Public Health Social Justice
by
Sridhar Venkatapuram
  • LAST MODIFIED: 25 February 2016
  • DOI: 10.1093/obo/9780199756797-0152

Introduction

Realizing social justice has always been a prominent concern of public health. From the initial founding of public health as a discipline, profession, and movement in the mid-19th century, different dimensions of the causes and societal distribution of disease, premature death, and longevity (“health inequalities”) have been understood as directly reflecting the way a society is organized and functioning. Appropriately responding to the different dimensions of health inequalities naturally leads to thinking about how a society should be organized or function—to develop a conception of a just or good society. However, the descriptive aspects of public health, the normative reasoning about social justice as well as the links between the two have been deeply contested from the beginning. The vibrant and often acrimonious public discussions in many countries and in various academic disciplines on the topic of health inequalities and social justice reflect our rapidly changing understanding of the causes and distribution of human diseases and health, scientific advances, and the social, political, and economic inequalities and transformations occurring in the world. The debates also reflect philosophical disagreements about what constitutes a good and just (global) society. Two phenomena are worth noting for their profound impact on current discussions on health and social justice. First, the initial decade of the 21st century saw the solidification and wider recognition of a corpus of epidemiological studies on the social determinants of health. This research is transforming our explanatory paradigm of disease and mortality, which previously had been focused largely on individual level factors such as genetics, individual behaviors, and proximate exposures to harmful agents. Social epidemiology expands the causal chain in time and space to include factors such as family and work environments, neighborhood, national economic and political systems, and global processes. The second phenomenon is that of globalization. Alongside the intensification of social, political, and economic interconnectedness of societies is the increased magnitude and movement of new and resurgent causes of disease and mortality—and, possibly, health and longevity—across national borders. Our knowledge of the social and global factors impacting health is rapidly expanding, and our ethical and political discussions on what the social responses should be are also quickly evolving. Despite the literature being vast, the following article reflects the fact that most of the literature has largely been produced in developed countries and in the Anglo-American philosophical traditions. The literature will likely evolve in the future to reflect both geographical and philosophical diversity.

Journals

These journals cover a range of disciplines including bioethics, political philosophy, and health policy where scholarly discussions of social justice in the domain of public health are presented. All of these journals publish state-of-the-art scholarship that is peer reviewed. Public Health Ethics frequently publishes articles on various aspects of social and global justice related to health issues. Other journals that largely focus on traditional bioethics issues such as Bioethics, American Journal of Bioethics, and Cambridge Quarterly of Healthcare Ethics have also begun publishing articles related to public and global health. The Hastings Center Report is unique as it usually publishes a few long articles considered to be of important and current relevance. Some journals are more explicitly international in scope. Developing World Bioethics was created to present bioethics issues that are specific to resource poor countries and non-Western traditions of ethics. Health & Human Rights was the first journal established to bring together health issues and human rights law, practice, and philosophy. While the Lancet is mainly a journal of medical research, various dimensions of public and global health policies and needs are prominently discussed in editorials, special issues and reports, commentaries, and articles.

History of Public Health and Social Justice

Mid to late 19th-century Britain is commonly understood to be the origin of modern public health. It is during that period that the concept of public health coalesced around the “sanitary idea” and control of infectious diseases. Intertwined with the advances in public health technologies during the 19th century as well as in health care during the 20th century was the concern for social justice. To put it simply, realizing social justice in relation to health was understood to mean ensuring greater equity in access to the benefits of public health and health-care goods and services. Hamlin 1998, Porter 1999, and Szreter 2007 provide very good historical evaluation of the social and political context of public health programs and improvements in population health during that time. All three works show that the motivations, justifications, and specific pathways chosen or abandoned in the path toward health improvements were contested. The first chapter in Trostle 2004 presents a rare and more recent history about a group of South African doctors who practiced social medicine in the 1950s and 1960s. These individuals became political exiles under apartheid and went on to profoundly shape the development of social epidemiology. Public health is sometimes described as having evolved in waves. In this view, the first wave, starting in the late 19th century, focused on public services including sanitation, clean water, and food safety. The second wave, starting in the early 20th century, was the rise of medicine as a productive science. The third wave started with the mid-20th century rise of the welfare state, which included universal access to health care. The fourth wave, starting in the late 1970s, entailed increasing attention to personal risk factors and behaviors. However, such teleological or heroic narratives may over simplify and obfuscate the conflicts, changing scope, purposes, agents, and ethical justifications of public health. Some would argue that social responses to the HIV/AIDS pandemic during the 1980s and 1990s fundamentally transformed public health and medicine. Using HIV/AIDS as a case study, Epstein 1996 provides a compelling analysis of the way scientific knowledge is produced and gains credence and how social justice activists transformed health sciences. Responding to the regressive HIV/AIDS policies and neglect around the world, Mann, et al. 1994 identified a new paradigm for public health that focuses on human rights. Krieger and Birn 1998 retrace and reassert the social justice foundations of public health. Hofrichter 2003 presents a useful collection of essays that captures the renewed focus on social justice in public health.

  • Epstein, Steven. 1996. Impure Science: Aids, activism, and the politics of knowledge. Medicine and Society. Berkeley: Univ. of California Press.

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    This book presents a sociological analysis of how health scientific knowledge is produced and becomes credible and how AIDS activists transformed drug development and research protocols.

