that produce the very disparities the response is trying to address. We explore the theoretical grounding and practical effects of this idea to provide the preparedness enterprise with an initial set of theoretical tools to move from a model of community resilience to one of community renewal. The community renewal model is based on an underlying ethics of care, in which systems are redesigned to become more prosocial during a public health response. We believe this model can more successfully address the tragic inequities in labor and health outcomes that we see during public health emergencies. (shrink)

In this article, we suggest that the evidence regarding the social determinants of health calls for a deep re‐thinking of our understanding of distributive justice. Focusing on John Rawls's theory of distributive justice in particular, we argue that a full reckoning with the social determinants of health requires a re‐working of Rawls's principles of justice. We argue first that the social bases of health – a Rawlsian conception of the social determinants of health – should be (...) considered a social primary good. We argue second that including the social bases of health as a social primary good would lead the parties to the original position to choose an additional principle of justice and assign it lexical priority over Rawls's second principle. According to this principle, inequalities in people's share of the social bases of health are to be arranged so as to improve the health status of those least advantaged on the social health gradient. -/- . (shrink)

Universal health coverage (UHC) is at the center of current efforts to strengthen health systems and improve the level and distribution of health and health services. This document is the final report of the WHO Consultative Group on Equity and Universal Health Coverage. The report addresses the key issues of fairness and equity that arise on the path to UHC. As such, the report is relevant for every actor that affects that path and governments in (...) particular, as they are in charge of overseeing and guiding the progress toward UHC. (shrink)

The endurance of depression, anxiety and suicidal ideation among gay and bisexual men persists despite advances in civil rights and wider social acceptance. While minority stress theory provides a framework for much scholarly debate as to the causes of mental distress among non-heterosexual men, there is a growing interest into the detrimental effects that competitiveness within the gay community itself can have. Past studies have celebrated involvement in gay culture as being associated with better mental health outcomes by tempering (...) the impact of hegemonic heteronormativity. Yet between non-heterosexual men and the general population, there are stark mental health inequalities that require investigation. As a means of proving manhood, men in general are predisposed toward competitiveness and risk, but within a subculture where the attention is exclusively on male sex, the focus is primarily status conscious. This article draws on minority stress theory to consider societal discrimination. It also applies inter-minority gay community stress theory to explore pressures emanating from gay spaces with fixations on masculinity, income and rivalry as major sources of mental health problems in gay and bisexual men. The causes for health disparities illustrated in this article, demonstrate a critical need for public health and social care organizations to respond with innovatory services, based on a firm understanding of stressors arising from interactions between men in gay spaces. (shrink)

The endurance of depression, anxiety and suicidal ideation among gay and bisexual men persists despite advances in civil rights and wider social acceptance. While minority stress theory provides a framework for much scholarly debate as to the causes of mental distress among non-heterosexual men, there is a growing interest into the detrimental effects that competitiveness within the gay community itself can have. Past studies have celebrated involvement in gay culture as being associated with better mental health outcomes by tempering (...) the impact of hegemonic heteronormativity. Yet between non-heterosexual men and the general population, there are stark mental health inequalities that require investigation. As a means of proving manhood, men in general are predisposed toward competitiveness and risk, but within a subculture where the attention is exclusively on male sex, the focus is primarily status conscious. This article draws on minority stress theory to consider societal discrimination. It also applies inter-minority gay community stress theory to explore pressures emanating from gay spaces with fixations on masculinity, income and rivalry as major sources of mental health problems in gay and bisexual men. The causes for health disparities illustrated in this article, demonstrate a critical need for public health and social care organizations to respond with innovatory services, based on a firm understanding of stressors arising from interactions between men in gay spaces. -/- . (shrink)

