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Explain how health disparities, social determinants of health and social justice theories contrast to more traditional clinical/Western models of health/disease (individual patient comes to doctor with set of symptoms and doctor gives diagnosis). Your discussion brief should be 1 page maximum in length, double-spaced, 12 point font

Required Ted Talks:

Mary Bassett: Why your doctor should care about social justice

https://www.ted.com/talks/mary_bassett_why_your_doctor_should_care_about_social_justice?language=en

 

(Links to an external site.)

 

Paula Johnson: His and Hers Healthcare

https://www.ted.com/talks/paula_johnson_his_and_hers_healthcare (Links to an external site.)

 

PJ Parmar: How doctors can help low-income patients (and still make a profit)

Health and social justice

Jennifer Prah Ruger, PhD
Department of Epidemiology and Public Health, School of Medicine, Yale University, New Haven,
CT 06520, USA

4 years into the new millennium, the health of the world’s citizens is remarkably uneven. A
child born today in Japan, for example, can expect to live to age 82 years on average,
whereas it is unlikely that a newborn infant in Zimbabwe will reach his or her 34th
birthday.1 Over several decades, scientific progress has expanded our ability to improve
human health, and many regions of the world have achieved significant health gains. Yet
extreme deprivation in health is still widespread. Resolving this predicament of major health
improvement in the midst of deprivation is one of the greatest global challenges of the new
millennium.

These health disparities exist in a world that is becoming more closely linked in all domains,
including health. The rapid spread and quick containment of severe acute respiratory
syndrome (SARS) demonstrates the interconnectedness of our world as well as any recent
health phenomenon. The same trend can be seen with HIV/AIDS and the potential to link
solutions and best practices studied in one part of the globe with persistent health problems
in another.

In the midst of such rapid global change and persistent health disparities, we need to revisit
and underscore the moral and philosophical foundations for health improvement activities—
to give them more forceful grounding and solidity. In this essay, I briefly survey some
traditional philosophies of justice and health care. I then offer an alternative view of justice
and health that is rooted in Amartya Sen’s capability approach and Aristotle’s political
theory, and discuss the implications of this approach for health improvement across the
globe.

Philosophical foundations
Theories of social justice (eg, fair and equitable treatment of people) have typically focused
on justifying health care (medicine and public health) as a special social good. Rationalising
greater equality in health care is typically the point of departure for most approaches to
medical ethics (bioethics), even for approaches that include health assessment. In general,
less attention has been paid to universal concerns of social justice with respect to health
itself. This essay focuses on the question of why health, as opposed to health care, has
special moral importance for social justice in health improvement activities. I also analyse
the implications of equity in health and health care.

Correspondence to: Dr Jennifer Prah Ruger, jennifer.ruger@yale.edu.

NIH Public Access
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Published in final edited form as:
Lancet. 2004 September 18; 364(9439): 1075–1080. doi:10.1016/S0140-6736(04)17064-5.

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Philosophical theories have been reluctant to give health (by contrast with health care)
special moral importance for at least one primary reason: they share the assumption that
health is not an appropriate focal variable for assessing social justice. Egalitarian theories,
for example, “propose that persons be provided an equal distribution of certain goods such
as health care, but all prominent egalitarian theories of justice are cautiously formulated to
avoid making equal sharing of all possible social benefits a requirement of justice”.2

Utilitarian theories, although consequentialist (eg, assessing states of affairs or actions in
terms of their consequences), focus on the space of “utilities” (satisfaction, desire fulfilment,
preference),3 whereas communitarian approaches focus on community values,4 rather than
on health itself. Liberal theories of justice are disinclined to focus on health because, as John
Rawls purports in his book, A theory of justice, natural goods like health are not included as
social values or social primary goods (eg, “liberty and opportunity, income and wealth and
the bases of self-respect”) that are “things that every rational man is presumed to want.”5 He
adds that “health and vigor, intelligence and imagination, are natural goods; although their
possession is influenced by the basic structure, they are not so directly under its control.”5

Thus, according to Rawls, health is not one of the social primary goods that should be
“distributed equally unless an unequal distribution of any, or all, of these values is to
everyone’s advantage.”5 Although he discusses basic health care later in his book, Law of
Peoples, Rawls does not include health in the list of social primary goods subject to
distributive principles.

