Abstract
Social Determinants of Health (SDH) theorists claim that the distribution of social goods such as income, housing and education, has as great or greater an impact on health outcome than does health care, narrowly construed. This article attempts to integrate this claim into a plausible theory of justice. I argue that such a theory must be both political, in that it focuses on goods that states can distribute or regulate effectively and appropriately, and holistic, in that it must integrate the various values that are relevant to distribution into a plausible overall theory. While SDH-based theories are appropriately political, many of their exponents tend to undertake the task of integration in an implausibly monistic manner. I argue that monists about health are caught between the horns of an unattractive dilemma: either they employ a narrow conception of health, in which case their prescriptions are grounded in an implausible conception of the human good, and give rise to an extreme form of paternalism; or they use a broader conception of health, which leads them to address the challenge of holism in a purely rhetorical manner. I argue for a pluralistic mode of integration, one that accepts that social goods are regulated by both consequentialist and non-consequentialist considerations, and that the range of consequences that are relevant do not relate merely to health.
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Notes
For example, Canadian provinces spend anywhere from 50 to 100 per cent more for health care and related services than they do for education. See the 2009 data collected by the École nationale d’administration publique, at etatscanadiens-canadiangovernments.enap.ca/en/nav.aspx?sortcode=2.0.3.3, accessed 26 April 2015.
The main protagonists in the ‘bedtime story debate’ are Brighouse and Swift (2009), Mason, (2006, 2011) and Segall (2011).
Paradigmatic luck egalitarians would include at least Dworkin (2000) and Cohen (1989).
Why start from the goods that are already distributed or regulated by developed modern states in trying to build up a theory of the kinds of goods that states ought to distribute and regulate? Briefly, two reasons can be adduced. First, normative political theory should in my view contribute to the improvement and reform of already existing institutions. In Rawlsian ‘ realistic utopian’ spirit, it should attempt to show how institutions of tolerably decent states should change in order to realize the values that underpin them. Second, and again in Rawlsian spirit, starting (but not ending) with a list of goods already distributed by states can be seen as part of an exercise in reflective equilibrium. By moving back and forth between conceptions of state action that are implicit in the institutional design and functioning of modern states and abstract norms such as appropriateness and effectiveness, the hope is that we will be able to contruct a theory that is both defensible on normative grounds and capable of informing institutional reform. I thank an anonymous reviewer for this journal for having pressed me on this point.
An example of a piecemeal approach with respect to health can be found in Segall (2013, pp. 93–94), and more generally in Segall (2010).
See my ‘Sites of Deliberation in Contemporary Electoral Systems’, forthcoming in The Journal of Parliamentary and Political Law. The term ‘platform’ is used here deliberately in order to echo the kinds of proposals that emanate from political parties, and that are presented to the democratic voting public for consideration in general elections.
It should be clear that the reference to monism here should be understood politically rather than morally or metaphysically. Monism as employed here is the view that the evaluation of state action should be carried out with reference to one unique value or outcome. It is not a view about what is ultimately of value, although political monists may (but need not) ground their political positions in deeper and more general philosophical positions. I thank an anonymous reviewer for having pressed me on this point.
Monism can be grounded in the thought that ‘health is a better guide to the quality of life than measures of real income and GNPpc’ (Wilkinson, 1996, p. 215). It can also be grounded in the view that people ascribe great, irreducible value to health (Marmot, 2013). For an instance of a monist theory, see Ruger (2009). For a kindred critique of health monism, see Latham (2013).
For such a sufficientarian view in the area of health, see Powers and Faden (2006).
This conception of health has been famously adopted by the World Health Organization, according to which ‘health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. An instance of this expansionary move in the philosophical literature is Venkatapuram (2013).
Cf. my ‘Integrating Intermediate Goods to Theories of Distributive Justice’, in Res Publica, DOI 10.1007/s11158-015-9274-1, 2015.
See my ‘Sites of Deliberation in Contemporary Electoral Systems’ (ibid.)
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Acknowledgements
The author wishes to thank Adina Preda, Kristin Voigt, Thomas Schramme and Sridhar Venkatapuram, among others, for their helpful comments on that occasion. He also wishes to thank two anonymous referees for this journal for their extensive comments.
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An earlier version of this article was delivered at a symposium on health justice at the Zentrum für Interdisciplinarische Forschung at the University of Bielefeld.
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Weinstock, D. Health justice after the social determinants of health revolution. Soc Theory Health 13, 437–453 (2015). https://doi.org/10.1057/sth.2015.11
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DOI: https://doi.org/10.1057/sth.2015.11