The past decade witnessed great progress in research on health inequities. The most widely cited definition of health inequity is, arguably, the one proposed by Whitehead and Dahlgren: "Health inequalities that are avoidable, unnecessary, and unfair are unjust." We argue that this definition is useful but in need of further clarification because it is not linked to broader theories of justice. We propose an alternative, pluralist notion of fair distribution of health that is compatible with several theories of distributive justice. Our proposed view consists of the weak principle of health equality and the principle of fair trade-offs. The weak principle of health equality offers an alternative definition of health equity to those proposed in the past. It maintains the all-encompassing nature of the popular Whitehead/Dahlgren definition of health equity, and at the same time offers a richer philosophical foundation. This principle states that every person or group should have equal health except when: (a) health equality is only possible by making someone less healthy, or (b) there are technological limitations on further health improvement. In short, health inequalities that are amenable to positive human intervention are unfair. The principle of fair trade-offs states that weak equality of health is morally objectionable if and only if: (c) further reduction of weak inequality leads to unacceptable sacrifices of average or overall health of the population, or (d) further reduction in weak health inequality would result in unacceptable sacrifices of other important goods, such as education, employment, and social security.
Rejecting strong equality of health, the question then becomes when we can reasonably diverge from strong health equality. Below, we will examine four widely held objections to strong equality of health: (1) the levelling down objection, (2) only those inequalities that are social are unjust, (3) individual responsibility, and (4) the problem of biological or technological limitations. On the basis of the examination of these four objections, we defend the weak principle of health equality as a backbone of our proposed framework of fair health distribution.
[PDF] The Lottery of Birth: On Inherited Social Inequalities
Arguably, the strongest objection historically to defining health equity as strong equality in health has been that health is a natural good and cannot be redistributed by institutions (such as the health care system or more broadly, a welfare system) in the same way as income. Many scholars think the distinction between naturally and socially created inequalities is of moral importance. Fairness or justice is concerned only about socially created inequalities, not naturally created inequalities.
Does this distinction between social and natural goods indeed hold, and is it morally relevant and useful? We shall not attempt to review the very interesting debate about the correct interpretation of Rawls' view on this issue, but rather question the factual premise this debate presupposes [36]. In our view, this distinction is irrelevant in thinking about when inequalities in health are unjust.
First, health is primarily a social good. In the world we live in today, the basic institutions of society determine to a large extent the level and distribution of health. According to statistics from the World Mortality Report, life expectancy in many countries has increased by as much as ten years since the early 1970s [37]. This change is mediated through social factors such as economic growth, technology, reduced inequalities, knowledge and investment in public health and health systems. The WHO reports that life expectancy at birth ranges from 77 (for males) and 82 (for females) in Norway to 41 (for both males and females) in Malawi [38]. Natural factors probably play a minor role in explaining this difference. The health of peoples, or nations, is not something given but fundamentally shaped by how societies are organized and how the benefits of cooperation are shared. We know that Malawi is a much poorer country than Norway, and that the social determinants of health (including health care and public health) are unequally distributed between and within the two countries. The literature on the social determinants of health has, convincingly in our view, demonstrated that social factors are dominantly associated with inequalities in health [39, 40]. Health is, then, a concern for social justice.
Third, natural and genetic inequalities in health are actually taken seriously in health policy and clinical practice. Convincing arguments are needed to depart from this view. For example, women who have inherited the BRA1 gene that increases their lifetime risk for breast and ovarian cancer by up to 70-80% are typically treated with more concern than others, not less. Indeed, why should genetically inherited disease (caused by the natural lottery) be given less or no priority compared to those who acquire a disease because they live in poverty or lack basic education? Whether risk is associated with unfair social circumstances or is the result of the natural lottery, it affects well-being, opportunities and freedom to the same degree. Disease and risk of disease are not in the same category as the colour of our eyes or beauty in our judgment of social obligations. In clinical practice, no one would consider whether a condition is caused by social or natural factors as a decisive reason for different prioritisation. Practice does not make a thing right, but if we consider principles against well-considered intuitions in reflective equilibrium, this widely held intuition should be considered seriously [43].
Finally, the implications of the distinction between natural and social factors are counterintuitive and not normatively attractive. Some people have low life expectancy because they are poor, lack education and employment. Others may have low life expectancy, even if not so poor, because they happen to be in a natural setting where there are a lot of malaria-carrying mosquitoes. Should this "natural fact" be a factor against a justice concern? "Freedom from malaria" is one of Sen's paradigmatic examples of what an egalitarian theory should focus on [44]. We agree. If anyone thinks that freedom from malaria should not be a concern for justice, it is probably a mistaken expression of the underlying intuitions that there are some health inequalities we cannot, as a society, do anything about. Consider the situation in the early 1980s before the existence of HIV was known, before its ways of transmission was known and before antiretroviral treatment was developed. The fact that some people died prematurely from AIDS at that time could not be considered unfair, because the disease was not possible to prevent or treat.1 Being free from malaria (and HIV today), on the other hand, is a concern for justice because society does have the knowledge and the means to prevent and treat them. In our view, the relevant distinction is whether the institutions of society can respond adequately to a disease or not, which we will elaborate below - not whether the causes are natural or social.
The upshot of this discussion is that most health inequalities should - as a starting point - be considered unjust. The division between health as a natural and a social good is not possible to define. Neither is it morally relevant. [Of course it would be judged unfair if they had been denied access to preventive measures. That many people died prematurely was also a reason to fund HIV research.]
Similarly, liberal egalitarian theories of distributive justice argue that a central goal of public policy should be to secure all individuals equal opportunities. All equal opportunity approaches argue that society should eliminate inequalities that arise from factors beyond individual control. One prominent position argues that equal opportunity requires that all inequalities that arise from factors outside the agent's control in the social and the natural lottery, such as a person's natural and genetic abilities should be eliminated, but that inequalities or costs that arise from factors under the agent's control should be accepted [45].
The final objection to strong health equality commonly found in the literature relates to considerations about biological and technological limitations. Many definitions of health inequity proposed by health science researchers suggest that inequalities in health are fair if those inequalities are unavoidable. Whitehead and Dahlgren explicitly incorporate unavoidability in their definition. Similarly, the pragmatic definition of health equity adopted by the International Society for Equity in Health in 2000 focuses on remediability: "Equity in health is the absence of systematic and potentially remediable differences in one or more aspects of health across socially, demographically, or geographically defined populations or population subgroups" [49]. Furthermore, though not as explicit as the two definitions above, Gakidou, Murray, and Frenk, in their proposal for measuring health inequities across countries for The World Health Report 2000, consider health inequalities caused by factors amenable to human interventions as unjust [4, 27].
We agree with Anand and Sen, that equity concerns inequalities that are avoidable. Although they do not clearly define when we should consider inequalities to be unavoidable, the term often includes limitations of biology, technology or knowledge. Anand and Sen refer to limitations of biology when they defend shortfall equality in the case of men and women as illustrated above. Our view of biological limitations is that, whether they are functional or mental limitations, egalitarians should not count them as legitimate shortfalls. Above, we argued against the view that only those inequalities that are social are unjust. In health policy and clinical practice, we take natural inequalities in health seriously and consider them as important as social inequalities in health. Inequalities due to biology are examples of natural inequalities, and we do not see why gender deserves special consideration among many other biological factors, such as genetics. 2ff7e9595c
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