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  • Hamlin, Christopher. 1998. Public health and social justice in the age of Chadwick: Britain, 1800–1854. Cambridge History of Medicine. Cambridge, UK: Cambridge Univ. Press.

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    This book reevaluates the early history of public health, a term often understood to mean sanitary reforms and infectious disease control. It examines the social context and politics around health during early 19th century Britain that determined what was included and excluded in the concept of public health.

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  • Hofrichter, Richard. 2003. Health and social justice: A reader on the politics, ideology, and inequity in the distribution of disease. San Francisco: Jossey-Bass.

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    A collection of essays that provides a broad overview including the social determinants health, theoretical issues at stake, and possible strategies and policies. They are largely focused on North America. The theoretical essays are informative but do not go deep in theories of justice.

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  • Krieger, N., and A. E. Birn. 1998. A vision of social justice as the foundation of public health: Commemorating 150 years of the spirit of 1848. American Journal of Public Health 88.11: 1603–1606.

    DOI: 10.2105/AJPH.88.11.1603Save Citation »Export Citation » Share Citation »

    This short article traces the social justice foundations of public health and argues for a return to those founding principles.

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  • Mann, J. M., L. Gostin, S. Gruskin, et al. 1994. Health and human rights. Health and Human Rights 1.1: 6–23.

    DOI: 10.2307/4065260Save Citation »Export Citation » Share Citation »

    This article was published in the very first volume of the Journal of Health & Human Rights. It outlines a global public health paradigm based on the idea that a healthy population and a good society is one which protects, promotes, and fulfills human rights.

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  • Porter, Dorothy. 1999. Health, civilization, and the state: A History of public health from ancient to modern times. London: Routledge.

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    This book traces the changing relationship between the state, citizen, and social groups over time through the social efforts to improve or regulate health of populations. It is focused on European and North American societies.

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  • Szreter, Simon. 2007. Health and wealth: Studies in history and policy. Rochester, NY: Univ. of Rochester Press.

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    This book is based on a series of essays that explore the demographic changes in Britain after the industrial revolution and lessons for modern times. It examines the links between economic change and population health and identifies a variety of underexplored social dynamics, values and policies that produced improvements in health.

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  • Trostle, James A. 2004. Epidemiology and culture. Cambridge Studies in Medical Anthropology 13. Cambridge, UK: Cambridge Univ. Press.

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    The first chapter of this book presents a rare but important history of social medicine in South Africa. Leaders of those efforts became dispersed around the world during apartheid and went on to profoundly shape the disciplines of epidemiology, social medicine, and public health.

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Social Justice Philosophy

Theories of social justice or arguments for what is a good and just society are identifiable in the Western tradition at least from the time of ancient Greece. Modern conceptions of social justice, particularly those that come out of the Enlightenment tradition, place the moral equality of persons and individual liberty to conceive and pursue one’s life plans as central and fundamental values. Sandel 2007 and Kymlicka 2002 present excerpts and discussions that survey the evolution and issues in social justice philosophy. One prominent theory of social justice that has persevered over centuries is that of utilitarianism, initially articulated by Jeremy Bentham in 1789. The simple philosophy conceptualizes a good society as one that aims to achieve the greatest amount of happiness for the greatest number of people. Over two centuries, Bentham’s theory guided the transformation of the British legal and social institutions, and through its empire, shaped public institutions throughout the world. Utilitarianism also influenced central paradigms of social sciences such as economics. It also profoundly shaped public health sciences and policy. For example, the justification for accepting adverse effects of vaccination programs or for limiting liberties of certain individuals for public health reasons is often for achieving the “greater public good.” (Warnock 1962). However, utilitarianism has been sharply criticized from its beginning. Sen and Williams 1982 provide one of the best critiques. It was only in the early 1970s that a credible alternative to utilitarianism that adhered to liberal values was put forward. Rawls 1971 presents a theory of justice that is based on the social contract tradition. He presents a hypothetical procedure where individuals designing a good society do not know much about themselves or what social position they will have in that society. As a result, certain goods are identified as being valuable to everyone, and rules are created to fairly distribute those goods. After Rawls, various philosophers have developed alternative theories that identify different valuable goods and/or distribution rules. Nozick 1974 identifies liberties, Dworkin 2000 identifies resources, and Sen 1999 identifies capabilities. There are more theories, while others are still being developed. An important criterion for evaluating all these theories is to see how they handle individual and public health issues within and across societies. That is, while a theory of justice should serve as a guide and an ideal, if the theory does not say very much about health or handle the issues well, then it may not be such a good theory.

  • Dworkin, Ronald. 2000. Sovereign virtue: The theory and practice of equality. Cambridge, MA: Harvard Univ. Press.

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    This book presents a theory of social justice where individuals are provided “personal” and “impersonal” resources based on their luck and personal choices.

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  • Kymlicka, Will. 2002. Contemporary political philosophy: An introduction. 2d ed. Oxford: Oxford Univ. Press.

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    This book provides a very thorough introduction to contemporary Anglo-American political philosophy, of which social justice is an important topic.

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  • Nozick, Robert. 1974. Anarchy, state, and utopia. New York: Basic Books.

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    This book provides a libertarian argument for a good society. It is conceived as one that has a minimal state that exists as a “nightwatchman” to protect the personal liberties and property of citizens.

