See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/267868566

Health and Social Justice

Article in The Lancet · September 2004

DOI: 10.1016/S0140-6736(04)17064-5

CITATIONS READS

327 2,337

1 author:

Jennifer Prah Ruger

University of Pennsylvania
154 PUBLICATIONS 4,444 CITATIONS

SEE PROFILE

All content following this page was uploaded by Jennifer Prah Ruger on 04 April 2019.

The user has requested enhancement of the downloaded file.

 Public Health

Health and social justice

Jennifer Prah Ruger Lancet 2004; 364: 1075–80
Department of Epidemiology
4 years into the new millennium, the health of the distribution of certain goods such as health care, but all and Public Health, School of
Medicine, Yale University, New
world’s citizens is remarkably uneven. A child born prominent egalitarian theories of justice are cautiously
Haven, CT 06520, USA
today in Japan, for example, can expect to live to age formulated to avoid making equal sharing of all possible (J P Ruger PhD)
82 years on average, whereas it is unlikely that a social benefits a requirement of justice”.2 Utilitarian Correspondence to:
newborn infant in Zimbabwe will reach his or her 34th theories, although consequentialist (eg, assessing states Dr Jennifer Prah Ruger
birthday.1 Over several decades, scientific progress has of affairs or actions in terms of their consequences), [email protected]
expanded our ability to improve human health, and focus on the space of “utilities” (satisfaction, desire
many regions of the world have achieved significant fulfilment, preference),3 whereas communitarian
health gains. Yet extreme deprivation in health is still approaches focus on community values,4 rather than on
widespread. Resolving this predicament of major health health itself. Liberal theories of justice are disinclined to
improvement in the midst of deprivation is one of the focus on health because, as John Rawls purports in his
greatest global challenges of the new millennium. book, A theory of justice, natural goods like health are not
These health disparities exist in a world that is included as social values or social primary goods (eg,
becoming more closely linked in all domains, including “liberty and opportunity, income and wealth and the
health. The rapid spread and quick containment of bases of self-respect”) that are “things that every rational
severe acute respiratory syndrome (SARS) demonstrates man is presumed to want.”5 He adds that “health and
the interconnectedness of our world as well as any recent vigor, intelligence and imagination, are natural goods;
health phenomenon. The same trend can be seen with although their possession is influenced by the basic
HIV/AIDS and the potential to link solutions and best structure, they are not so directly under its control.”5
practices studied in one part of the globe with persistent Thus, according to Rawls, health is not one of the social
health problems in another. primary goods that should be “distributed equally unless
In the midst of such rapid global change and an unequal distribution of any, or all, of these values is to
persistent health disparities, we need to revisit and everyone’s advantage.”5 Although he discusses basic
underscore the moral and philosophical foundations for health care later in his book, Law of Peoples, Rawls does
health improvement activities—to give them more not include health in the list of social primary goods
forceful grounding and solidity. In this essay, I briefly subject to distributive principles.
survey some traditional philosophies of justice and Norman Daniels argues that, “health is an
health care. I then offer an alternative view of justice and inappropriate object, but health care, action which
health that is rooted in Amartya Sen’s capability promotes health, is appropriate.” 6 He and others
approach and Aristotle’s political theory, and discuss the emphasise that “. . . a right claim to equal health is best
implications of this approach for health improvement construed as a demand for equality of access or
across the globe. entitlement to health services . . . ”,6 and note that a “‘right
to health’ embodies a confusion about the kind of thing
Philosophical foundations which can be the object of a right claim”.6 Such
Theories of social justice (eg, fair and equitable reasoning illustrates the strong bias against health as a
treatment of people) have typically focused on justifying focal variable in current ethical theory.
health care (medicine and public health) as a special
social good. Rationalising greater equality in health care A capability view of health
is typically the point of departure for most approaches to A contrasting argument is that health has special moral
medical ethics (bioethics), even for approaches that importance because of its status as an end of political
include health assessment. In general, less attention has and societal activity. According to Aristotle, society’s
been paid to universal concerns of social justice with obligation to maintain and improve health rests on the
respect to health itself. This essay focuses on the ethical principle of “human flourishing” 7–11—the ability
question of why health, as opposed to health care, has to live a flourishing, and thus healthy, life.7–11 Flourishing
special moral importance for social justice in health and health are inherent to the human condition.7–11
improvement activities. I also analyse the implications of Indeed, certain aspects of health sustain all other aspects
equity in health and health care. of human flourishing because, without being alive, no
Philosophical theories have been reluctant to give other human functionings are possible, including
health (by contrast with health care) special moral agency, the ability to lead a life one has reason to
importance for at least one primary reason: they share value.12–14 It can be argued, therefore, that public policy
the assumption that health is not an appropriate focal should focus on the ability to function, and that health
variable for assessing social justice. Egalitarian theories, policy should aim to maintain and improve this ability
for example, “propose that persons be provided an equal by meeting health needs.15,16 This view values health