Type 1 diabetes (T1D) is a chronic illness that requires intensive lifelong management of blood glucose concentrations by means of external insulin administration. There have been substantial developments in the ways of measuring glucose levels, which is crucial to T1D self-management. Recently, continuous glucose monitoring (CGM) has allowed people with T1D to keep track of their blood glucose levels in near real-time. These devices have alarms that warn users about potentially dangerous blood glucose trends, which can often be shared with (...) ther people. CGM is consistently associated with improved glycemic control and reduced hypoglycemia and is currently recommended by doctors. However, due to the costs of CGM, only those who qualify for hospital provision or those who can personally afford it are able to use it, which excludes many people. In this paper, I argue that unequal access to CGM results in: (1) unjust health inequalities, (2) relational injustice, (3) injustice with regard to agency and autonomy, and (4) epistemic injustice. These considerations provide prima facie moral reasons why all people with T1D should have access to CGM technology. I discuss the specific case of CGM policy in the Netherlands, which currently only provides coverage for a small group of people with T1D, and argue that, especially with additional considerations of cost-effectiveness, the Dutch government ought to include CGM in basic health care insurance for all people with T1D. (shrink)

The application of machine-learning technologies to medical practice promises to enhance the capabilities of healthcare professionals in the assessment, diagnosis, and treatment, of medical conditions. However, there is growing concern that algorithmic bias may perpetuate or exacerbate existing health inequalities. Hence, it matters that we make precise the different respects in which algorithmic bias can arise in medicine, and also make clear the normative relevance of these different kinds of algorithmic bias for broader questions about justice and fairness in (...) healthcare. In this paper, we provide the building blocks for an account of algorithmic bias and its normative relevance in medicine. (shrink)

Recent epidemiological reports of associations between socioeconomic status and epigenetic markers that predict vulnerability to diseases are bringing to light substantial biological effects of social inequalities. Here, we start the discussion of the moral consequences of these findings. We firstly highlight their explanatory importance in the context of the research program on the Developmental Origins of Health and Disease (DOHaD) and the social determinants of health. In the second section, we review some theories of the moral status of (...) health inequalities. Rather than a complete outline of the debate, we single out those theories that rest on the principle of equality of opportunity and analyze the consequences of DOHaD and epigenetics for these particular conceptions of justice. We argue that DOHaD and epigenetics reshape the conceptual distinction between natural and acquired traits on which these theories rely and might provide important policy tools to tackle unjust distributions of health. (shrink)

The phenomenon of medical overtesting in general, and specifically in the emergency room, is well-known and regarded as harmful to both the patient and the healthcare system. Although the implications of this problem raise myriad ethical concerns, this paper explores the extent to which overtesting might mitigate race-based health inequalities. Given that medical malpractice and error greatly increase when the patients belong to a racial minority, it is no surprise that the mortality rate similarly increases in proportion to white (...) patients. For these populations, an environment that emphasizes medical overtesting may well be the desirable medical environment until care evens out among races and ethnicities; additionally, efforts to lower overtesting in conjunction with a high rate of racist medical mythology may cause harm by lower testing when it is actually warranted. Furthermore, medical overtesting may help to assuage racial distrust. This paper ultimately concludes that an environment of medical overtesting may be less pernicious than the alternative. (shrink)

Reprinted with modification and permission from Kennedy Institute of Ethics Journal. The phenomenon of medical overtesting in general, and specifically in the emergency room, is well-known and regarded as harmful to both the patient and the healthcare system. Although the implications of this problem raise myriad ethical concerns, this chapter explores the extent to which overtesting might mitigate race-based health inequalities. Given that medical malpractice and error greatly increase when the patients belong to a racial minority, it is no (...) surprise that the mortality rate similarly increases in proportion to white patients. For these populations, an environment that emphasizes medical overtesting may well be the desirable medical environment until care evens out among races and ethnicities; additionally, efforts to lower overtesting in conjunction with a high rate of racist medical mythology may cause harm by lower testing when it is actually warranted. Furthermore, medical overtesting may help to assuage racial distrust. This paper ultimately concludes that an environment of medical overtesting may be less pernicious than the alternative. (shrink)