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  • Rawls, John. 1971. A theory of justice. Cambridge, MA: Harvard Univ. Press.

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    Recognized as the most important work in modern political philosophy, this book presents an argument for a good society as one that ensures every citizen as certain basic “primary goods” that are distributed according to certain rules.

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  • Sandel, Michael J. 2007. Justice: A reader. Oxford: Oxford Univ. Press.

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    This book provides a good introduction to Anglo-American social justice philosophy through a collection of readings based on a course at Harvard University. Also see online lectures provided by Harvard University.

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  • Sen, Amartya. 1999. Development as freedom. New York: Knopf.

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    Responding to both utilitarianism and other theories of justice, this book presents an argument that the focus of social justice should be on what individuals are actually able to be and do in their lives or their capabilities.

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  • Sen, Amartya, and Bernard Arthur Owen Williams, eds. 1982. Utilitarianism and beyond. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9780511611964Save Citation »Export Citation » Share Citation »

    The introductory section of the book presents a very clear analysis of the different aspects of utilitarianism and the moral failings of each of those aspects. Other chapters also provide different critiques.

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  • Warnock, Mary. 1962. Utilitarianism: On liberty. Essay on Bentham: Together with selected writings of Jeremy Bentham and John Austin. London: Collins.

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    This book provides a background introduction by Warnock to the philosophy and its main advocates. It also provides selected writings by Bentham, Mill, and Austin, three of its most important advocates.

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Health(Care) and Social Justice Philosophy

The origins of public health lie in the interaction of advances in scientific knowledge and technologies with social movements agitating for great social equity and justice that gave importance to health issues. In the 20th century a similar interaction between advances in science and technology, particularly in medicine, combined with social and intellectual movements. The diverse interactions in different societies produced unique social agreements or “settlements” regarding access to health care. For example, in 1948 the United Kingdom instituted a publicly funded and provided health-care system that is free at point of delivery to all citizens. In the United States, most citizens access health care through private institutions through health insurance. The current global movement spearheaded by the World Health Organization for universal health care in every country relies on a variety of scientific, ethical, economic, and political justifications. The lack of universal health care in the United States prompted philosophical discussions in the 1970s on moral claims or rights to health care. It was argued that every citizen should have a right to health care. Such arguments were criticized for being incoherent philosophically and for being economically and politically impractical. Outka 1975 reviews the ethics of different distributional principles of health care and asserts the right of equal access for every citizen. Fried 1975 argues for a right to a decent minimum package of health care. Childress 1979 reviews both Freid’s and Outka’s arguments to conclude that a legal right to health care for all citizens may be better off on different foundations than a moral right. Daniels 2013 provides an up-to-date overview of various social justice bases for providing universal access to health care (within a society). As previously stated, two defining features of a social justice theory are that it defines certain goods produced through social cooperation as being valuable and rules for fairly distributing such goods. Health care is defined as being valuable for different reasons and distributed differently by different theorists. Daniels 1985 presents a Rawlsian argument. Sen 2002 explains how health equity is not just about health care or simple distributions. Buchanan 2009 provides a collection of essays on justice in health care that is systematic but not from a single theory. In contrast, Kittay 1999 presents a possible feminist approach to health-care justice that questions the usual framework and assumptions of moral and political philosophy. All of these approaches critique a utilitarian approach to health-care justice.

  • Buchanan, Allen E. 2009. Justice and health care: Selected essays. New York: Oxford Univ. Press.

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    This book provides a collection of essays written over three decades that identify and reason through some important issues related to health-care and social justice.

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  • Childress, James F. 1979. A right to health care? Journal of Medicine and Philosophy 4.2: 132–147.

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    This essay evaluates the arguments for a right to a decent minimum of health care and to equal access to health care.

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  • Daniels, Norman. 1985. Just health care. Studies in philosophy and health policy. Cambridge, UK: Cambridge Univ. Press.

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    This book is the first iteration of an argument, based within a Rawlsian framework of justice, for providing every citizen access to health care because of its important role in ensuring equality of opportunity.

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  • Daniels, Norman. 2013. Justice and access to health care. Rev. ed. In The Stanford encyclopedia of philosophy. Edited by Edward N. Zalta.

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    This online article by Daniels presents a thorough overview of the concept of health care and social justice based arguments for access to health care.

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  • Fried, Charles. 1975. Rights and health care: Beyond equity and efficiency. New England Journal of Medicine 293.5: 241–245.

    DOI: 10.1056/NEJM197507312930507Save Citation »Export Citation » Share Citation »

    This was a seminal essay that motivated much discussion on if and how a right to health care could be meaningful in the context of limited resources.

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  • Kittay, Eva Feder. 1999. Love’s labor: Essays on women, equality, and dependency. Thinking Gender. New York: Routledge.

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    This book is described as a feminist critique of moral and political philosophy as it shows how individuals who are severely dependent on others as well as their carers, usually women, are not recognized and their work and concerns are not addressed in theorizing.

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  • Outka, Gene. 1975. Social justice and equal access to health-care. Perspectives in Biology and Medicine 18.2: 185–203.

    DOI: 10.1353/pbm.1975.0008Save Citation »Export Citation » Share Citation »

    This essay reviews how health care could be distributed differently based on different ethical arguments and concludes that there should be a right for everyone to equal access to health care.