Norman Daniels argues that, “health is an inappropriate object, but health care, action which
promotes health, is appropriate.” 6 He and others emphasise that “… a right claim to equal
health is best construed as a demand for equality of access or entitlement to health services
… ”,6 and note that a “‘right to health’ embodies a confusion about the kind of thing which
can be the object of a right claim”.6 Such reasoning illustrates the strong bias against health
as a focal variable in current ethical theory.

A capability view of health
A contrasting argument is that health has special moral importance because of its status as
an end of political and societal activity. According to Aristotle, society’s obligation to
maintain and improve health rests on the ethical principle of “human flourishing”7–11—the
ability to live a flourishing, and thus healthy, life.7–11 Flourishing and health are inherent to
the human condition.7–11 Indeed, certain aspects of health sustain all other aspects of human
flourishing because, without being alive, no other human functionings are possible,
including agency, the ability to lead a life one has reason to value.12–14 It can be argued,
therefore, that public policy should focus on the ability to function, and that health policy
should aim to maintain and improve this ability by meeting health needs.15,16 This view
values health intrinsically and more directly than solely “instrumental” social goods, such as
income or health care. It gives special moral importance to health capability: an individual’s
opportunity to achieve good health and thus to be free from escapable morbidity and
preventable mortality.15,16

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This line of reasoning—focusing on human capability—contrasts with the idea that health
care is special because of its impact on equality of opportunity.6 It also differs from the
utilitarian view that health care is important for maximising the sum total of utilities and
from procedural views that focus on guaranteed due process. The distinction between these
approaches is rooted in the different points of focus that these theories support. Capability
describes what individuals are able to do and be, offering a realistic sense of their freedom to
pursue the lives they have reason to value. Thus, society is morally obligated to attach
importance to averting or ameliorating loss in physical functioning even if a person’s
subjective utility assessment is quite high and even if opportunity of employment is still
possible. In short, a person’s ability to function, rather than to be happy or to have
employment opportunities, should be the gauge for assessing public policy.

A capability view of health also includes human agency (ie, people’s ability to live a life
they value).17,18 Although health directly affects the ability to exercise agency, agency
influences health as well. For example, the ability to lead the life one values can improve
one’s mental health or well-being. Conversely, the ability to make unhealthy choices can
degrade one’s health status. Enabling individuals to exercise their agency—both individually
and collectively—enables them to prioritise and decide which health domains they value
most (eg, to trade-off quality and quantity of life) and to choose what health services they
would like to consume (eg, making choices among treatment options).

The exercise of human agency can occur at both the individual and collective levels.
Individual agency is important in decisions about health habits and risks, lifestyle, individual
priorities, and decisions about treatment options. Collective agency is more important at the
policy level, where open discussion and collective decision-making influence policy and
resource allocation. This relates to the “process” aspect of freedom in the capability
approach.14

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Policy implications
There are several sets of policy implications related to a capability view of health. First, the
distinction between a capability approach to health and other well-known ethical approaches
has implications for assessing social inequalities and for evaluating the effects of social
policy on broader health determinants. Health care is not the only health determinant, as
Michael Marmot and his colleagues’ work has shown,19 and one must not assume that more
and better health care is all that is needed to improve health. The main impact of health care
may depend on the type of care and sometimes on other factors. This places both health and
health policy in a larger policy context and requires a greater understanding of social
justice.15,16 Thus, health and its determinants must be valued against other social ends in a
broader public exercise of policy priorities. This exercise should be inclusive and democratic
and should represent a process of public reasoning about the ends and means of public
policy more broadly and about health policy specifically.