We discuss the role of prior authorization (PA) in supporting patient-centered care (PCC) by directing health system resources and thus the ability to better meet the needs of individual patients. We begin with an account of PCC as a standard that should be aimed for in patient care. In order to achieve widespread PCC, appropriate resource management is essential in a healthcare system. This brings us to PA, and we present an idealized view of PA in order to argue (...) how at its best, it can contribute to the provision of PCC. PA is a means of cost saving and as such it has mixed success. The example of the US demonstrates how implementation of PA has increased health inequalities whereas best practice has the potential to reduce them. In contrast, systems of universal coverage, like those in Europe, may use the cost savings of PA to better address individuals' care and PCC. The conclusion we offer therefore is an optimistic one, pointing towards areas of supportive overlap between PCC and PA where usually the incongruities are most evident. (shrink)

The scarcity of livers available for transplants forces tough choices upon us. Lives for those not receiving a transplant are likely to be short. One large group of potential recipients needs a new liver because of alcohol consumption, while others suffer for reasons unrelated to their own behaviour. Should the former group receive lower priority when scarce livers are allocated? This discussion connects with one of the most pertinent issues in contemporary political philosophy; the role of personal responsibility in distributive (...) justice. One prominent theory of distributive justice, luck egalitarianism, assesses distributions as just if, and only if, people's relative positions reflect their exercises of responsibility. There is a principled luck egalitarian case for giving lower priority to those who are responsible for their need. Compared to the existing literature favouring such differentiation, luck egalitarianism provides a clearer rationale of fairness, acknowledges the need for individual assessments of responsibility, and requires initiatives both inside and outside of the allocation systems aimed at mitigating the influence from social circumstances. Furthermore, the concrete policies that luck egalitarians can recommend are neither too harsh on those who make imprudent choices nor excessively intrusive towards those whose exercises of responsibility are assessed. (shrink)

Winds of change, from the political perspective in Mexico, invite us to reformulate the methodological vision for the direction of public policy in the field of social development, directing their actions towards the construction of a methodological proposal that allows us to direct ourselves towards achieving higher levels of Well-being Social in our country, as a desirable objective of public policy and which is expected to be inclusive, participatory and democratic. -/- In this sense, it is important to recognize that (...) the current debate, in the academic and political sphere, questions what is being well? What is the life that is worth living? And that, additionally, the recognition of the satisfaction of life goals, at an individual and collective level, which invites us to reflect, if the current economic and social policy and strategy has produced results in what we envision as social welfare? Is a new approach necessary to solve the problem? What strategy should it be to consider the new methodological approach that seeks social welfare? And what components should be considered in the measurement of social welfare? This document is an invitation to review the concept of social welfare, as a proposal whose purpose is to correct the deficiencies or historical deficiencies suffered by the population, in the elemental enjoyment of social rights, a situation that causes social backwardness, marginalization, and that it is aimed at the impossibility of participating in the social decisions of the community and in collective decisions, such as: speaking, proposing, being heard and demanding compliance with fundamental human rights such as: health, food, housing, employment and security, among others. These deficiencies in the enjoyment of social and human rights are seen in the presence of social exclusion, and that together these social deficiencies explain the degree of multidimensional poverty suffered by the population in rural and urban areas. It is here that he invites us to reflect: what is the problem that social welfare seeks to solve? Multidimensional poverty, social exclusion, social backwardness or social inequality? And consequently, how to define the components to identify social welfare? -/- The document is made up of three sections: i) Social welfare: A retrospective look; ii) Social Welfare, an integrative view: The contribution of Sen, Naussbam, Rawls, Actis Di Pasquale and Keyes; and iii) Social Welfare: The recognition of limits in economic development -/- The first section presents a review of the proposals, which in the area of economic development have been presented since 1968 in the Human Condition Project, until the 2015 proposal of Sustainable Development Goals. -/- In the second section, the contributions of (Rawls, 1995), (Sen, 1982), (Nussbaum, 2011), (Keyes, 1998) , (Actis Di Pasquale, 2015) and (Actis Di Pasquale, 2017) are presented in order to present an integrative approach to the concept of social welfare. And finally, the third section presents the recognition of limits in development, as well as an invitation for action from a transdisciplinary and interdisciplinary perspective in the study of social welfare. -/- August 2020 DOI: 10.13140/RG.2.2.24147.20006/1 LicenseCC BY-SA 4.0 -/- . (shrink)

