I have noted several times on this blog what I perceive to be a marked lack of development on some of the most complex and difficult ethical questions that attend the social determinants of health. That is, once we accept the premise – which we ought to, based on the abundance and quality of the evidence – that social and economic conditions are primary determinants of health and illness at the population level, what ought we to do from a policy perspective? I have generally been disappointed to find that the answer to this question is frequently assumed, e.g., 'we ought to eliminate inequality.' But a basic tenet of moral thinking is that not all inequalities are unjust. Plato recognized this, as have the majority of the most influential Western thinkers on justice (including Rawls, whose concept of distributive justice expressly delineates between inequalities that are unjust, and those that are not).
So if the moral basis for eliminating inequality is tenuous at best, perhaps the normatively preferable policy option is "to compress inequality." But how should we do so? Which inequalities should we seek to compress? What is the priority for compression? Health inequalities? Income inequalities? Inequalities in housing conditions? Inequalities in tax policy? Of course, remediation of all of these inequalities are not mutually exclusive, but part of the reason for this is that they seem to be, to some extent, functions of each other. The links between health inequalities and income inequalities are well demonstrated, but there is also good evidence linking housing conditions and health inequalities, and housing conditions and income inequalities, and it seems implausible that the housing conditions that correlate with health and income are unaffected by their distribution (a quick search does not reveal studies directly addressing the question, but I would imagine they exist).
Another example of a difficult question to answer is whether radical redistribution of income normatively (that is, ethically) preferable to remediation educational inequalities? Why or why not? What does justice demand? If justice demands we do both, and that neither is ethically preferable to the other, does the pragmatic policy outlook for each color our perspective on relative priority? (I argue yes).
The point of the above discussion is not to offer any answers, but to suggest that the questions are important. Given my view on this importance, there are few philosophers from whom I learn more than Gopal Sreenivasan, who recently took up a position at Duke University. Sreenivasan writes extensively on the issue of what policies are ethically warranted in light of the best evidence regarding the SDOH. His recent article, published in the fine new journal Public Health Ethics,* tackles the relative vs. absolute income debate (namely, whether health is more properly viewed as a function of relative vs. absolute deprivation). Here is the Abstract:
This paper reviews the epidemiological debate between the relative income hypothesis and the absolute income hypothesis. The dispute between these rival hypotheses has to do with whether an adequate account of the relationship between income and life expectancy requires the definition of 'income' to include any comparative element. I discuss the evidence offered for the relative hypothesis (which answers, 'yes'), as well as two important criticisms that have been levelled against this evidence. I also offer some critical reflections on the debate from a philosophical standpoint concerned with the ethics of population health. Both hypotheses agree that a redistribution of income towards the worst off will improve their life expectancy.
Sreenivasan concludes that there is as yet no reliable evidence in favor of the relative income hypothesis, but also admits to puzzlement as to why it matters. Proponents of both camps accept the strong correlation between income and health, proponents of both camps support income redistribution as a means of improving population health, and proponents of both camps may, he notes, consistently support the idea that psychosocial pathways are key mediators of the effects of social and economic conditions on health.
In any case, Sreenivasan's analysis is penetrating, lucid, and rewards close reading. His work is some of the best available in reflecting from an ethical perspective on the policy implications of the SDOH.
*Disclosure: I recently had a paper published in PHE.
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