Second, although health care is only one of many health determinants, its influence on
health should not be denied. Thus, health care is important and therefore, special, due to its
role in influencing health and it must be socially guaranteed. It must be socially guaranteed
in a manner that is consistent with improving health overall and reducing health inequalities
that are attributable to health care—not in terms of equality in health care delivery (equal
amounts or types), irrespective of health consequences.

Third, a capability view of health does not specify which type of health care (eg, a list or
basic benefits package) should be guaranteed and to what level. Rather, it recognises the
need for further specification through a democratic process that combines both procedural
and substantive principles. Substantively, Sen’s notion of “basic capabilities” provides
guidance since this formulation generally implies that societal efforts be made to bring each
individual’s health functioning as close as possible to (or above) a certain level of minimal
normal functioning (in so far as an individual’s circumstances permit). “Basic capabilities”
include the ability to avoid escapable morbidity and premature and preventable mortality.
Premature mortality implies placing special emphasis on efforts to avert deaths from
preventable causes that do not allow individuals to live a life of normal length (eg, a child
dying of AIDS). On the question of how much priority should be given to society’s worst-off
individuals, this view promotes the use of “public reasoning” to forge a compromise
between strict maximisation and prioritisation.

Fourth, this “process aspect” of freedom in the capability approach has implications for how
health-related policy is made. It emphasises an individual’s ability to participate in broad
public-policy decision-making (eg, in prioritising between environmental and health care
programmes) and in health policy decision-making (eg, in prioritising domains of health and
health care for resource allocation). A democratic process can help define a comprehensive
package of health benefits to which all should have equal access, and it can help prioritise
different types of health care in efforts to maintain and improve health with the fewest
possible resources. Such a process is not merely instrumental, however, since its justification
lies in the concept that individuals should have the capability to participate in decision-

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making that affects them, such as about the goods and services that society will guarantee to
them.

Fifth, the equity implications of access to those goods and services cannot be separated from
the equity implications of financing them, because the capability principle requires that
resources be allocated on the basis of medical need, not ability to pay. The costs of health-
related goods and services directly affect health by reducing the demand for necessary health
care or by increasing consumption of unnecessary care. Leaving people vulnerable to
economic barriers therefore would fail to reduce deprivations in health. Additionally, the
uncertainty of health need, the catastrophic costs of medical care, and the risk-averse nature
of individuals places risk pooling (eg, through insurance) at the centre of health-care
financing.20 An expensive medical event can prevent access to health care or be a primary
cause of financial ruin. From a capability point of view, “protective security”,14 through
health insurance, is a necessary safety net. And the economic burden of health care should
be justly shared by all through the redistribution of funds from the well to the ill and the rich
to the poor, using progressive financing and community rating.21

Sixth, one of the most difficult tasks in applying an ethical framework that values health
intrinsically is the conceptualisation and measurement of health and inequalities in its many
domains. There are many approaches to measuring health equity. As Sudhir Anand and
colleagues have shown,22 the choice depends on numerous considerations, ranging from
health domains to the weights attached to those domains.22 Another consideration is the
choice of groups for stratification.22 Even within the capability perspective, one would need
to determine what set of inequality measures would be most appropriate for a given exercise,
although certain types of inequality assessment—for example, a goal of complete “health
equality” (levelling down to lowest common denominator)—have less appeal than others.
And certain health equity evaluations—for example, deciding how much priority to give the
“worst-off”—will undoubtedly require public reasoning about values imbedded in the health
equity concept. Although the capability view of health does not come down on an exact
formula for judging inequalities in health, Sen has noted the potential use of “partial
ordering” (eg, ordering some alternatives as opposed to ordering them all) of health states
for assessing relative inequalities. In a collective exercise, incomplete theorisation may
facilitate evaluation in health policy.15,16,23