Many of the social deprivations of Mexico will be worsened due to the SARSCOV2 pandemic. Namely, the insufficient access to public health, lack of labor rights, and the unsuccessful government’s response to eradicate male violence against women. The historical unconcern in promoting a culture rooted in mutual aid and self-care has provoked many citizens are disconnected from their social and health rights. Thus, people’s inability to carry through one direction –stay home- is unfulfilled, in part, due to structural (...) inequalities. I affirm that effective liberty could be obtained by approving a Universal Basic Income from a feminist perspective. I conclude that the aftermath of COVID-19, which will define everyday life for a while, require the endorsement of such measure. Likewise, women as a class deserve protection from a feminist critical framework. (shrink)

Our Viewpoint argues that expanding access to less effective or more toxic treatments is supported not only by utilitarian ethical reasoning but also by two other ethical frameworks: those that emphasise equality and those that emphasise giving priority to the patients who are worst off. The inadequate resources available for global health reflect not only natural constraints but also unwise social and political choices. However, pitting efforts to reduce inequality and better fund global health against efforts to (...) put available resources to their best use mistakes complementary objectives for conflicting ones. (shrink)

This 4000 word entry to Routledge’s Handbook of Development Ethics (Jay Drydyk & Lori Keleher, eds., 2018) considers development within United States of America and Canada. Indigenous peoples and their nations are also featured. Canada and USA are both characterized by the UN Development Program as maintaining very high human development. Addressable weaknesses are nevertheless evident when performance is compared, for example, with OECD member nations. This entry focuses upon such comparison, noting characteristic political institutions and attendant social inequality (...) in the areas of social welfare, education and health. The histories of both nations over the past half-century suggest that cultural shifts within USA have displaced the ethos of social responsibility that the country had previously shared with Canada, replacing it with an ideal of self-reliance. The turn may be a factor in the USA’s increasing inequality and general weakness in social welfare programs since the 1980s. Events since 2016 especially also display a turn towards another ideal of self-reliance: isolationism. USA’s reduction in global commitments – to open trade, to limits on environmental impact, and especially, to immigration – contrast greatly with Canada’s evolving commitment to a global society and to a cultural ideal of multiple non-assimilated cultures within its borders, including cultures of new immigrant populations. Canada is by many measures a more equal society, but it shares with USA continued failings in development for aboriginal groups and vulnerability for that group and others. (shrink)

This paper considers the obligation higher income countries have to lower and middle income countries during a global pandemic. Further considers which reforms are needed to the global supply-chain of medical resources. The short-comings in distribution and medical infrastructure have exacerbated the health crisis in developing countries. Global justice demands radical redistribution of medical resources in order to prevent mass casualties. This is argued first by highlighting that the COVID-19 pandemic should be acknowledged as an issue of global justice, (...) secondly, higher income countries ought to account for distribution inequity as a matter of rectifying past injustices, and thirdly argue for reform in distribution while considering the vaccine rollout as a prime example. We aim to show how the differences from country to country in response capabilities are a result of the economic foundation colonialism established and a direct result of cyclical poverty, which wealthy countries perpetuate to this day. (shrink)

