Thursday, July 26, 2007

Health Inequalities or Health Care Inequalities?

Much of the health care literature attempts to distinguish between health care and health. In my estimation, most of the literature (at least as I have read thus far) fails to properly distinguish between the two concepts and as a result, comes out with muddled or confusing takes on distributive justice and the health care problem. In this brief section, I will argue that if we take the call to properly distinguish health from health care, we find that health care remains as important as ever. In fact, the theorist who wants to take health seriously will find that in order to do so, she must not lose sight of the health care problem, and in particular, she must recognize that the health care problem is primarily about economic inequality.

The distinction between health and health care is quite difficult to make. Hoedemekers and Dekkers identify these difficulties in their paper “Key Concepts in Health Priority Setting”. They illustrate how much the definitions of health care and how these variations can affect the way health care planners and resource allocators make their decisions. In discussing the WHO definition of health (“health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”), the authors show that health is holistic in such a way that individual demand for any health care services based upon it cannot be realistically restricted. On the other hand, many, especially health practitioners, restrict health to the bodily dimension only. The focus is not found in total well being but rather in whether or not the biological functioning of the organism is in working order. The dichotomy between the two views can also be seen in the way the patient and the physician view the term ‘abnormality’. The patient will often associate normality with health and abnormality with disease, based solely on personal standards of reference. For example, the fact that the smoker is hacking up a lung may be normal, while the contraction of lung cancer is not. For the physician, however, the definitions are much more precise with the definition of ‘normality’ determined by empirical data used to establish an objective standard of biological function in an organism. Comparisons of diagnostic data with these statistical standards reveal abnormalities and thus, for the physician, that same smoker who thought he was normal, is abnormal.

We’ve all heard stories about hardened older men who refuse to go visit the doctor because they’ve always been healthy and think that the doctor is just out to cause them trouble. These people have one concept of what health means, while the annoying mother who takes her children in for every ache and sniffle has a different concept of what health is. So how do we navigate these waters, especially as we try to discover the best way to distribute scarce health care resources?

In a very interesting paper, Dan Brock argues that one of the biggest failures of bio-ethicists is that they have focused too much on the problems related to health care and not enough on the problems related to health. He argues that the application of distributive justice to health care neglects very important issues brought up by the very concept of health. One of the most important things, Brock argues, is that those concerned with distributive justice and health care ought to take seriously the need for prioritization of health care services and the inevitable health care rationing that does and will occur. By focusing on health care rather than health, bio-ethicists only handicap themselves by attaching themselves to a project with no end. Justice (implied to be some kind of equity among the distribution of resources) is just not possible; theorists would be better off focusing on the prioritization of health needs rather than health care needs.

In one important paragraph, Brock attacks the idea of a right to health care, arguing that it cannot properly account for the reality of rationing.
Moreover, specifying in detail what services the right encompassed, and in particular what services it did not encompass, smacked of and was easily attacked as rationing. Although most bio-ethicists recognized the unavoidability and even the desirability of rationing, few politicians did, at least openly, and in public and health policy debates one’s views were often an easy target for discrediting if they could be tarred with the label of rationing. The general public, irresponsibly encouraged by many politicians and physicians, preferred to believe that in a rich country like ours with such an important good as health care, rationing was not necessary and did not in fact occur. Of course, this perspective overlooked the rationing imposed on the uninsured, as well as on others, but somehow this cognitive dissonance survived widely. And, given the pervasive belief that rationing did not occur, was not necessary, was politically dangerous, and would be morally wrong if it did occur, serious public discussion of it and of the limits to the right to health care was unlikely, and in fact rarely occurred. All this was quite remarkable during a period, which continues to this day, in which cost containment was the dominant issue of health policy, since the most obvious means of controlling health care costs is to deny some people some care, that is to ration care. But the preference was to believe that, by such means as cutting the “waste, fraud, and abuse” out of the health care system, costs could be adequately controlled without rationing.