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Incompletely theorised agreements
Incomplete theorisation is useful to a theory of health and social justice because it provides a
framework for understanding collective decision-making on human goods that are plural and
indistinct (such as health and inequality), and allows individuals to take divergent paths to a
common, though often partial, agreement. It describes how people with divergent, even
opposing, views on health, equity, and health-policy issues might reach agreement in
specific situations and thus generate health-policy decisions that are legitimate and stable
and reflect mutual respect.15,16,23 The method of reaching agreement described here is
called incompletely theorised agreements, developed by Cass Sunstein,24 and it holds
promise for health-policy decision-making at several levels.15,16,23

An incompletely theorised agreement is one that is not uniformly theorised at all levels,
from high-level justifications to low-level particulars. It complements and extends the
capability approach by providing a framework for operationalising the capability approach
at three or more levels. The first level is the conceptual level, which specifies the valuable
functionings that constitute human flourishing and health. The second level is the policy
level, which specifies policies and laws. The third level is the intervention level, which
specifies actions in particular cases and decisions about medical treatments, public-health
interventions or social services. This framework constitutes three different types of
incompletely theorised agreements: incompletely specified agreements, incompletely
specified and generalised agreements, and incompletely theorised agreements on particular
outcomes.

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Incompletely specified agreements
The first type of incompletely theorised agreement occurs when there is agreement on a
general principle but sharp disagreement about particular cases. People who accept a general
principle, such as the illegality of murder, need not agree on the application of this principle
to particular cases. For example, they could disagree about whether abortion should be
classified as murder.24 This first type of agreement is closely connected to Rawls’
“overlapping consensus”. In the health-policy context, citizens might agree on cost-
effectiveness as a general principle, but also agree that β interferon, a drug that helps some
individuals with multiple sclerosis, should be provided to such patients even though its cost
per quality-adjusted life year (QALY) ranges from US$35 000 to $20 million, or agree that
kidney dialysis should be provided despite its exorbitant cost for relatively small
improvements in health-related quality of life.

Incompletely specified and generalised agreements
The second type of incomplete theorisation occurs when people agree on a mid-level
principle but disagree about both the more general theory that accounts for it and outcomes
in particular controversies. Here, Sunstein argues that the connections between the general
theory and mid-level principles and also between specific cases and mid-level principles are

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unclear.24 In the health policy context, citizens might agree that all should have access to
life saving interventions, but disagree on both the underlying theoretical doctrine for this
view and on whether all life saving interventions at all stages of life should be provided.

Incompletely theorised agreements on particular outcomes
This third type of incompletely theorised agreement describes how people reach agreement
on particular public policy options. In this model, agreement is reached on low-level
principles that are not necessarily derived from a particular high-level theory of the right or
the good. In fact, the same low-level principles may be compatible with more than one high-
level theory because people may disagree on or not fully understand a relatively high-level
abstraction while agreeing on “a point of less generality”.

In such contexts, people “can know that X is true without entirely knowing why X is true.”24

The emphasis here is on not knowing something entirely—completely theorising it from
high to low levels. People might agree, for instance, that governments should prevent
famine, eradicate malaria or tuberculosis, and not condone genital mutilation, but they might
not know exactly why they hold such beliefs. This reasoning might be both moral and
reasonable, but the deliberators might not explicitly state that their decision is derived from
an underlying theory, even though it certainly might be informed by a lower level
conception of the good life they articulated. This aspect of the framework complements the
capability approach’s emphasis on partial agreements and on identifying workable solutions
that make the most of consensus and that can be “based on the contingent acceptance of
particular provisions, without demanding complete social unanimity”.14