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  • Sen, Amarta. 2002. Why health equity? Health Economics 11.8: 659–666.

    DOI: 10.1002/hec.762Save Citation »Export Citation » Share Citation »

    This article, meant for an audience of health economists, explains how health has a central role to play in social equity and justice. It describes the multiple ways health is valuable, including the idea of health capability versus health outcome.

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Social Determinants of Health

For much of the late 20th century, Anglo-American literature on health and social justice focused on individual rights to or fair distribution of health care. However, outside of bioethics literature, such as in the social sciences, epidemiology, and activist movements, there was increasing investigation of the social environments and non-health-care policies that directly impact health outcomes. The seminal report by Black and Whitehead 1992 considers various causes for the persistence of social group health inequalities in the British population despite decades of equal access to health care. Sen 1998 disputes a prominent theory that economic development automatically brings improved health. Sen shows that economic growth must be supplemented by specific investments such as in education, public health, and health care. Farmer 1999 describes how HIV/AIDS infections and ill health more broadly track social disadvantage, inequalities, and exclusion. These three works from different disciplines show how the determinants of individual health or social group health inequalities go far beyond health care and result from social policies and choices including inaction. Even the earliest founders of public health in the 19th century recognized that addressing causes was different from treating disease (i.e., health care). This may have been clearer to them as they were working at a time before the stupendous achievements and scale of modern medicine. Nevertheless, during the 19th century as well as in the late 20th century, there were a number of competing theories about what causes disease and particularly why ill health most affects the worst off in society. These debates were significantly transformed in the 1980s due to advances in the science of epidemiology. The use of computers to analyze large data sets, new statistical methods, large cohort studies, and so on in the hands of epidemiologists motivated by an ethic to identify and address the causes of social inequalities in health produced some startling revelations. For example, Marmot, et al. 1991 discovered a “social gradient” in health outcomes. Rather than health being unevenly distributed between rich and poor, each socio-economic class has better health outcomes than the one below it. A whole range of pathways to ill health that operate from conception all the way through the entire life course are being identified. In contrast to explaining disease in individuals, these pathways explain both why disease occurs in individuals and in social groups. Marmot and Wilkinson 1999 and Berkman and Kawachi 2000 present the main ideas and theories in social epidemiology. Deaton 2003 attempts to bring together economic and epidemiological research on health inequalities. Commission to Build a Healthier America 2009 reflects the American context of addressing social determinants of health.

  • Berkman, Lisa F., and Ichir o Kawachi. 2000. Social epidemiology. New York: Oxford Univ. Press.

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    This book serves as textbook for social epidemiology that reviews the historical evolution of epidemiology and some central research areas.

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  • Black, Douglas and Margaret Whitehead. 1992. Inequalities in health: The Black report/The health divide. Edited by Peter Townsend and Nick Davidson. London: Penguin.

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    This book presents two important reports. The first is the report (The Black Report, by Douglas Black, edited by Peter Townsend and Nick Davidson) of a working group appointed in 1977 to examine the causes of the differences in health among social classes and implications for policy. The second report (The Health Divide, by Margaret Whitehead) reviews health inequalities studies since the first report was published in 1980 up to and including 1992.

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  • Commission to Build a Healthier America. 2009. Beyond health care: New directions to a healthier America. Princeton, NJ: Robert Wood Johnson Foundation.

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    This report describes the work of the first and second commissions organized by the Robert Wood Johnson Foundation to identify the knowledge of social determinants of health inequalities in the United States, and their policy recommendations.

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  • Deaton, Angus. 2003. Health, inequality, and economic development. Journal of Economic Literature 41.1: 113–158.

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    This article presents an economist’s evaluation of the theory and evidence that socio-economic or income inequality impacts health.

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  • Farmer, Paul. 1999. Infections and inequalities: The modern plagues. Berkeley: Univ. of California Press.

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    This book presents a first-hand account of addressing health issues of the world’s poorest as well as a critical analysis of the prevailing approaches to health issues, particularly in developing countries.

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  • Marmot, Michael G., G. D. Smith, S. Stansfeld, et al. 1991. Health inequalities among British civil servants: The Whitehall II study. Lancet 337.8754: 1387–1393.

    DOI: 10.1016/0140-6736(91)93068-KSave Citation »Export Citation » Share Citation »

    This article describes the follow-up study to the initial 1967 Whitehall study that found the social gradient in health.

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  • Marmot, Michael G., and Richard G. Wilkinson. 1999. Social determinants of health. Oxford: Oxford Univ. Press.

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    This book provides the scientific evidence for social determinants of health including stress, employment, transport, social support, and ethnicity.

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  • Sen, Amartya. 1998. Mortality as an indicator of economic success and failure. Economic Journal 108.446: 1–25.

    DOI: 10.1111/1468-0297.00270Save Citation »Export Citation » Share Citation »

    The author shows how mortality, as a core indicator of health, reflects the broader functioning of social institutions and how health does not automatically improve from economic growth.