The technological revolution and appropriation of internet tools began to reshape the material basis of society and the urban space in collaborative, grassroots, leaderless, and participatory actions. The protest squares’ representation on Television screens and mainstream media has been broad. Various health, governmental, societal, and urban challenges have marked the advent of the Covid-19 virus. Inequalities have become more salient as poor people and minorities are more affected by the virus. Social distancing makes the typical forms of protest impossible (...) to carry out. Under social distancing, some state-led policies took advantage of social media to focus on the Covid-19 pandemic to silence social and political activities, censor criticism, and control the press. However, during the pandemic era, the movements for social justice have been particularly active, focusing on defending workers’ rights, mutual aid and solidarity, monitoring policymakers, and popular education. These progressive movements combined concrete practices and experiences to confront the reactionary, capitalist, and governmental actors that sought to shape and envision the world. Through different case studies of protest movements during the pandemic in Europe, the UK, and Asia, this paper argues that at the time of rising racial, social, and economic inequalities, the social activities adapted to the circumstances determined by the social distancing and the impossibility of people gathering in physical spaces. Subsequently, the people in different countries had various individual and collective responses to the support of health workers, systemic inequalities, loss of jobs, and other societal and financial challenges imposed by the governments. It means that, rather than disappearing, the social movements have adapted to the unexpected situations during the pandemic outbreak. The pandemic broke the new digital global wave of protests in this sense. (shrink)

This essay frames systemic patterns of mental abuse against women of color and Indigenous women on Turtle Island (North America) in terms of larger design-of-distribution strategies in settler colonial societies, as these societies use various forms of social power to distribute, reproduce, and automate social inequalities (including public health precarities and mortality disadvantages) that skew socio-economic gain continuously toward white settler populations and their descendants. It departs from traditional studies in gender-based violence research that frame mental abuses such as (...) gaslighting--commonly understood as mental manipulation through lying or deceit--stochastically, as chance-driven interpersonal phenomena. Building on structural analyses of knowledge in political epistemology (Dotson 2012, Berenstain 2016), political theory (Davis and Ernst 2017), and Indigenous social theory (Tuck and Yang 2012), I develop the notion of cultural gaslighting to refer to the social and historical infrastructural support mechanisms that disproportionately produce abusive mental ambients in settler colonial cultures in order to further the ends of cultural genocide and dispossession. I conclude by proposing a social epidemiological account of gaslighting that a) highlights the public health harms of abusive ambients for minority populations, b) illuminates the hidden rules of social structure in settler colonial societies, and c) amplifies the corresponding need for structural reparations. (shrink)

MY CHAPTER CONTRIBUTION: "Paul Tillich's Enduring Relevance to Ecophilosophy and Environmental Ethics" *** -/- BOOK DESCRIPTION: Paul Tillich's ideas and methods continue to inspire and guide students, teachers, and professionals in all fields. He crosses boundaries between the academy and the community, religions and spiritualities, cultures and societies, taking leaders deeper and further than they ever imagined. Tillich is a master of conversation. His thought bridges social polarizations, program silos, and educational specialization. His ideas cannot be contained in a closed (...) system. His methodology has the power to engage other philosophies of life, religions and spiritualities, scientific research, culture shifts, and lifestyle diversity critically and appreciatively. Tillich is also a master of confrontation. His thought challenges political structures, racial and gender inequalities, and social injustice. He is an acute observer of social change and struggles courageously with moral quandaries. He inspires action for today and hope for tomorrow. Each essay explores another facet of Tillich's influence in education, religion, popular culture, science, health, social reform, and political action. They are chosen to be "snapshots" of his ongoing influence, accessible to both undergraduate and graduate students, and relevant to corporate and non-profit leaders alike. Reading this book will open your eyes to discern Tillich's hidden presence in academic curricula, contemporary research, political speeches and social policies, entertainment and internet, books and podcasts, and social media. Tillich can be your intellectual companion in whatever endeavor you choose to pursue. -/- . (shrink)

