BOOKS & ELECTRONIC MEDIA

Public health, ethics, and equity

James Dwyer

Center for Bioethics and Humanities, SUNY Upstate Medical University, 725 Irving Avenue, Suite 406, Syracuse, NY 13210, USA (email: dwyerja@upstate.edu)

Editors: Sudhir Anand, Fabienne Peter, and Amartya Sen
Publisher: Oxford University Press, Oxford; 2004
ISBN: 0-19-927636-6; hardback; 328 pages; price: £55

We live in a world with staggering inequalities in health. In Australia, Japan, Sweden, and Switzerland, the average life expectancy is greater than 80 years. But in Angola, Malawi, Sierra Leone, and Zimbabwe, the average life expectancy is less than 40 years. In Sweden, the under-5 mortality rate is 3 per 1000, while in Sierra Leone it is almost 300 per 1000. In Austria, Denmark, Spain, and Sweden, the maternal mortality rate is less than 6 per 100 000. But in Afghanistan, Chad, Rwanda, and Sierra Leone, the rate is greater than 1000 per 100 000.

The situation is actually worse than these figures suggest because national averages tend to mask inequalities within a country. Within particular countries, health prospects vary significantly and systematically with race, ethnic group, gender, region, and socioeconomic class. Although the average life expectancy in America is 77 years, that of African–American men is closer to 70 years. The under-5-mortality rate in the north-east of Brazil is double the average in the rest of the country. And in most societies, there is a social gradient in health: groups higher along the socioeconomic curve enjoy better health. This is not a matter of absolute deprivation, but of relative standing. In many societies, relatively small differences in income and power make a significant difference to health.

Although most public health interventions improve average health, many of them increase health inequalities within a society because they tend to benefit the better-off groups more than the disadvantaged. The universal immunization programme in India has achieved much higher coverage rates among families that are wealthier, more educated, and live closer to health centres. Smoking cessation programmes in the USA have had more effect among wealthier and better-educated groups. And years from now, I wouldn't be surprised to learn that public health programmes designed to combat obesity have effects that vary along socioeconomic lines.

What, if anything, should we do about health inequalities within and between countries? What do justice and equity demand? These important ethical questions have received surprisingly little attention within bioethics. Most scholars have focused their attention on ethical issues that arise in treating individual patients, using human subjects for research, and applying new technologies. Very few have focused their attention upstream, on the social determinants of health and the ethical issues that arise in population health.

People in public health have not ignored the ethical issues raised by health inequalities, but they have tended to adopt approaches that are too simple to deal with the complexity of the problems. Some people have adopted an approach that emphasizes cost-effectiveness analysis. Although it makes sense to consider the amount of health that a given amount of resources can produce, this approach looks at overall averages and tends to ignore inequalities. Some scholars and activists in public health have adopted an approach based on the discourse of human rights. Although there are humanitarian reasons for claiming that health is a basic human right, the discourse of rights tends to ignore all the hard questions about priorities, duties, and responsibilities. More recently, some people in public health have begun to adopt an "equity perspective." But what this perspective entails remains to be worked out.

In Public health, ethics, and equity, a group of distinguished philosophers, economists, epidemiologists, and anthropologists develop equity perspectives that they think are appropriate for public health. In one key chapter, Daniel Wikler considers how much emphasis we should place on individual responsibility for poor health. Some critics claim that health inequalities associated with socioeconomic status are not unjust, and don't demand remediation, because they are due to individual choices, habits, and lifestyles. These critics use the idea of individual responsibility to absolve society of blame and to assign lower priority to programmes designed to reduce tobacco use, obesity, and HIV infection. Wikler articulates the practical and philosophical problems involved in assigning individual responsibility such a central role. Although he favours educating and empowering people to adopt healthier lifestyles, he opposes simplistic views that ignore social structures and devalue public responsibility.

Once we acknowledge that society bears considerable responsibility for health inequalities, questions arise about how to address the problems and how to set priorities. In a lucid and cogent chapter, Dan Brock considers the ethical issues that arise in using cost-effectiveness analysis to set health-care priorities. This quantitative approach relies on the use of measures such as quality-adjusted life years, which combine benefits in length of life and quality of life. But when this approach is used to calculate benefits, it often discriminates against people with disabilities. And when it is used to maximize overall benefits, it fails to give appropriate priority to the worst off. The problem here is not merely technical, but a matter of "justice or equity raised by the fact that a cost-effectiveness analysis is insensitive to the distribution of health benefits." So Brock concludes that this sort of analysis must be supplemented with democratic deliberations that include considerations of equity.

But what does equity or justice require? Norman Daniels, Bruce Kennedy, and Ichiro Kawachi address this question in a chapter on health, inequality, and justice. These authors use Rawls's theory of justice to evaluate the distribution of the social determinants of health. According to Rawls, justice requires social institutions that work to ensure equal liberty, fair value of political liberty, meaningful equality of opportunity, the social bases of self-respect, and an economic order that maximizes the position of the worst off. Daniels, Kennedy, and Kawachi show how institutions that ensured these values would flatten the social gradient in health and improve the health prospects of the worst off. Although they use Rawls's theory, these authors note how their approach converges, at least in practice, with one based on Amartya Sen's view of freedom and capabilities.

The fifteen chapters in this book are not easy reading. Some of them are quite technical, even tedious. But all of the authors address vitally important issues about health and justice. In different ways, they address issues about the kind of social world we should strive to create.