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Health and Social Justice Philosophy

The scope of health and social justice philosophy literature is expanding much beyond the access and fair distribution of health care. This is due to a range of factors including the social responses to HIV/AIDS, the growing evidence from social epidemiology, the growing global nature of disease, and the increasing awareness of global inequalities. One prominent aspect of the literature is the reliance on social justice philosophy rather than moral philosophy. Traditionally, health sciences and policymaking relied on moral philosophy because the focus was on the behavior of individuals, particularly physicians and medical researchers in their interactions with patients and research subjects. When looking at health of populations, the social determinants of individual health, and global inequalities in health, the more appropriate ethical guides are theories of social and global justice. Although “public health ethics” seeks to take up some of these concerns, a distinct and growing body of literature grounds health issues in theories of social and global justice. Wikler and Brock 2007 presents a good overview of the philosophical issues when the focus moves from individuals to populations. Anand, et al. 2004 focuses specifically on the normative investigations of epidemiological literature on social determinants of health inequalities. In social justice philosophy literature and in the health justice literature more specifically, arguments are presented in a dialectical manner to show how and why one particular theory of social justice is more coherent or “does more justice” than competing conceptions. Utilitarianism is often the foil or contrasting theory. As previously stated, utilitarianism has persevered for two centuries and is still going strong, particularly in public health. Murray, et al. 2002 presents a comprehensive series of topics in relation to the development of a health measure called the disability adjusted life year and disability adjusted life year maximizing policies across the world. Daniels 2008 presents a revised version of the author’s theory taking into account social determinants of health. Segall 2009 presents a luck egalitarian approach to health issues. Powers and Faden 2008 argues for sufficiency of some basic goods. Venkatapuram 2011 argues for every human being’s right to a capability to be healthy. Asada 2007 is agnostic about theories of justice to show that determining what is happening to health inequalities depends on the ethical and philosophical positions that inform the empirical strategies of the researchers.

  • Anand, Sudhir, Fabienne Peter, and Amartya Kumar Sen. 2004. Public health, ethics and equity. Oxford: Oxford Univ. Press.

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    This book presents essays by notable academics including philosophers on the normative or ethical implications of the growing research findings on the social determinants of health and health inequalities.

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  • Asada, Yukiko. 2007. Health inequality: Morality and measurement. Toronto: Univ. of Toronto Press.

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    This book presents a very interesting analysis of how the evaluation of the dynamics of inequalities in health depends on the ethical and philosophical assumptions or positions of the researchers and their research methods.

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  • Daniels, Norman. 2008. Just health: Meeting health needs fairly. Cambridge, UK: Cambridge Univ. Press.

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    This is a revised version of the Daniels’s initial argument based on Rawls’s theory (see Daniels 1985, cited under Health(Care) and Social Justice Philosophy). In the revised version, he attempts to improve the principles for allocating health care, incorporate social determinants of health, and address global health inequalities.

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  • Murray, Christopher J. L., Joshua A. Salomon, Colin D. Mathers, and Alan D. Lopez, eds. 2002. Summary measures of population health: Concepts, ethics, measurement and applications. Geneva, Switzerland: World Health Organization.

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    This is a very comprehensive book that presents the various empirical, philosophical, and ethical issues with measuring the health of populations and using that measure of policy. It reflects a utilitarian approach.

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  • Powers, Madison, and Ruth R. Faden. 2008. Social justice: The moral foundations of public health and health policy. New York: Oxford Univ. Press.

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    Partly based on the capabilities approach, this book presents an argument that the aim of health policy should be to ensure that every person is sufficiently able to be and do certain things.

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  • Segall, Shlomi. 2009. Health, luck, and justice. Princeton, NJ: Princeton Univ. Press.

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    This book presents an argument for approaching health justice that can be sensitive to both bad luck in people’s lives as well as to the bad choices they make. See also Fairness and Personal Responsibility.

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  • Venkatapuram, Sridhar. 2011. Health justice. An argument from the capabilities approach. Cambridge, UK: Polity.

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    This book extends the capabilities approach to social justice into the health domain and argues for a moral or human right to the capability to be healthy.

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  • Wikler, Daniel, and Dan W. Brock. 2007. Population-level bioethics: Mapping a new agenda. In Ethics, prevention, and public health: Issues in biomedical ethics. Edited by Angus Dawson and M. F. Verweij, 78–94. Oxford: Clarendon.

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    This book chapter is a very good overview of the various ethical issues that come to the fore when we look at population health rather than individual health.

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Global Health Justice and Inequalities

The concern for providing health care to the worst off or all citizens looks markedly different when set against the backdrop of global health inequalities. If a conception of social justice motivates ensuring that the benefits of health care and public health are widely shared, especially by those most burdened with ill health, then do demands from justice extend beyond national borders to others who are even worse off? That is, is the concept of social justice confined to political borders such as those of nation states? O’Neill 2002 presents one of the initial discussions on health, justice, and national borders. Macklin 2012 presents essays on the prospect of a shared global set of ethics related to health. Different conceptions of social justice have different views on how societal entities like nation-states, economic unions, or weak and non-existent states affect demands of justice in general and in relation to health more narrowly. Global justice arguments can often be put on a spectrum. On one side is a view that social justice is a national concept that is derived through an agreement of citizens that is then backed by force. At the other end is the view that political borders are arbitrary and historically contingent and all human beings have equal standing to each other with equal rights and obligations. Few philosophers take either extreme position. Yet, it is still unclear where on the spectrum lies the most coherent argument. On top of these theoretical debates exists the growing empirical literature that shows that citizens of richer countries are deriving health benefits from poorer countries through health tourism, research trials, organ donations, cheaper medicines, and so forth. There is also growing awareness of how global institutions and processes—whether legal, economic, or political—disadvantage the worst off in developed as well as in developing countries by impacting their health negatively through social determinants of disease. World Health Organization Commission on Social Determinants of Health 2008 is the first global analysis of social determinants of health. Chatterjee 2004 presents philosophical essays on global justice with a focus on the world’s worst off. Health issues are not the primary focus, but the inequalities in life expectancy and disease prevalence act as jumping-off points. Benatar and Brock 2011 presents discussions on global health ethics informed by global justice debates. Similarly, Lenard and Straehle 2012 provides philosophical essays on the global dimension of health inequalities. Farmer 2003 and Wolff 2012 provide an argument for and assessment of a human rights approach to health.

