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Is Health Inequality Across Individuals of Moral Concern?

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Abstract

The history of the documentation of health inequality is long. The way in which health inequality has customarily been documented is by comparing differences in the average health across groups, for example, by sex or gender, income, education, occupation, or geographic region. In the controversial World Health Report 2000, researchers at the World Health Organization criticized this traditional practice and proposed to measure health inequality across individuals irrespective of individuals’ group affiliation. They defended its proposal on the moral grounds without clear explanation. In this paper I ask: is health inequality across individuals of moral concern, and, if so, why? Clarification of these questions is crucial for meaningful interpretation of health inequality measured across individuals. Only if there was something morally problematic in health inequality across individuals, its reduction would be good news. Specifically, in this paper I provide three arguments for the moral significance of health inequality across individuals: (a) health is special, (b) health equity plays an important and unique role in the general pursuit of justice, and (c) health inequality is an indicator of general injustice in society. I then discuss three key questions to examine the validity of these arguments: (i) how special is health?, (ii) how good is health as an indicator?, and (iii) what do we mean by injustice? I conclude that health inequality across individuals is of moral interest with the arguments (b) and (c).

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Notes

  1. The WHO researchers throughout this paper are the health inequality team for the production of The World Health Report 2000 [47] in Evidence and Information for Policy, the WHO headquarters.

  2. In this paragraph, I follow an excellent summary of philosophical discussion on equality by Hausman and McPherson [25, pp.135–149].

  3. For example, Dworkin does not include health or health care in his list of resources to be equalized. In his view, we should equalize income (and other resources) so people can buy health insurance according to their life plans [30, 36].

  4. Two scholars independently developed a so-called capability approach, albeit following a period of collaboration. As is well known, Amartya Sen fashioned the idea of capability in development economics [40, 41], and, Martha Nussbaum in philosophy [33]. When working together in 1980s, they recognized a “striking resemblance” in each other’s idea [33, p. 11]. Their ideas were, however, not identical and did not merge after that collaborative period. Sen is deliberately ambiguous about of what capabilities consisting, and therefore, it is unclear if he would include health in a capability set and if he would also agree to separate health from a capability set and independently examine its distribution. For this reason, it is Nussbaum’s version of the capability approach on which I focus here.

  5. A word of caution is in order regarding the interpretation of this basic minimum. Nussbaum favours its recognition with “reference to an idea of human worth or dignity,” instead of the literal interpretation that below it people are better off if dead [33, p. 73].

  6. Due to the lack of data, the WHO researchers only examined individual health inequality among children aged five or younger. For the purpose of the discussion in this paragraph, I assume that individual health inequality for this particular age group is the same as individual health inequality for the entire population.

Abbreviations

WHO:

World Health Organization

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Acknowledgments

I am indebted to Drs. David Kindig, John Mullahy, Patrick Remington, Alberto Palloni, Daniel Hausman, and Daniel Wikler for their general assistance for my dissertation, from which this present paper was derived. I am also grateful to Drs. Nuala Kenny and Susan Sherwin and reviewers for their comments on an earlier version of the manuscript. All remaining errors are mine. This project was supported by grant number 1 R03 HS 13116 from the Agency for Healthcare Research and Quality, and the Canadian Institute of Health Research Training Program for Ethics and Health Policy and Research.

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  1. Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, 5790 University Avenue, Halifax, Nova Scotia, B3H 1V7, Canada

    Yukiko Asada

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Asada, Y. Is Health Inequality Across Individuals of Moral Concern?. Health Care Anal 14, 25–36 (2006). https://doi.org/10.1007/s10728-006-0008-6

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