Pursuing Justiceand Equity in Health
Public Health, Ethics, and Equity
edited by Sudhir Anand, Fabienne Peter and Amartya Sen; Oxford University Press, New Delhi, 2006; pp 316, Rs 595.
D NARAYANA
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The extensive empirical and policy research and initiatives on health and health inequalities of the last two decades have yet to be matched by an appreciation of the normative underpinnings of health equity. The present volume seeks to initiate this subject area from a variety of perspectives, which are the five parts of the book: (1) what is health equity? (chapters 1-2); (2) health equity in relation to social justice (chapters 3-5); (3) health inequalities and responsibilities for health (chapters 6-8); ethical issues in health evaluation and prioritisations (chapters 9-12); and anthropological perspectives in health equity (chapters 13-15).
Health Equity
Sudhir Anand (chapter 1) starts by asking the question: why are we concerned with health equity. He argues that health should be treated as a special good because it is a prerequisite to a person functioning as an agent. Inequalities in health thus constitute inequalities in people’s capabilities to function – a denial of equality of opportunity. In chapter 2, Amartya Sen provides the broader considerations of social justice, which have a bearing on health and he goes on to emphasise the distinction between outcome-related evaluations and process-related evaluations.
Michael Marmot (chapter 3) draws on his famous “Whitehall” studies of British civil servants and discusses why social gradients in health outcomes should be a matter of policy concern. He rejects the “health selection” argument, emphasises the role of social factors in the production of ill health and shows that a social gradient in health outcomes remains after controlling for those disparities in health that may be linked to individual life style choices such as smoking. Daniels, Kennedy and Kawachi (chapter 4) use the social gradient in health outcomes as a starting point and seek to answer the question “when are social inequalities in health unjust”, drawing on an extension of Rawl’s theory of justice developed by Daniels (1985) in the context of Just Healthcare. As there are many factors other than healthcare that affect a person’s health, they extend Rawl’s principle of fair equality of opportunity to the entire range of factors that influence health.
The problem a theory of health equity faces is how to go from an empirical identification of social inequalities in health to a normative judgment about health inequities. What is needed is a framework within which the ethical issues raised by empirical literature can be addressed and that helps in determining which inequalities in health outcomes are unjust. Fabienne Peter (chapter 5) contributes to this literature on public health ethics. She takes an indirect approach based on the premise that social inequalities in health are wrong because they are an expression and product of unjust economic, social, and political institutions, thus embedding the pursuit of health equity in the pursuit of social justice in general. One advantage of the indirect approach is that it provides a basis for choosing relevant social groups in the assessment and explanation of social inequalities in health.
A pertinent question in the context of inequalities in health is that of individual responsibility for health, especially in the wake of infectious diseases giving way to life style diseases (Daniel Wikler, chapter 6). For many of these maladies, the most effective actor is the individual and not the state, and the way to ensure that people do not burden others with the cost of care stemming from imprudence is to enforce
Economic and Political Weekly March 10, 2007 “healthy behaviour”, offer low priority for treatment of avoidable illnesses, and have the potential risk-taker pay in advance for any added risk. However, the correlation of health and longevity with social position compels us to view the “healthy behaviour” in a new light.
Justice and Health
Moral assessment must be sensitive not only to the distribution of health outcomes but also to how these outcomes are produced. In institutional contexts, many kinds of social institutions can substantially contribute to the incidence of medical conditions. Persons materially involved in upholding such economic institutions are then materially involved in the causation of such medical conditions. While local economic institutions play an important role in the reproduction of extreme poverty and ill health, the role of global institutions is no less. With this background Thomas Pogge (chapter 7) turns to the central question: what kinds of entities are possible judicanda (judicandum – that which is to be judged) under the headings of justice, fairness and equity. The concept of justice is primarily applied to subjects such as persons and groups, to the conduct of such subjects, to social rules and to other states of affairs and is fundamentally toward certain recipients in regard to the distribution of something.
The health equity theme provokes a clash of two variants of egalitarian liberalism. One side is committed to the expansion of the healthcare system by devoting it to neutralise all handicaps, disabilities and other medical conditions not of their making. The other side is committed to the view that we need do no more for persons whose health is poor through no fault of ours. This focus may be a residue of the consequentialist idea that we should assess subjects, conduct, and social rules by their effects on the quality of overall distribution of goods and ills among the recipients but treating recipients justly does not boil down to promoting the best distribution among them. The most plausible general structure for a conception of social justice would involve weighting the impact that social institutions have on the relevant quality of life according to how they have this impact. If this is right, then it is no truer of social rules than of subjects and conduct that they are just if and in so far as they promote a good overall distribution.