  • Benatar, S. R., and Gillian Brock, eds. 2011. Global health and global health ethics. Cambridge Medicine. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9780511984792Save Citation »Export Citation » Share Citation »

    This edited book presents philosophical essays on various topics in global health including whether there is a need for distinct global health ethics.

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  • Chatterjee, Deen K. 2004. The ethics of assistance: Morality and the distant needy. Cambridge Studies in Philosophy and Public Policy. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9780511817663Save Citation »Export Citation » Share Citation »

    This book presents a range of philosophical arguments about the possible duties of those in rich countries to help those in poor countries.

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  • Farmer, Paul. 2003. Pathologies of power: Health, human rights, and the new war on the poor. California Series in Public Anthropology 4. Berkeley: Univ. of California Press.

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    Based on first-hand account of addressing health crises, this book presents an approach to applying human rights to the most severe health inequalities in the world.

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  • Lenard, Patti Tamara, and Christine Straehle, eds. 2012. Health inequalities and global justice. Edinburgh, UK: Edinburgh Univ. Press.

    DOI: 10.3366/edinburgh/9780748646920.001.0001Save Citation »Export Citation » Share Citation »

    This edited book presents a range of philosophical essays on the normative aspects of global health inequalities such as a human right to health, measuring health, and identifying responsible actors.

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  • Macklin, Ruth. 2012. Ethics in global health: Research, policy, and practice. Oxford: Oxford Univ. Press.

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    This book presents a set of essays by a notable bioethicist on the prospect of globalizing bioethics or developing shared ethical principles.

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  • O’Neill, Onora. 2002. Public health or clinical ethics: Thinking beyond borders. Ethics & International Affairs 16.2: 35–45.

    DOI: 10.1111/j.1747-7093.2002.tb00395.xSave Citation »Export Citation » Share Citation »

    This article is important for it was one of the first to explicitly identify how health threats cross borders but our ethical reasoning is often bounded by national borders.

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  • Wolff, Jonathan. 2012. The human right to health. New York: Norton.

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    This book reviews the recent flourishing of the human right to health in policy and philosophy. It reviews its history, criticisms, and some practical issues with application.

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  • World Health Organization Commission on Social Determinants of Health. 2008. Closing the gap in a generation. Health equity through action on the social determinants of Health. Geneva, Switzerland: World Health Organization.

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    This report is the first analysis of the scientific evidence on the social determinants of health worldwide. It is notable for making an argument for addressing health inequalities as a matter of social justice.

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Fairness and Personal Responsibility

In philosophical discussions about social justice, one of the central issues is whether the distributional principles for allocating valuable and finite social goods should reflect the choices that individuals make. For example, it does not seem fair to provide certain individuals with more income because they have expensive tastes or provide them basic income if they choose to not take up socially productive roles. At the same time, individuals experience disadvantages as a result of factors beyond their control such as genetic endowments or social upbringing. This concern for fairness that reflects personal responsibility for one’s choices is also apparent in the health justice literature. In the casual chain that leads to impairments and disease, an individual’s personal choices or behaviors may have an important role. One line of argument is that if we are to assist individuals who are disadvantaged because of factors that they did not choose, then we should not assist those individuals who suffer negative consequences from choices they freely made. This matters because social resources are finite, and we cannot assist everyone. Given the rising spending on health care in many developed countries and very limited resources in others, such a view on personal responsibility is finding traction. Especially in relation to the growing burden of chronic diseases that are linked to long-term behaviors, limiting assistance or rewarding individuals for healthy behaviors is thought to express fairness. However, the ever-growing social determinants of health literature puts the onus of responsibility onto society. Where social determinants stop and individual choice begins is, needless to say, is unsettled and contentious in health care and beyond. Cohen 1989 assesses different valuable goods proposed by various theories and identifies the need to take account of personal choices. Arneson 1989 presents an approach to social justice that identifies equality of opportunity for welfare as the valuable good. Scheffler 1992 is an important paper that argues for why liberalism should be more concerned with holding people responsible for their choices. Matravers 2007 reviews four theories that seek to establish moral responsibility. Roemer 1993 presents an approach that seeks to allocate health care based on social group belonging and personal choices. Anderson 1999 is a seminal paper in which the author argues for what is wrong with the focus on responsibility using access to health care as her main example. Segall 2009 attempts to refute Anderson’s objection and save a responsibility sensitive approach to health care and health determinants (p. 400).

  • Anderson, Elizabeth. 1999. What is the point of equality? Ethics 109.2: 287–337.