www.thelancet.com Vol 364 September 18, 2004 1075

For personal use. Only reproduce with permission from Elsevier Ltd
 Public Health

Although health directly affects the ability to exercise

agency, agency influences health as well. For example,
the ability to lead the life one values can improve one’s
mental health or well-being. Conversely, the ability to
make unhealthy choices can degrade one’s health
status. Enabling individuals to exercise their agency—
both individually and collectively—enables them to
prioritise and decide which health domains they value
most (eg, to trade-off quality and quantity of life) and to
choose what health services they would like to consume
(eg, making choices among treatment options).
The exercise of human agency can occur at both the
individual and collective levels. Individual agency is
important in decisions about health habits and risks,
lifestyle, individual priorities, and decisions about
treatment options. Collective agency is more important
at the policy level, where open discussion and collective
decision-making influence policy and resource
allocation. This relates to the “process” aspect of
freedom in the capability approach.14

Policy implications
There are several sets of policy implications related to a
capability view of health. First, the distinction between
a capability approach to health and other well-known
ethical approaches has implications for assessing social
inequalities and for evaluating the effects of social
policy on broader health determinants. Health care is
Cass Sunstein not the only health determinant, as Michael Marmot
and his colleagues’ work has shown,19 and one must not
intrinsically and more directly than solely assume that more and better health care is all that is
“instrumental” social goods, such as income or health needed to improve health. The main impact of health
care. It gives special moral importance to health care may depend on the type of care and sometimes on
capability: an individual’s opportunity to achieve good other factors. This places both health and health policy
health and thus to be free from escapable morbidity and in a larger policy context and requires a greater
preventable mortality.15,16 understanding of social justice.15,16 Thus, health and its
This line of reasoning—focusing on human determinants must be valued against other social ends
capability—contrasts with the idea that health care is in a broader public exercise of policy priorities. This
special because of its impact on equality of exercise should be inclusive and democratic and should
opportunity.6 It also differs from the utilitarian view represent a process of public reasoning about the ends
that health care is important for maximising the sum and means of public policy more broadly and about
total of utilities and from procedural views that focus health policy specifically.
on guaranteed due process. The distinction between Second, although health care is only one of many
these approaches is rooted in the different points of health determinants, its influence on health should not
focus that these theories support. Capability describes be denied. Thus, health care is important and there-
what individuals are able to do and be, offering a fore, special, due to its role in influencing health and it
realistic sense of their freedom to pursue the lives they must be socially guaranteed. It must be socially
have reason to value. Thus, society is morally obligated guaranteed in a manner that is consistent with
to attach importance to averting or ameliorating loss in improving health overall and reducing health
physical functioning even if a person’s subjective utility inequalities that are attributable to health care—not in
assessment is quite high and even if opportunity of terms of equality in health care delivery (equal amounts
employment is still possible. In short, a person’s ability or types), irrespective of health consequences.
to function, rather than to be happy or to have Third, a capability view of health does not specify
employment opportunities, should be the gauge for which type of health care (eg, a list or basic benefits
assessing public policy. package) should be guaranteed and to what level.
A capability view of health also includes human Rather, it recognises the need for further specification
agency (ie, people’s ability to live a life they value).17,18 through a democratic process that combines both

1076 www.thelancet.com Vol 364 September 18, 2004

For personal use. Only reproduce with permission from Elsevier Ltd
 Public Health