The choice of a conception of justice in healthcare can crucially affect the conquest of a city and the survival of a country (Philippe Van Parijs, chapter 8). Belgium is a federal state consisting of the prosperous Flanders, poorer Wallonia, and national capital Brussels. The consumption of healthcare – largely funded by proportional social security contributions levied at the same rate throughout the country – is significantly high by the Walloon population compared to the Flemish population. Once the facts became widely known, a feeling of injustice quickly developed among the Flemish. The response to the challenge, it would seem, was a tighter monitoring of the application of common norms of entitlements. But the challenge is deeper: firstly, objective medical needs themselves may be influenced by the use regions are making of their powers in areas other than healthcare; and secondly, the three regions, and its two main linguistic communities could develop distinct conceptions of the overall share of public resources to be devoted to
Economic and Political Weekly March 10, 2007
healthcare and the make up of the specific package of services to be offered.
Measuring Health
How should we aggregate health consumption across people, time, and different types of health conditions is the central issue taken up in part IV. Since the publication of the World Development Report 1993: Investing in Health, disability adjusted life years (DALY) has become a popular measure of ill-health and is widely used in evaluating health interventions and for resource allocation or priority settings. The elaboration of the ethical underpinnings of these measures is a valuable contribution of this part and a must read for all public health researchers and practitioners.
A methodology that combines in a single measure the two broad kinds of benefits produced by health interventions – extension of the length of life and improvements in the quality of life – is one of the central problems of health economics. The construction of any measure entails a two-step process: first, a description of the different states of disability or limiting conditions and second, assigning different relative values to these conditions (chapter 10). The first is an empirical question but the second is a question of people’s preferences for life with those conditions. DALY used the preference of expert health professionals; the health utilities index and quality of well-being used the value judgments of a random group of ordinary citizens. Each has its biases. The problem is to determine an appropriate evaluative standpoint for ranking the importance of different disabilities. Any summary measure assigning different values to disability conditions is faced with the following questions: how should states of health and disability be evaluated, do all quality adjusted life years (QALYs) count equally, should discount rates be applied to healthcare benefits, and what life expectancies be used for calculating the benefits of life saving interventions.
Anand and Hanson (chapter 9) argue that age weighting and discounting future life adopted in DALY is ethically unacceptable. The DALY framework, through age-weighting and discounting, values life years lived by people of different ages and generations differently. In measuring the burden of disease or in allocating resources, why should a life year lived by a young or old person be valued less than that lived by a person in the middle age group? Further, the burden measured by DALY is the burden of disease and underdevelopment, and not that of disease alone.
Brock’s (chapter 10) concern is with the ethical issues in the construction and use of a cost effectiveness analysis (CEA) for the prioritisation of healthcare resources. In the context of a CEA, the following questions become relevant: what priority should be given to the sickest; when should small benefits to a large number of persons receive priority over large benefits to a small number of persons; the conflict between fair chances and best outcomes; and does the use of a CEA to set healthcare priorities unjustly discriminate against the disabled. Brock succeeds in showing that there are important ethical and value choices to be made in constructing and using the measures and that the choices are not merely technical, empirical, or economic.
Kamm (chapter 11) discusses the issue of misallocation of healthcare resources – allocating excessively in favour of one service or product than others. This means that at the micro level, health is treated as a separate sphere of justice but at the macro level, decisions might require an “all-things considered judgment” about how well-off people will be. That is, health would not be treated as a separate sphere of justice at the macro level. A related issue is, if it is not unfair to consider outcomes in deciding where to allocate resources is it permissible to “discriminate” in such decisions against the disabled?
Chapter 12 (John Broome) is about valuing health, measuring the value of health rather than the quantity of health. Each person in a country enjoys some degree of well-being at a point of time. For the country as a whole, at any point of time there is a distribution of well-being across people which changes over time. The problem with this valuation is to set a value on the distribution. Presumably, this could be done in two ways: One, by aggregating across people, doing so for each time separately, and then to aggregate across times. An alternative approach is to set a value on each person’s overall well-being, aggregating over her life time and then to aggregate all those values, one for each person, across people. Broome makes the point that we cannot legitimately make the former snapshot-valuation of health.