    DOI: 10.1086/233897Save Citation »Export Citation » Share Citation »

    This article presents a seminal critique of various philosophers’ attempts to include personal responsibility as a central part of a theory of justice.

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  • Arneson, R. J. 1989. Equality and equal-opportunity for welfare. Philosophical Studies 56.1: 77–93.

    DOI: 10.1007/BF00646210Save Citation »Export Citation » Share Citation »

    This article presents an argument that rather than resources or welfare/happiness, social justice should be focused on distributing opportunities for welfare. Such opportunities will then be sensitive to disadvantages as well as free choices.

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  • Cohen, Gerry A. 1989. On the currency of egalitarian justice. Ethics 99.4: 906–944.

    DOI: 10.1086/293126Save Citation »Export Citation » Share Citation »

    This article presents a critical review of the various valuable social goods that competing theories of justice advocate.

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  • Matravers, Matt. 2007. Responsibility and justice. Cambridge, UK: Polity.

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    This book accessibly reviews different philosophical theories of personal responsibility and their relation to social justice theories.

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  • Roemer, John E. 1993. A pragmatic theory of responsibility for the egalitarian planner. Philosophy and Public Affairs 22:144–166.

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    This article presents an argument that aims to identify how to allocate resources fairly to individuals in light of their social group belonging and their individual choices.

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  • Scheffler, Samuel. 1992. Responsibility, reactive attitudes, and liberalism. Philosophy & Public Affairs 4.4: 299–323.

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    This is an important article in the debates about the need for political liberals as well as philosophers of liberalism to hold individuals more responsible for their actions.

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  • Segall, Shlomi. 2009. Health, luck, and justice. Princeton, NJ: Princeton Univ. Press.

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    This book presents an argument for addressing health issues in a way that is both sensitive to individual choices but not undermined by the charge that it is inhumane or unjust to leave a person to suffer because of their choices. See also Health and Social Justice Philosophy.

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Health Economics

Striving to realize social justice through public policy in general and in the domain of health in particular invariably involves economic analysis. Economists, including health(care) economists, have particular tools and methodologies for evaluating policy options. Generally called cost-benefit analysis, there are many variants according to what is included in the costs or benefits. Sen 2000 reviews some of the theoretical and ethical aspects of cost-benefit analysis. Nussbaum 2000 presents a philosophical analysis of the morality of cost-benefit analysis. Clearly, how and what are measured as costs and benefits in relation to various policy options are an important input in the determination of which policies are chosen. Such an analysis is also central to choosing among health-care or health policies. Despite the growing literature on non-health-care care determinants of health, most of health economics is focused on the economic evaluation of public health and health-care policies, programs, and technologies. Following Sen’s analysis of the influence of utilitarianism in welfare economics, a number of health economists also trace its influence in health economics. Culyer 1989 presents the initial analysis and argues for an “extra-welfarist” approach to health economics. Cost-benefit analysis reflects a maximizing philosophy otherwise stated as efficiency. The principle of equity is often referred to by health economists to identify alternative distributions of health-care outcomes. Pereira 1993 and Williams and Cookson 2000 consider the possible meaning and different approaches to equity in health economics. McIntyre and Mooney 2007 argues that, despite equity being said to be important, there has not been much progress in health economics. Mooney 2009 presents a new paradigm for health economics that gives more of a central focus on equity and the social determinants of health.

  • Culyer, Anthony. 1989. The normative economics of health care finance and provision. Oxford Review of Economic Policy 5.1: 34–58.

    DOI: 10.1093/oxrep/5.1.34Save Citation »Export Citation » Share Citation »

    The author identifies the utilitarian underpinnings in health economics and suggests that the discipline needs to move away from those moorings toward “non-welfarism.”

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  • McIntyre, Di, and Gavin H. Mooney. 2007. The economics of health equity. Cambridge, UK: Cambridge Univ. Press.

    DOI: 10.1017/CBO9780511544460Save Citation »Export Citation » Share Citation »

    This is a very useful book that examines the concept of equity in health economics and looks at different dimensions of the concept and in the context of different health systems.

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  • Mooney, Gavin H. 2009. Challenging health economics. Oxford: Oxford Univ. Press.

    DOI: 10.1093/acprof:oso/9780199235971.001.0001Save Citation »Export Citation » Share Citation »

    This book presents a novel argument for a new paradigm for health economics that eschews utilitarianism and builds on a communitarian philosophy and incorporates the social and global determinants of health.

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  • Nussbaum, Martha C. 2000. The costs of tragedy: Some moral limits of cost-benefit analysis. Journal of Legal Studies 29.S2 Part 2: 1005.

    DOI: 10.1086/468103Save Citation »Export Citation » Share Citation »

    This article presents a novel argument that cost-benefit analysis is aimed to answer what should we do, but that it does not to help answer an equally important question of whether any of the available options are free from moral wrongdoing.

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  • Pereira, João. 1993. What does equity in health mean? Journal of Social Policy 22:19–48.

    DOI: 10.1017/S0047279400019097Save Citation »Export Citation » Share Citation »

    This is a good review of the various understandings of equity in health economics with reference to ethics or theories of justice.

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  • Sen, Amartya. 2000. The discipline of cost-benefit analysis. Journal of Legal Studies 29.S2: 931–952.