By ignoring prioritization and rationing, argues Brock, those bio-ethicists who have influence in the realm of public policy are contributing to this “cognitive dissonance” within the American population (note that Brock admits that many bio-ethicists recognize the unavoidability of rationing. They just have a tendency to ignore it). Indeed even Brock agrees that the greatest inequity in the health care system is the fact that 44 million Americans have no health insurance whatsoever. To Brock’s credit, he exposes the lie that cost-effectiveness and utilitarian calculi will be able to address the issues of prioritization properly. By focusing on a population as a whole, utilitarian calculations have a cold and cruel way of neglecting the needs of those who are worst off. Others argue that utilitarianism actually focuses more on those that are worse off because it sees the utility gains from those in the poorest health as contributing more to the over all utility of the population (Gandjour, Lauterbach, 2003). While compelling, this argument fails to take into account the fact that the worst off are also those who cannot afford to pay for any services rendered, and thus in order to focus on the improvement of those who are worst off, utility would decrease as resources are a key function of aggregate utility.

That said, Brock wants to question the focus on those who are worst off. It’s not that he doesn’t think those who are worst off deserve our care. They do. But, argues Brock, there are often situations in which providing care for someone who is dying of AIDS provide less benefit than expanding inadequate funding for nonfatal conditions like substance abuse or mental health disorders.

Before you have a heart attack, remember how I began this discussion. It is important to see that Brock is drawing a line in the sand between health care priorities and health priorities. Perhaps the AIDS patient is in need of a bone marrow transplant or some other treatment for a disease that will lead to his eventual death, a definite health care priority. But perhaps a drug addict is seeking help in a facility, looking to get off the street. If one looks at health in a holistic sense, a dilemma becomes quite clear. Where do limited resources go? What justifies their allocation? Or, alternatively, suggests Brock, what reasons do we have to give priority to the worst off? Who are the worst off? How much priority should they receive in health care prioritization?

As Hoedemekers and Dekker suggest and Brock agrees with, the more expansive your definition of health, the more resources will be necessary. And unfortunately, the more resources needed, the more justification will be needed for prioritizing those who are worst off.

This brings us to a second issue for Brock. This concerns the socioeconomic factors laden in the health care issue. The question is really one of chicken and egg, as far as I can tell. It’s well documented that socioeconomic factors have an influence on the ability to obtain health care and more dangerously, poor socioeconomic status has a negative effect on the health of an individual. What’s more difficult to show is that poor health has an effect on socioeconomic status (Hausman, Asada, Hedemann, 2002; Brock 2000). The key thing to note is this: by focusing on health care rather than on health, bio-ethicists have neglected the links and ties of health to socio-economic factors that surround health. Brock writes, rather forcibly,
More important, inequalities in health among individuals and groups that are within human and social control are not primarily the result of inequalities in access to or use of health care. This is not to deny, of course, that medical care is often of great importance for the life and well-being of individual patients. But differences in access to and use of health care have only a negligible effect on health inequalities among social groups, in particular individuals of different socioeconomic classes. The crucial point is that differences in the incidence of illness and injury from social causes swamp the effects on health of differences in access to and use of medical care to treat that illness and injury (Wilkinson 1996). So if inequalities in access to health care are of moral concern because they result in inequalities in health, then focusing on health care will miss most of the action on the real matter of concern—health and health inequalities.

Now this may cause the reader to question the focus on the health care system, thinking that those concerned with distributive justice and health care must instead focus on the inequalities found in health rather than on health care. However, I don’t think this shift should happen that fast. In another section, Brock unwittingly gives us a clue as to why. He writes,
Higher societal income inequality adversely affects citizens’ health and life expectancy; for example, infant mortality and death rates of the lowest social classes in Sweden, which has low inequality in income, are lower than those of the highest social classes in England and Wales, which have much less egalitarian income distributions (Wilkinson 1996). So there are at least two important social determinants of health at work, where one stands in the socioeconomic hierarchy affects one’s health, and the degree of income inequality in a society affects the society’s overall level of health and health inequality. If the effects of poverty and inequality are combined, even in a rich country like the United States, the size of the impact is striking. In the U.S. the difference in age-adjusted mortality between metropolitan areas with the combination of high inequality and low per capita income and those with low inequality and high per capita income is greater than the combined loss of life from lung cancer, diabetes, motor vehicle crashes, HIV infection, suicide, and homicide (Lynch et al. 1998).
So it turns out that economically unequal societies have greater incidences of health inequality, and more importantly, the negative effects from economic inequality are greater than the negative effects of negative health. Not only does one’s place on the socioeconomic ladder determine health, but so does the overall degree of income inequality in that society.

