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Anger and Forgiveness"Are You There Alone?"10 Good Questions about Life and DeathA Casebook of Ethical Challenges in NeuropsychologyA Companion to BioethicsA Companion to BioethicsA Companion to GenethicsA Companion to GenethicsA Companion to Muslim EthicsA Cooperative SpeciesA Critique of the Moral Defense of VegetarianismA Delicate BalanceA Life for a LifeA Life-Centered Approach to BioethicsA Matter of SecurityA Natural History of Human MoralityA Philosophical DiseaseA Practical Guide to Clinical Ethics ConsultingA Question of TrustA Sentimentalist Theory of the MindA Short Stay in SwitzerlandA Very Bad WizardA World Without ValuesAction and ResponsibilityAction Theory, Rationality and CompulsionActs of ConscienceAddiction and ResponsibilityAddiction NeuroethicsAdvance Directives in Mental HealthAfter HarmAftermathAgainst AutonomyAgainst BioethicsAgainst HealthAgainst Moral ResponsibilityAgency and AnswerabilityAgency and ResponsibilityAgency, Freedom, and Moral ResponsibilityAging, 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With Social Justice: The Moral Foundations of Public Health and Health Policy the multidisciplinary writers' team of Madison Powers and Ruth Faden have delivered an interesting and compelling answer to the questions of how much inequality in health a just society can tolerate and which inequalities matter most. They arrive at the answers to these questions through the development of their own theory of social justice. As in John Rawls' theory of justice, the authors are primarily concerned with the basic structure of society. However, unlike his, Powers & Faden's is not an ideal theory. Rather, their interest is in what justice requires of social institutions and practices in the here and now, and in the way multiple social determinants systematically compromise the wellbeing of socially situated groups.
In Chapter Two, the authors explain that the job of justice is to satisfy six intersecting but distinct dimensions of wellbeing: health, personal security, reasoning, respect, attachment, and self-determination. This entails a rejection of any "separate spheres" account of health (like the one Michael Walzer gives, for example). It also means that in promoting health, other dimensions should be taken into account, while health, in turn, cannot be left out of any consideration of social justice, including those made by non-health segments of government. Powers & Faden admit that this functional account of wellbeing draws heavily upon Sen (and Nussbaum)'s capabilities approach to justice. They argue for their theory in discussion with authors like Rawls, Dworkin, Sen and some other of the most important theories in the field and although their arguments are thoughtful, some might ask whether yet another new account of justice with yet another list of elements of wellbeing can add anything substantive to the debate. The authors claim that their theory does add something new, as the important differences between the capabilities approach and theirs is that this dimensions of wellbeing approach focuses on the actual satisfaction of each dimension to a certain basic level. An important reason for this requirement, is that in the early stages of life, actual fulfillment, rather than the capability of it, is to be ensured -- otherwise health as well as other dimensions of wellbeing could be compromised throughout the lifecourse. Children play an important role in Powers & Faden's account of justice for another reason: in their view, society is morally responsible for the health and wellbeing of its children, as they are not self-determining and cannot ensure the satisfaction of all dimensions of their wellbeing themselves. In any case, the requirement of sufficiency determines which levels of inequalities cannot be tolerated in a just society: certainly not those that allow parts of the population to fall below the sufficiency level in any dimension. In addition, these dimensions can function as a justificatory basis for basic human rights, the authors explain.
As to the question which inequalities matter most, the authors identify those that form part of systematic patterns of disadvantage. Chapter Three gives a detailed account of different possible ways in which social determinants influence health and other dimensions of well being and singles out those where multiple social determinants interact in such a way that insufficiencies for multiple dimensions of wellbeing compound. Three types of such densely woven patterns of injustices are identified. First there are forms of group oppression and subordination such as racism, sexism and ethnic conflict. Next, they write about conditions that have powerful effects on self-determination (social constraints, lack of suitable choice, unequal political power relations -- all associated with poverty, for example). Finally, once more, it is stressed that children's life prospects can also be severely compromised by living in adverse social circumstances even for a short period of time.
In Chapter Four the positive and negative implications for public health are spelled out. Negatively, we should monitor and "police" existing and emerging patterns of systematic disadvantage. Positively, the theory does not require precise equality, but it does ask for a level of sufficiency and for the leveling up of gradients in health that coincide with gradients in social and especially economic status. They identify inequalities in well-being associated with poverty as the most morally significant ones and the first ones to be tackled by public health policy.