    DOI: 10.1086/468100Save Citation »Export Citation » Share Citation »

    This article presents a very thorough analysis of cost-benefit analysis, its utilitarian underpinnings, and the possibilities of it reflecting other kinds of values.

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  • Williams, Alan, and Robert Cookson. 2000. Equity in health. In Handbook of health economics. Vol. 1B. Edited by A. J. Culyer and J. P. Newhouse, 1863–1910. Amsterdam: Elsevier.

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    This chapter presents a technical and rigorous analysis of the concept of equity in health in contrast to equity in access to health care or distribution of health-care resources.

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Philosophy of Epidemiology (and Evidence)

As argued from the beginning of this article, health and social justice has always entailed the interaction of scientific advances and social and intellectual movements. For example, determining what the right social response should be to the high burden of ill health among the poorest in society is very linked to prevailing knowledge of the causes of such ill health. If it is thought to be random, God’s will, genetic inferiority, or personal choices, then the scope of social policies will reflect that. Like in the 19th century, there continue to be debates about the causes of disease and mortality. Even today scientific outputs can transform ethical reasoning about health justice, and ethical/philosophical reasoning can transform scientific questions, methods, and outputs. This mutual interaction is why epidemiology and the study of health and social justice is thoroughly linked. Epidemiology is the informational engine of clinical medical care and public health. It identifies the causes and distribution of disease and mortality as well as the effectiveness of interventions. The expansion of the scope of epidemiology to look at causal chains behind the proximate causes as well as new psychosocial pathways has transformed how we reason about social justice. However, the basic paradigm of epidemiology itself is undergoing transformation to incorporate factors that go beyond the individual level of analysis. Consequently, an important body of literature discusses the scope and purpose of epidemiology and the philosophy of causation underlying research and their conclusions. There are related debates about the kind of evidence produced from different types of epidemiological studies that would support or reject health policy options. Syme 1996 discusses the limits of the current explanatory paradigm of epidemiology. Susser and Susser 1996a and Susser and Susser 1996b present a thorough conceptual analysis of current and possible causal models of disease. Krieger 1994 describes how the political and social context produced a causal model in epidemiology that focuses only on individual level factors. In contrast, Zielhuis and Kiemeney 2001 argues that epidemiology should not focus on social level factors. Rothman, et al. 2008 is a popular textbook that presents the conceptual and methodological issues in current epidemiology. Broadbent 2013 is the first philosophy book to deeply examine causation underlying epidemiology. Killoran and Kelly 2010 presents various issues and challenges of trying to produce public health policy evidence (p. 387).

  • Broadbent, Alex. 2013. Philosophy of epidemiology. New Directions in the Philosophy of Science. New York: Palgrave Macmillan.

    DOI: 10.1057/9781137315601Save Citation »Export Citation » Share Citation »

    This book is the first comprehensive attempt to philosophically examine various concepts in epidemiology, particularly how causation is concluded.

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  • Killoran, Amanda, and Michael P. Kelly, eds. 2010. Evidence-based public health: Effectiveness and efficiency. Oxford: Oxford Univ. Press.

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    This edited book contains a variety of essays on different aspects of public health research and issues dealing the kind of knowledge it produces and how such knowledge ranks in relation to other kinds of knowledge in relation to health and public policy.

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  • Krieger, Nancy. 1994. Epidemiology and the web of causation: Has anyone seen the spider? Social Science and Medicine 39.7: 887–903.

    DOI: 10.1016/0277-9536(94)90202-XSave Citation »Export Citation » Share Citation »

    This seminal article describes how the social and political context in the 1950s and 1960s in the United States shaped the development of the explanatory model of epidemiology.

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  • Rothman, Kenneth J., Sander Greenland, and Timothy L. Lash. 2008. Modern epidemiology. 3d ed. Philadelphia: Lippincott Williams & Wilkins.

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    This is a population textbook of epidemiology that thoroughly presents the state of the art information of basic concepts, methodologies, and special topics.

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  • Susser, Mervyn, and Ezra. Susser. 1996a. Choosing a future for epidemiology: I. Eras and paradigms. American Journal of Public Health 86.5: 668–673.

    DOI: 10.2105/AJPH.86.5.668Save Citation »Export Citation » Share Citation »

    This article presents an analysis of the history of causal explanations of disease and their distribution.

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  • Susser, Mervyn, and Ezra. Susser. 1996b. Choosing a future for epidemiology: II. From black box to Chinese boxes and eco-epidemiology. American Journal of Public Health 86.5: 674–677.

    DOI: 10.2105/AJPH.86.5.674Save Citation »Export Citation » Share Citation »

    This article reviews the implications of social epidemiology for the explanatory paradigm of epidemiology.

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  • Syme, S. Leonard. 1996. Rethinking disease: Where do we go from here? Annals of Epidemiology 6.5: 463–468.

    DOI: 10.1016/S1047-2797(96)00097-XSave Citation »Export Citation » Share Citation »

    This article, written by a leading figure in social epidemiology, describes the shortcomings of epidemiology that only focuses on individual level causes.

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  • Zielhuis, Gerhard, and Lambertus Kiemeney. 2001. Social epidemiology? No way. International Journal of Epidemiology 30:43–44.

    DOI: 10.1093/ije/30.1.43Save Citation »Export Citation » Share Citation »

    This article represents the view that epidemiology should not look at non-natural factors of disease such as social determinants of health.

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