Hassoun argues that the poor in the world have a right to health and that the Global Health Impact Index provides consumers in well-off countries with the opportunity to ensure that more people have access to essential medicines. Because of this, these consumers would be ethically obliged to purchase Global Health Impact Index-labeled products in the face of existing global inequalities. In presenting her argument, Hassoun rejects the so-called democratic account of ethical consumption in favor of the (...) positive change account. Two versions of the democratic change account are relevant. One underscores the importance of democratic procedures and institutions, while the other stresses our fundamental moral equality. While at least one prominent institutionalist account has problems, revised versions would be less vulnerable to Hassoun’s counterexamples. Furthermore, institutionalist accounts come with the epistemological gains from democratic procedures and deliberations, which may be especially important under uncertainty. Finally, and perhaps more challenging for the Global Health Impact index project, this measure may place the burden unfairly on those who need to buy medicines. This is a pivotal insight from the non-institutionalist version of the democratic account of ethical consumption. (shrink)

Drugs used to provide improvement of cognitive functioning have been shown to be effective in healthy individuals. It is sometimes assumed that the use of these drugs constitutes cheating in an academic context. We examine whether this assumption is ethically sound. Beyond providing the most up-to-date discussion of modafinil use in an academic context, this contribution includes an overview of the safety of modafinil use in greater depth than previous studies addressing the issue of cheating. Secondly, we emphasize two crucial, (...) but hitherto nearly overlooked, nuances to the issues: the potential for modafinil to decrease inequality and disadvantage in academic settings, and the fact that how modafinil is used dramatically impacts its effects on health, coercion, fairness, authenticity and effort. Finally, we explicitly defend the position that there are no qualitatively morally relevant differences between modafinil use and other enhancement modalities; any such differences are in degree,... (shrink)

In various responses to the COVID-19 pandemic, we can observe insufficient sensitivity towards the needs and circumstances of poorer citizens. Particularly in a context of high inequality, policy makers need to engage with the wider public in debates and consultations to gain better insights in the realities of the worst-off within their jurisdiction. When consultations involve members of traditionally underrepresented groups, these are not only more inclusive, which is in itself an ethical aim, but pool ideas and observations from (...) a much more diverse array of inhabitants. Inclusivity increases the odds to identify a larger range of weak spots for health security and to design health interventions that are less burdensome on those worst-off. (shrink)

Some proponents of global justice question that opening borders is an effective strategy to alleviate global poverty and reduce inequalities between countries. This article goes a step further and asks whether an open borders policy is compatible with the objectives of global distributive justice. The latter, it will be argued, entails the ordering of needs, the assignment of priorities and the preference or subordination of some interests over others. In other words, global justice requires the establishment of conditions and restrictions (...) on mobility. On the contrary, open borders claim an unrestricted and unconditional (not unqualified) freedom of movement, limited only by public health considerations, serious threats to national security or democratic institutions, but not by an aspiration for maximizing global redistributive utility. The main point is that not only would freedom of movement be instrumentalized, losing its presumptive moral force, but ultimately open borders as a remedy of global justice are an oxymoron. The article concludes with an alternative defence of freedom of international movement. (shrink)

Exercise-based rehabilitation forms a key part of the UK National Health Service patient-care pathway for cardiac rehabilitation (CR). Only around half of all eligible patients attend core CR, however, with social inequalities affecting participation. Few qualitative studies have explored in-depth the key factors influencing engagement with CR, specifically from a sociological theoretical, and ethnographic perspective. Utilising an ethnographic approach allowed us to get a sense of the embodied experiences of 10 participants attending or declining core CR, together with a (...) further seven family members/significant others. This provided in-depth appreciation of participants’ lifeworld contexts as key influences on CR participation. The article draws on these qualitative data and focuses on 1) participants’ initial thoughts about CR; and 2) navigating the field of CR, analysed via thematic analysis. We utilise a Bourdieusian theoretical perspective to theorise the findings, including salient socio-cultural factors influencing attendance/non-attendance and (non)adherence. The article findings highlight how perceptions of CR and the ability to navigate the field are strongly influenced by habitus and capital, and how personal biographies and socio-material conditions affect adherence to CR programmes. The study provides original insights into embodied experiences of exercise-based CR, and novel understandings of the reasons for drop-out/poor adherence, theorised from a Bourdieusian perspective. (shrink)