This is then applied, in Chapter Five, to the context of (insurance) market based health systems, with the US as example. Step by step, and drawing on some classics in market theory, Powers & Faden explain how the American insurance market developed to its present state, with a small group at the top overinsured, the majority under- or not at all insured, and prices constantly rising. This last aspect, and the fact that the US, although it spends more than any other country on healthcare, is not healthier than other countries, would perhaps have deserved a little more attention. But the authors do not aim to attack market based system per se. Rather, they want to explain its logic and to point out the challenges that every health system has to deal with. In any case, drawing on their theory of social justice, they do make it abundantly clear exactly what is morally objectionable about the employer based health insurance system as it exists. "Those who are economically and medically better off, or at least well enough off to be employed, get a big helping hand from the government," in the form of tax cuts. At the same time "many of the working poor and others without employer-based insurance", that is those who cannot work because they are old, sick, disabled, caring for children, … and those who work in small companies or in temporary and short term contracts -- a disproportionately large percentage of which are African Americans, Latino's or migrants -- "get nothing." (p 132). A highly technical chapter at first, the final views it proposes are highly relevant to current discussions about distributive justice and health in the US. Even if it might therefore seem of little interest to non-US readers, it does provide a clear insight into the logic of the US health insurance system and of how this system, that is sometimes very difficult for Canadians and Europeans to understand, came about. The authors' initial generosity towards (insurance) markets in health, not wanting to reject them per se, unfortunately also results in very few directions as to where things should go from here. They make it very clear what has gone wrong, but do not show how it can be made right again.
In the next chapter, the authors turn to reflections on justice in priority setting and discuss the techniques of cost-benefit analysis, cost-effectiveness analysis and cost-utility analysis in health, all of which are more and more commonly used to inform health care policy making. Powers and Faden emphasize that, from the point of view of sufficiency of wellbeing, a major concern about these techniques is that "its use in concrete social circumstances results in systematic disadvantage" as they give systematic priority to some groups (the young) and types of people (the already healthy) as compared to others. Nevertheless the data concerning QALY's and DALY's coming out of these analyses do have their worth as a source of essential moral data which can show which social groups experience the greatest burden of disease. The authors emphasize that, in setting priorities their theory requires special attention to sufficiency of wellbeing of children and young people, as well as to other dimensions of wellbeing than health, which must be taken into account in determining priorities. They also give examples as to how paying attention to, for example, the crucial dimension of respect, shakes up priorities in many cases.
Finally, Chapter 7 explains how public decision-making regarding health cannot do without some kind of theory concerning social justice. The authors stress the importance in a deliberative democracy, "to compel policy makers and citizens alike to articulate and defend their positions" in order to "advance the public process of policy making". This may not regress in to majoritarianism in decision-making -- therefore, Powers and Faden say, "preferences and processes must be "laundered" or "filtered" by theories of social justice and human rights in order to ensure that policies … do not reinforce or compound those inequalities that are already amongst the most unjust."
In the final chapter, then, it is emphasized that just as empirical data in themselves cannot lead to decisions without a theory of justice to help interpret them, theories of justice can also not do without data. The authors stress the need for empirical research that can shed light on the social circumstances that determine the life prospects of socially situated groups and express the hope that their theory has provided inspiration for further inquiry that can provide better guidance as to which inequalities matter most.
The wide variety of disciplines (philosophy, health, law, economics, policy,…) with which it engages and the extent to which it does this in various different chapter, do not make this book an easy read. But this is exactly the reason why it deserves a broad readership. Neither philosophers, nor public health scientists, nor -- I presume -- health economists will be disappointed about the way Powers & Faden take up their disciplines. More importantly, they will learn a great deal about what else is at stake in health, apart from the things they already know. Moreover, policy makers, especially those in the US who stand before important decisions concerning questions of distributive justice and health, should read the chapters about insurance markets and priority setting, if not the entire book, with great interest.
Finally, where the initial chapter may have left the reader with questions as to whether yet another theory of justice (however well argued) could contribute to the debate, the final, more empirical chapters of the book show the value of this theory in action and the new views it brings to public health, health policy and research. They interestingly show how health and other dimensions intersect and how a health policy that only takes health into account isn't always a just policy, just as much as other policies that do not take health into account are not just either. Although the book only discusses other dimensions off wellbeing in health policy, and says disappointingly little about "health in other/all policies", Powers & Faden have made a valuable contribution to thinking about social justice and it can only be hoped that the implications of their theory in non-health policy get more attention in the future.
© 2009 Aagie Ieven
Aagje Ieven's background is in Health (BA Medical Studies), Political Philosophy (MA Thesis on Gender Equity) and Law (currently finalizing a PhD in Human Rights). She studied at University of Leuven (Belgium), Radboud University Nijmegen (the Netherlands) and Columbia University New York (USA) and is currently associated researcher at University of Leuven and research coordinator at EuroHealthNet where she coordinates the FP7 Gradient project.