procedural and substantive principles. Substantively, Sixth, one of the most difficult tasks in applying an
Sen’s notion of “basic capabilities” provides guidance ethical framework that values health intrinsically is the
since this formulation generally implies that societal conceptualisation and measurement of health and
efforts be made to bring each individual’s health inequalities in its many domains. There are many
functioning as close as possible to (or above) a certain approaches to measuring health equity. As Sudhir
level of minimal normal functioning (in so far as an Anand and colleagues have shown,22 the choice depends
individual’s circumstances permit). “Basic capabilities” on numerous considerations, ranging from health
include the ability to avoid escapable morbidity and domains to the weights attached to those domains.22
premature and preventable mortality. Premature Another consideration is the choice of groups for
mortality implies placing special emphasis on efforts to stratification.22 Even within the capability perspective,
avert deaths from preventable causes that do not allow one would need to determine what set of inequality
individuals to live a life of normal length (eg, a child measures would be most appropriate for a given
dying of AIDS). On the question of how much priority exercise, although certain types of inequality
should be given to society’s worst-off individuals, this assessment—for example, a goal of complete “health
view promotes the use of “public reasoning” to forge a equality” (levelling down to lowest common denom-
compromise between strict maximisation and inator)—have less appeal than others. And certain health
prioritisation. equity evaluations—for example, deciding how much
Fourth, this “process aspect” of freedom in the priority to give the “worst-off”—will undoubtedly require
capability approach has implications for how health- public reasoning about values imbedded in the health
related policy is made. It emphasises an individual’s equity concept. Although the capability view of health
ability to participate in broad public-policy decision- does not come down on an exact formula for judging
making (eg, in prioritising between environmental and inequalities in health, Sen has noted the potential use of
health care programmes) and in health policy decision- “partial ordering” (eg, ordering some alternatives as
making (eg, in prioritising domains of health and opposed to ordering them all) of health states for
health care for resource allocation). A democratic assessing relative inequalities. In a collective exercise,
process can help define a comprehensive package of incomplete theorisation may facilitate evaluation in
health benefits to which all should have equal access, health policy.15,16,23
and it can help prioritise different types of health care
in efforts to maintain and improve health with the
fewest possible resources. Such a process is not merely
instrumental, however, since its justification lies in the
concept that individuals should have the capability to
participate in decision-making that affects them, such
as about the goods and services that society will
guarantee to them.
Fifth, the equity implications of access to those goods
and services cannot be separated from the equity
implications of financing them, because the capability
principle requires that resources be allocated on the
basis of medical need, not ability to pay. The costs of
health-related goods and services directly affect health
by reducing the demand for necessary health care or by
increasing consumption of unnecessary care. Leaving
P Virot/WHO

people vulnerable to economic barriers therefore would

fail to reduce deprivations in health. Additionally, the
uncertainty of health need, the catastrophic costs of
Gro Harlem Brundtland at the Framework Convention on Tobacco Control, 2002
medical care, and the risk-averse nature of individuals
places risk pooling (eg, through insurance) at the
centre of health-care financing.20 An expensive medical Incompletely theorised agreements
event can prevent access to health care or be a primary Incomplete theorisation is useful to a theory of health
cause of financial ruin. From a capability point of view, and social justice because it provides a framework for
“protective security”,14 through health insurance, is a understanding collective decision-making on human
necessary safety net. And the economic burden of goods that are plural and indistinct (such as health and
health care should be justly shared by all through the inequality), and allows individuals to take divergent
redistribution of funds from the well to the ill and the paths to a common, though often partial, agreement. It
rich to the poor, using progressive financing and describes how people with divergent, even opposing,
community rating.21 views on health, equity, and health-policy issues might

www.thelancet.com Vol 364 September 18, 2004 1077

For personal use. Only reproduce with permission from Elsevier Ltd
 Public Health

