Abstract
Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health care justice, and outlines a new approach that can justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
Beginning in the 1930s, immunizations, antibiotics and other medical interventions nonetheless did hasten the further decline in mortality from infectious diseases, especially among young people (Nolte and McKee, 2004, p. 12).
High-tech medical procedures (coronary angiography, angioplasty or artery bypass surgery) can be effective, but are apparently overused in the United States. The development and increased use of pharmaceuticals has also played an important role in decreasing mortality from cardiovascular disease.
This view is endorsed at least by most versions of liberal theory.
Most European states offer coverage of all or most of these services.
For example, it violates the assumption of an equal distribution of risks and perfect information, leading to adverse selection by both insurance companies and individuals. Individuals are also notoriously bad at assessing their own risks and making adequate provisions for them.
References
Arrow, K. (1963) Uncertainty and the Welfare Economics of Medical Care. The American Economic Review 53 (5): 941–973.
Barr, N. (2004) Economics of the Welfare State, 4th edn. Oxford: Oxford University Press.
Barry, B. (2005) Why Social Justice Matters. Cambridge, UK: Polity.
Blank, R. and Burau, V. (2007) Comparative Health Policy, 2nd edn. New York: Palgrave Macmillan.
Brock, D. (2000) Broadening the Bioethics Agenda. Kennedy Institute of Ethics Journal 10 (1): 21–38.
Buchanan, A. (2009) Justice and Health Care. Oxford: Oxford University Press.
Colby, J. (2009) Normal Daniels: Just health: Meeting health needs fairly. Journal of Health Politics, Policy and Law 34 (5): 839–846.
Conti, G., Heckman, J. and Urzua, S. (2010) The education-health gradient. American Economic Review 100 (2): 234–238.
Cutler, D. (2004) Your Money or Your Life: Strong Medicine for America’s Health Care System. Oxford: Oxford University Press.
Daniels, N. (1985) Just Health Care. Cambridge, UK: Cambridge University Press.
Daniels, N. (2007) Rescuing university health care. Hasting Center Report 37 (2): 3.
Daniels, N. (2008) Just Health: Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press.
Daniels, N. (2011) Justice and access to health care. In: E. Zalta (ed.) The Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/archives/spr2011/entries/justice-healthcareaccess/, accessed 5 October 2012.
Engster, D. (2007) The Heart of Justice: Care Ethics and Political Theory. Oxford: Oxford University Press.
Frank, J., Lomax, G., Baird, P. and Lock, M. (2006) Interactive role of genes and environment. In: J. Heymann, C. Hertzman, M. Barer and R. Evans (eds.) Healthier Societies. Oxford: Oxford University Press, pp. 11–34.
Gilligan, C. (1982) In A Different Voice: Psychological Theory and Women’s Development. Cambridge, Massachusetts: Harvard University Press.
Goldman, D. and Lakdawalla, D. (2010) Can the ACA improve population health? The Economists’ Voice 7 (5): 1–5.
Held, V. (2006) The Ethics of Care. Oxford: Oxford University Press.
Heymann, J., Hertzman, C., Barer, M. and Evans, R. (eds.) (2006) Healthier Societies: From Analysis to Action. Oxford: Oxford University Press.
Kittay, E. (1999) Love’s Labor. New York: Routledge.
Kunst, A. and Mackenbach, J. (1994) The size of mortality differences associated with educational level in nine industrialized countries. American Journal of Public Health 84 (6): 932–937.
Levy, T. (2005) At the intersection of intimacy and care: Redefining ‘Family’ through the lens of a public ethic of care. Politics and Gender 1 (1): 65–95.
Mann, J. (1997) Medicine and public health, ethics and human rights. Hastings Center Report 27 (3): 6–13.
Marmot, M. (2004) The Status Syndrome. New York: Henry Holt.
Marmot, M. and Wilkinson, R. (2006) Social Determinants of Health, 2nd edn. Oxford: Oxford University Press.
McKeown, T. (1979) The Role of Medicine. Princeton, NJ: Princeton University Press.
McKinlay, J. and McKinlay, S. (1977) The questionable contribution of medical measures to the decline of mortality in the United States in the twentieth century. Health and Society 55 (3): 405–428.
Miller, S.C. (2011) The Ethics of Need: Agency, Dignity, and Obligation. New York: Routledge.
Noddings, N. (2002) Starting at Home. Berkeley, CA: University of California Press.
Nolte, E., Bain, C. and McKee, M. (2009) Population health. In: P. Smith, E. Mossialos, I. Papanicolas and S. Leatherman (eds.) Performance Measurement for Health System Improvement: Experiences, Challenges, and Prospects. Cambridge, UK: Cambridge University Press.
Nolte, E. and McKee, M. (2004) Does Health Care Save Lives? Avoidable Mortality Revisited. London: Nuffield Trust.
Nolte, E. and McKee, M. (2011) Variations in amenable mortality – Trends in 16 high-income nations. Health Policy 103 (1): 47–52.
OECD. (2010) Health Care Systems: Efficiency and Policy Settings. Paris: OECD Publishing.
Powers, M. and Faden, R. (2006) Social Justice. Oxford: Oxford University Press.
Rawls, J. (1999) A Theory of Justice, Revised Edition. Cambridge, Massachusetts: Harvard University Press.
Rice, T. and Unruh, L. (2009) The Economics of Health Reconsidered, 3rd edn. Chicago, IL: Health Administration Press.
Roos, N., Brownell, M. and Menec, V. (2006) Universal medical care and health inequalities: Right objectives, insufficient tools. In: J. Heymann, C. Hertzman, M. Barer and R. Evans (eds.) Healthier Societies: From Analysis to Action. Oxford: Oxford University Press, pp. 107–131.
Ruger, J. (2010) Health and Social Justice. Oxford: Oxford University Press.
Segall, S. (2007) Is health care (Still) special? The Journal of Political Philosophy 15 (3): 342–361.
Segall, S. (2010) Is health (Really) special? Health policy between rawlsian and luck egalitarian justice. Journal of Applied Philosophy 27 (4): 344–358.
Shapiro, D. (2007) Is the Welfare State Justified? Cambridge, UK: Cambridge University Press.
Siegrist, J. and Marmot, M. (eds.) (2006) Social Inequalities in Health. Oxford: Oxford University Press.
Silvers, A. (2009) No talent? Beyond the worst off! A diverse theory of justice for disability. In: K. Brownlee and A. Cureton (eds.) Disability and Disadvantage. Oxford: Oxford University Press, pp. 163–199.
Slote, M. (2007) The Ethics of Care and Empathy. New York: Routledge.
Sreenivasan, G. (2007) Health care and equality of opportunity. The Hastings Center Report 37 (2): 21–31.
Sreenivasan, G. (2009) Justice, inequality, and health. In: E. Zalta (ed.) The Stanford Encyclopedia of Philosophy. http://plato.stanford.edu/archives/spr2009/entries/justice-inequality-health/, accessed 5 October 2012.
Tronto, J. (1993) Moral Boundaries: A Political Argument for an Ethic of Care. New York: Routledge.
White, J. (2000) Democracy, Justice, and the Welfare State. University Park, PA: Pennsylvania State University Press.
Wilkinson, R. (1996) Unhealthy Societies: The Afflictions of Inequality. New York: Routledge.
Wilkinson, R. and Pickett, K. (2009) The Spirit Level. New York: Bloomsbury Press.
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Engster, D. The social determinants of health, care ethics and just health care. Contemp Polit Theory 13, 149–167 (2014). https://doi.org/10.1057/cpt.2013.14
Published:
Issue Date:
DOI: https://doi.org/10.1057/cpt.2013.14