Public Health Ethics: Beyond the Social Determinants of Health

Aim of the project

Substantial health differences exist even within affluent and relatively egalitarian societies. Thus far, the social-determinants-of-health approach has been applied to mitigate such differences. But it is severely criticized. The aim of this project is to develop an effective and fair alternative, that engages with the rich histories of analyzing poverty, inequality and (ill) health in philosophy and theology

Theoretical background

In Japan the average life expectancy is 86 years; in Sierra Leone that number is 60 years. In the Netherlands, the highest-educated people live nearly 15 years longer in good health than the least-educated. The internationally dominant strategy for mitigating such health differences has been the social determinants of health approach, which focuses on reducing health inequities through redistribution and social change (Preda and Voigt 2015). But inequalities within countries have not decreased, not even in very affluent and relatively egalitarian societies. In such countries, unhealthy habits and life-style related risk factors such as obesity, smoking, alcohol and poor diet have turned out to be rather persistent, in particular among people with a low socio-economic status (SES) (Marmot 2010). This has come to the fore again during the Covid-19 pandemic, which editor-in-chief of The Lancet, Richard Horton (2020) has characterized as a “syndemic”: a combination of viral infections and non-communicable diseases such as hypertension and obesity, the latter caused by social inequalities.

According to recent critics, the social-determinants-of-health approach has not delivered health equity because it fails to prioritize (1) efficiency and (2) individual responsibility (Canning and Bowser 2020; Nathanson and Hopper 2010) This project sets out to develop a framework for a fair and effective alternative. To this end, it uses the resources of philosophical and theological ethics. (1) Its first part concerns efficiency and its relation to equity. A key component of public health justice proposals has been that health actions must be a combination of universal and targeted measures, proportionate to the level of disadvantage (proportionate universalism). However, in a recent public health policy brief, the Dutch governmental thinktank WRR proposes to pay less attention to disadvantage (Broeders et al. 2018/2019). The argument is that, as attempts aimed at eliminating differences have failed, it is better to focus on areas where there is a lot of potential for health gains (critical discussion: Jedan 2021). Is such a radical reorientation justified? (How) can it be implemented without sacrificing equity?

(2) The second part of the project pertains to individual and collective responsibility. According to the aforementioned critiques, collective arrangements come at the expense of individual responsibility. But a renewed emphasis on individual responsibility can be counterproductive: for instance, people with a higher SES and from certain cultural backgrounds tend to be better at realizing health gains, which means that policy changes might unjustly favor them. Furthermore, the use of financial incentives to promote healthy life styles might inadvertently undermine individual autonomy. This seems to stand in tension with the principle of subsidiarity. To resolve these issues, the project investigates whether and how an emphasis on individual responsibility can be combined with collective responsibilities at various levels (Wikler 2002, 2006; Hindriks 2019).

Thus, the project will result in a balanced reappreciation of efficiency and responsibility in public health ethics, which is of direct policy relevance. It will be stimulated by, and conversely shed new light on, analyses of poverty, inequality and (ill) health in the history of philosophy and theology.

Research design

Literature study, overview of empirical findings, theory assessment, theoretical integration

Project initiators

Christoph Jedan (RCS), Frank Hindriks (Phil)

Embedding

Centre Religion, Health and Wellbeing (RCS), Centre for PPE (Phil), Aletta Jacobs School of Public Health

Advisory board

Andreas Schmidt (Phil), Els Maeckelberghe (UMCG), Jochen Mierau (AJSPH)

Literature

Broeders, D.W.J., et al. (2018/2019) Van verschil naar potentieel: een realistisch perspectief op de sociaaleconomische gezondheidsverschillen, WRR Policy Brief 7, The Hague 2018; English edition: From Disparity to Potential: A Realistic Perspective on Socio-Economic Health Inequalities. WRR Policy Brief 7, The Hague 2019.

Canning, D., and Bowser, D. (2020) “Investing in Health to Improve the Wellbeing of the Disadvantaged: Reversing the Argument of Fair Society, Healthy Lives (The Marmot Review).” Social Science and Medicine 71 (2020), 1223–1226.

Daniels, N. (2007) Just Health: Meeting Health Needs Fairly. Cambridge: Cambridge University Press.

Hindriks, F. (2019) “The Duty to Join Forces: When Individuals Lack Control.” Monist 102, 151-71.

Horton, R. (2020) “Offline: COVID-19 Is not a Pandemic.” The Lancet 396, 874.

Jedan, C. (2021) “Proportionate Universalism and Public Health: An Analysis of WRR Policy Brief From Disparity to Potential.” NTT: Journal for Theology and the Study of Religion 75, 73–93.

Marmot, M. (2010) Fair Society, Healthy Lives: Strategic Review of Health Inequalities in England post-2010. The Marmot Review 2010.

Nathanson, C., and Hopper, K. (2010) “The Marmot Review – Social Revolution by Stealth.” Social Science and Medicine 71, 1237–1239.

Preda, A., and Voigt, K. (2015) “The Social Determinants of Health: Why Should We Care?” The American Journal of Bioethics 15, 25–36.

Schmidt, H., Voigt, K., and Wikler, D. (2010) “Carrots, Sticks, and Health Care Reform — Problems with Wellness Incentives.” New England Journal of Medicine 362 (2): e3.

Wikler, D. (2002) “Personal and Social Responsibility for Health.” Ethics & International Affairs 16 (2): 47–55.

———. (2006) “Justice, Socioeconomic Status, and Responsibility for Health.” In Public Health, Ethics, and Equity, edited by Sudhir Anand, Fabienne Peter, and Amartya Sen. Oxford: Oxford University Press.

Key words

Public health; health inequities; social determinants of health; socio-economic status; efficiency; individual and collective responsibility; philosophical and theological ethics