Thus, in matters of public decision-making about health and health policy, the incomplete
theorisation framework is useful in furthering a capability approach to health.15,16 First,
health, and thus health capabilities, is a multidimensional concept about which different
people might have different, and sometimes conflicting, views, especially at an
epistemological level. This heterogeneity makes complete theorisation difficult to achieve.
Second, there might be no view of health, and thus health capabilities, that is ideal for all
evaluative purposes; therefore, the pragmatism of the incomplete ordering of the capability
approach and the incompletely theorised agreement on that ordering of the incomplete
theorisation approach allows for reasoned public-policy decision-making in the face of
multiple, and even conflicting, views on health. Third, there could be no single quantitative
scale for comparing health capabilities and the inequalities in them; deviations in
individuals’ capability for functioning may occur in different domains of health capability
that may not be quantifiably comparable. For example, one cannot quantifiably compare one
individual’s inability to hear or see with another’s inability to bear children or to walk. These
reductions in individuals’ capabilities for functioning are qualitatively different and different
people will have widely diverging views on which functional capability reduction is better
or worse than the other. Thus, a framework for articulating and agreeing upon a conception
of health functioning for prioritising health goods and services is required. Given the
demands of policy evaluation in particular contexts, the combined approaches also allow
reasoned agreement on central aspects of health and their respective capabilities without
requiring people to agree on non-central aspects or fully understand their beliefs.

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Global health institutions
What do these philosophical arguments imply for global health institutions? Global health
institutions have important roles in the implementation of a capability approach to health
because they can help generate and disseminate the knowledge and information required to
reduce health disparities. For example, they can help create new technologies (eg, an HIV/
AIDS vaccine), transfer, adapt, and apply existing knowledge (eg, prevention of malaria
transmission), manage knowledge and information (eg, statistics on inequality in infant/child
mortality and best practices), and help countries develop information and research
capacity25,26 (eg, health surveillance and information systems).

Global health institutions can also empower individuals and groups in national and global
forums. Indirectly, they can push for greater citizen participation in health-related decision-
making in developing countries, both within (eg, in determining resource allocation) and
outside the health sector. Since greater empowerment in the health sector is built on more
democratic governance overall, reform of state and social institutions may be needed to
achieve these goals. And encouraging the political will for public action to reduce health
inequalities will be essential. Global health institutions, particularly WHO and World Bank,
can help governments improve the public administration needed to deliver quality health
care to all. They should also give individuals and groups a greater voice in national and
international forums and programmes, such as a health-sector loan or an international
tobacco-control agreement, and engage more with civil society and the private sector.

Global health institutions can also provide technical assistance, financial aid, and global
advocacy to support the development of equitable and efficient health systems and public
health programmes. This assistance can occur at the macro level (eg, standardising
diagnostic categories) or the micro level (eg, providing antiretroviral medicines for AIDS
patients). Some global health institutions (eg, WHO) have tended to organize around
specific diseases (HIV/AIDS, malaria, tuberculosis, polio, and SARS), whereas others such
as the World Bank have favoured sector-wide initiatives. Although both perspectives are
valuable, greater coordination among policy actors is essential. Such efforts should build on
existing work such as the Rockefeller Foundation’s global health equity initiative.27

Finally, global health institutions should be linked to other institutions in a coordinated and
integrated way. The Framework Convention on Tobacco Control (FCTC), for example,
recognises the importance of integrating public policies into a comprehensive set of health
improvement strategies. Through the FCTC, ministries of health and health-related
associations, such as physician groups, are united with ministries of finance, economic
planning, taxation, labour, industry, and education as well as with citizen groups and the
private sector, to create a multisectoral national and international tobacco-control effort. The
FCTC represents a growing trend in development policy toward an alternative paradigm that
is broad, integrated, and multifaceted.14,17,28–31 Adopting a multifaceted and integrated
approach to health improvement requires rejecting a narrow view of health and its
determinants and the philosophical foundations that support such a view.

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Acknowledgments
I thank Amartya Sen, Sudhir Anand, Michael Marmot, and participants in the workshop on Rights, Dignity, and
Inequality at Trinity College, Cambridge, UK, for helpful comments. I also thank Washington University School of
Medicine and Center for Health Policy for support. J P Ruger is supported in part by a Career Development Award
(grant 1K01DA016358–01) from the US National Institutes of Health.

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