If we remember back to a post I wrote a few days ago and something I alluded to at the beginning of this post, health care is primarily an economic problem. Unlike normal products, it involves an individuals well being, the commodification of knowledge and an undesired state of being that needs to be rectified. It is precisely the commodification of health inequality that makes health care an economic issue. Brock is right – a greater focus on health inequalities will broaden the agenda of the bio-ethicist and show her that not only does the definition of health matter, but so do the economic inequalities found in the social system as a whole. I think that Brock answers his own questions though he fails to see the answer supplied by his own arguments. Focusing on health, coming to the recognition that prioritization and health care rationing in inevitable, and understanding that economic inequalities in the system itself contribute to poor health is precisely why theorists should pay attention to the health care system and not simply health as a general idea. Not only is the concept of health contentious, broad and open to interpretation, but it doesn’t deal with the currency of care – money. When a theorist interested in justice, and in particular justice for the worse off, finds herself interested in the health question, she ought to turn her attention primarily to health care inequalities over health inequalities. The maximization of resources in a way that takes rationing into account and pays attention to the worse off, while recognizing all the external socioeconomic factors involved will go a lot further towards achieving economic equality than will theorizing about an ill-defined and subjectively interpreted category of human existence.


Brock, Dan. (2000) Broadening The Bioethics Agenda. Kennedy Institute of Ethics Journal. 10: 21-38.

Gandjour, Afschin; Lauterbach, Karl. (2003) Utilitarian Theories Reconsidered: Common Misconceptions, More Recent Developments and Health Policy Implications Health Care Analysis 11: 229-244.

Hausman, Daniel M et al. (2002) Health Inequalities and Why They Matter. Health Cara Analysis 10: 177-191.

Hoedemaekers, Rogeer; Dekkers, Wim. (2003) Key Concepts in Health Care Priority Setting. Health Care Analysis 11: 309-323.


David Hunter said...

Interesting post Peter.

I should say to start off I agree both with Brock's comments and your expansion of them. (Though by the by as per usual with some American academics when they describe the state of play in the field they really seem to be describing the state of play in America) So both health and health care would be important on your view? Is that right? This seems sensible given that presumably insofar as we care about health care it is because we care about health, and that health care is only one means among many of promoting good health.

Those points seem generally true, regardless of which view you take of distributive justice. I'm generally a bit bothered about the over all assumption that we ought to be paying more attention to the needs of the worst off, but that is something which bothers me over all anyway and it certainly seems a popular view.

Peter Thurley said...


On my view, both health and health care are important. I don't think that Brock was trying to say that bioethicists should abandon the health care question, he was just asking that they focus primarily upon health. I think that this is a mistake, and that the focus should be primarily upon health care (while not ignorning health), as health care is primarily a socioeconomic injustice, and it has been demonstrated that socioeconomic injustices contribute to poor health and health injustices.

As far as the comment about America, being Canadian, I agree. If I could defend this Americocentrism for a minute, I would suggest that the American health care system is the most unjust of all the systems in the developed world. It would make sense, then, that authors concerned with health care injustices would focus on the United States.

In terms of your worries about the attention paid to the worst off, I'm curious as to why the attention paid to the worst off bothers you. Personally speaking, I think the attention paid to the worst off is what makes theories of distributive justice better than other moral theories.

David Hunter said...

Okay, good that makes that clearer, health care on your view is prior to health but both are important.

And it seems your view turns on the empirical claim that social inequalities cause health inequalities.

Let me push you a little on this (not because I disagree with you) and see. Suppose it turned out that health care was a remarkably inefficient/ineffective way of achieving good health, instead a variety of preventative measures or other things were the best path to good health. Would you then switch to focusing on those other measures or would you stick with health care and just aim to add in those other measures?

On the worst off stuff, I'll go into this in more detail in a future post, but I'm broadly inclined to think that while the worst off are important, it is general injustice that distributive justice is concerned with. While I am egalitarian in my approach, I am not a Rawlsian egalitarian. In particular I don't think a Rawlsian approach (as for example Veatch or Daniels) is sustainable in health care, it leads rapidly to a bottomless pit style argument.