reach agreement in specific situations and thus generate Incompletely specified agreements
health-policy decisions that are legitimate and stable and The first type of incompletely theorised agreement
reflect mutual respect.15,16,23 The method of reaching occurs when there is agreement on a general principle
agreement described here is called incompletely but sharp disagreement about particular cases. People
theorised agreements, developed by Cass Sunstein,24 and who accept a general principle, such as the illegality of
it holds promise for health-policy decision-making at murder, need not agree on the application of this
several levels.15,16,23 principle to particular cases. For example, they could
An incompletely theorised agreement is one that is not disagree about whether abortion should be classified as
uniformly theorised at all levels, from high-level murder.24 This first type of agreement is closely
justifications to low-level particulars. It complements connected to Rawls’ “overlapping consensus”. In the
and extends the capability approach by providing a health-policy context, citizens might agree on cost-
framework for operationalising the capability approach effectiveness as a general principle, but also agree that
at three or more levels. The first level is the conceptual  interferon, a drug that helps some individuals with
level, which specifies the valuable functionings that multiple sclerosis, should be provided to such patients
constitute human flourishing and health. The second even though its cost per quality-adjusted life year (QALY)
level is the policy level, which specifies policies and laws. ranges from US$35 000 to $20 million, or agree that
The third level is the intervention level, which specifies kidney dialysis should be provided despite its exorbitant
actions in particular cases and decisions about medical cost for relatively small improvements in health-related
treatments, public-health interventions or social quality of life.
services. This framework constitutes three different
types of incompletely theorised agreements: incom- Incompletely specified and generalised
pletely specified agreements, incompletely specified and agreements
generalised agreements, and incompletely theorised The second type of incomplete theorisation occurs when
agreements on particular outcomes. people agree on a mid-level principle but disagree about
both the more general theory that accounts for it and
Incompletely specified agreements (high-level agreement) outcomes in particular controversies. Here, Sunstein
Level Model Agree/disagree argues that the connections between the general theory
High Agreement
and mid-level principles and also between specific cases
and mid-level principles are unclear.24 In the health
policy context, citizens might agree that all should have
Mid Disagreement access to life saving interventions, but disagree on both
the underlying theoretical doctrine for this view and on
whether all life saving interventions at all stages of life
Low Disagreement should be provided.

Incompletely specified and generalised agreements (mid-level agreement)

Incompletely theorised agreements on
particular outcomes
High Disagreement This third type of incompletely theorised agreement
describes how people reach agreement on particular
public policy options. In this model, agreement is
Mid Agreement reached on low-level principles that are not necessarily
derived from a particular high-level theory of the right or
the good. In fact, the same low-level principles may be
Low Disagreement compatible with more than one high-level theory because
people may disagree on or not fully understand a
Incompletely theorised agreements on particular outcomes relatively high-level abstraction while agreeing on “a
(low-level agreement) point of less generality”.
In such contexts, people “can know that X is true
High Disagreement
without entirely knowing why X is true.”24 The emphasis
here is on not knowing something entirely—completely
Mid Disagreement
theorising it from high to low levels. People might agree,
for instance, that governments should prevent famine,
eradicate malaria or tuberculosis, and not condone
Low Agreement genital mutilation, but they might not know exactly why
they hold such beliefs. This reasoning might be both
moral and reasonable, but the deliberators might not
Models of incompletely theorised agreements explicitly state that their decision is derived from an

1078 www.thelancet.com Vol 364 September 18, 2004

For personal use. Only reproduce with permission from Elsevier Ltd
 Public Health

underlying theory, even though it certainly might be

informed by a lower level conception of the good life they
articulated. This aspect of the framework complements
the capability approach’s emphasis on partial agreements
and on identifying workable solutions that make the
most of consensus and that can be “based on the
contingent acceptance of particular provisions, without
demanding complete social unanimity”.14
Thus, in matters of public decision-making about
health and health policy, the incomplete theorisation
framework is useful in furthering a capability approach
to health.15,16 First, health, and thus health capabilities, is
a multidimensional concept about which different Rights were not granted to
people might have different, and sometimes conflicting, include this image in
views, especially at an epistemological level. This
heterogeneity makes complete theorisation difficult to electronic media. Please refer to
achieve. Second, there might be no view of health, and the printed journal.
thus health capabilities, that is ideal for all evaluative
purposes; therefore, the pragmatism of the incomplete
ordering of the capability approach and the
incompletely theorised agreement on that ordering of
the incomplete theorisation approach allows for
reasoned public-policy decision-making in the face of
multiple, and even conflicting, views on health. Third,
there could be no single quantitative scale for
comparing health capabilities and the inequalities in
them; deviations in individuals’ capability for