Different Perspectives
Part V begins with a short exposition (Sen, chapter 13) of how to proceed if there are conflicting narratives of health and illness. He juxtaposes the “internal” or “perception oriented” views with the observation oriented, or “externally observed” view of health. The need to draw from both the perspectives for an informed understanding of illness and health is emphasised. Arthur Kleinman (chapter 14) sketches an anthropological orientation to health equity and health rights arguing that by cobbling together a framework that incorporates both local, moral processes in everyday experiences and transnational ethical discourses, can health equity receive adequate treatment. Experience occurs in local worlds, which are open to many influences extending from the local to the global but are positioned in an empirically describable cluster of current statuses, roles, and networks. What is at stake varies across historical epochs and cultures and what really matters most are the moral conditions of the local world. While moral experience is always about practical engagements in a particular local world, ethical discourse is globally elaborated abstract articulation striving for a contextual universality and objectivity. Then, local worlds may be unethical: what is at stake for most participants in a local setting may be condemnable from the perspective of a translocal ethical orientation. The other side of this duality is that ethics can be irrelevant to local, moral worlds. Kleinman uses this juxtaposition between ethics and morals to throw light on some popular ideas of “human nature” underpinning ethical framings as a universal basis for codes, standards and actions.
Vincanne Adams (chapter 15) further develops the theme of cultural relativism of health equity. The chapter makes two linked arguments: one that shows how social policies and cultural policies can lead to ill-health, and another one that shows how competing medical epistemologies, in a world that continuously prioritises biomedical science over all other medical theories, might also be discussed as an issue of health equity. Secularism forms an important part of the liberal humanism behind the Alma Ata’s efforts to promote universal equality in health. But is a secularist ethical discourse the best way to promote health in all cases? China has prided itself on meeting better than most other nations the requirements of the Alma Ata as well as secularist mandates for the provision of health for all. The Tibetan case illustrates how even when basic healthcare is provided universally, certain
Economic and Political Weekly March 10, 2007 culturally specific ethical formulations of health and health itself can be compromised. The Chinese barefoot doctor programme to promote health equity called for subjecting the public to state political objectives. The barefoot doctor programme revitalised traditional Chinese medicine into a set of practices that served the socialist agenda but in the case of Tibet it meant denigration of Tibetan’s medicine’s epistemological foundation in Buddhism. The chapter explores how culture can be taken into account when discussing health equity and in what ways a discussion of equity can be aided by exploration of non-western medical epistemology.
Beginning with the question of why equity in health in part I, the volume opens a spectrum of issues in the next four parts. It successfully challenges some of the popular notions of “healthy behaviour” and “human nature” and the related universal basis for codes, standards and actions. It places before us the complexity of providing just healthcare in multicultural societies with federal political structures. It bares the important ethical and value choices that go into the making of measures such as DALY and HALY beyond their technical, empirical and economic gloss. However, what I fail to understand is how the two chapters, Marmot’s ‘Social Causes of Social Inequalities in Health’ and Sen’s ‘Health Achievement and Equity: External and Internal Perspectives’ fit into this structure. We have been reading Marmot’s by now famous “Whitehall” study for a while and I wonder what new insights the chapter here provides. Similarly, Sen (1994) presented “positional objectivity” and “transpositional objectivity” with the example of highest reported morbidity in Kerala, a state known for high health achievements. Except for a change in terminology what insight the chapter here offers eludes me.
The Indian edition has arrived at a most opportune time as many chapters of the book have a larger relevance than just health equity, especially when we are battling with questions of reservation for other backward classes (OBCs) in centres of higher learning and reservations for Muslims. A key premise of Rawl’s theory of justice as fairness is that of society as a fair system of cooperation (Fabienne Peter). According to this view, the social condition into which somebody is born has a profound impact on what she can achieve and aspires to achieve. From the point of view of justice, there is then a limit on the claims people who do well have on their achievements. By the same token, people who do not do as well may have a larger claim on social goods. This is the issue in the context of reservation for OBCs and Muslims in the Indian context.
Another chapter of equal relevance is that titled ‘Just Healthcare in a Pluri-National Country’ where the author illustrates the choice of a concept of justice in healthcare can crucially affect the conquest of a city and the survival of a country as seen in Belgium. Don’t we face similar problems in the distribution of resources among the states? Is it just to offer less central grants for healthcare to a state just because its health status is better, especially when it has achieved such a status by devoting a larger share of its total resources to health determining sectors? Do these considerations come into reckoning when the allocations are made for the states under the National Rural Health Mission?
There is something for everyone in this book. By reading at least parts of the book, not only public health researchers but also jurists, administrators and policy-makers will understand our institutions better, think of new ones, and possibly help build a more equitable society.
EPWEmail: narayanadelampady@gmail.com
Economic and Political Weekly March 10, 2007