AP
functioning may occur in different domains of health
capability that may not be quantifiably comparable. For countries develop information and research capacity25,26
example, one cannot quantifiably compare one (eg, health surveillance and information systems).
individual’s inability to hear or see with another’s Global health institutions can also empower
inability to bear children or to walk. These reductions in individuals and groups in national and global forums.
individuals’ capabilities for functioning are qualitatively Indirectly, they can push for greater citizen participation
different and different people will have widely diverging in health-related decision-making in developing
views on which functional capability reduction is better countries, both within (eg, in determining resource
or worse than the other. Thus, a framework for allocation) and outside the health sector. Since greater
articulating and agreeing upon a conception of health empowerment in the health sector is built on more
functioning for prioritising health goods and services is democratic governance overall, reform of state and social
required. Given the demands of policy evaluation in institutions may be needed to achieve these goals. And
particular contexts, the combined approaches also allow encouraging the political will for public action to reduce
reasoned agreement on central aspects of health and health inequalities will be essential. Global health
their respective capabilities without requiring people to institutions, particularly WHO and World Bank, can
agree on non-central aspects or fully understand their help governments improve the public administration
beliefs. needed to deliver quality health care to all. They should
also give individuals and groups a greater voice in
Global health institutions national and international forums and programmes,
What do these philosophical arguments imply for global such as a health-sector loan or an international tobacco-
health institutions? Global health institutions have control agreement, and engage more with civil society
important roles in the implementation of a capability and the private sector.
approach to health because they can help generate and Global health institutions can also provide technical
disseminate the knowledge and information required to assistance, financial aid, and global advocacy to support
reduce health disparities. For example, they can help the development of equitable and efficient health
create new technologies (eg, an HIV/AIDS vaccine), systems and public health programmes. This assistance
transfer, adapt, and apply existing knowledge (eg, can occur at the macro level (eg, standardising
prevention of malaria transmission), manage knowledge diagnostic categories) or the micro level (eg, providing
and information (eg, statistics on inequality in antiretroviral medicines for AIDS patients). Some global
infant/child mortality and best practices), and help health institutions (eg, WHO) have tended to organise

www.thelancet.com Vol 364 September 18, 2004 1079

For personal use. Only reproduce with permission from Elsevier Ltd
 Public Health

around specific diseases (HIV/AIDS, malaria, 8 Nussbaum MC. Nature, function, and capability: Aristotle on
tuberculosis, polio, and SARS), whereas others such as political distribution. In: von Gunther Patzig H. Aristoteles politik.
Gottingen: Vandenhoeck and Ruprecht, 1990.
the World Bank have favoured sector-wide initiatives. 9 Nussbaum MC. The good as discipline, the good as freedom. In:
Although both perspectives are valuable, greater Crocker D, ed. The ethics of consumption and global stewardship.
coordination among policy actors is essential. Such Lanham, MA: Rowman and Littlefield, 1998: 312–41.
10 Nussbaum MC. Human functioning and social justice: in defense of
efforts should build on existing work such as the Aristotelian essentialism. Polit Theory 1992; 20: 202–46.
Rockefeller Foundation’s global health equity initiative.27 11 Aristotle. The politics. Translated by Lord C. Chicago, IL: University
Finally, global health institutions should be linked to of Chicago Press, 1994.
other institutions in a coordinated and integrated way. 12 Sen AK. Commodities and capabilities. Amsterdam; North-Holland,
1985.
The Framework Convention on Tobacco Control 13 Sen AK. Inequality reexamined. Cambridge, MA: Harvard
(FCTC), for example, recognises the importance of University Press, 1992.
integrating public policies into a comprehensive set of 14 Sen AK. Development as freedom. New York: Knopf, 1999.
health improvement strategies. Through the FCTC, 15 Ruger JP. Aristotelian justice and health policy: capability and
incompletely theorized agreements. PhD thesis, Harvard University,
ministries of health and health-related associations, such 1998.
as physician groups, are united with ministries of 16 Ruger JP. Social justice and health policy: Aristotle, capability, and
finance, economic planning, taxation, labour, industry, incompletely theorized agreements— lecture given at Harvard
University, 1997.
and education as well as with citizen groups and the
17 Ruger JP. Health and development. Lancet 2003; 362: 678.
private sector, to create a multisectoral national and 18 Ruger JP. Combating HIV/AIDS in developing countries. BMJ
international tobacco-control effort. The FCTC 2004; 329: 121–22.
represents a growing trend in development policy 19 Marmot MG, Bobak M, Davey Smith G. Explorations for social
inequalities in health. In: Amick BC, Levine S, Tarlov AR, Chapman
toward an alternative paradigm that is broad, integrated, D, eds. Society and health. London: Oxford University Press, 1995.
and multifaceted.14,17,28–31 Adopting a multifaceted and 20 Ruger JP. Catastrophic health expenditure. Lancet 2003; 362: 996–97.
integrated approach to health improvement requires 21 VanDoorslaer E, Wagstaff A, Ruttern F, eds. Equity in the finance
rejecting a narrow view of health and its determinants and delivery of health care: an international perspective. New York:
Oxford University Press, 1993.
and the philosophical foundations that support such a 22 Anand S, Diderichsen F, Evans T, Shkolnikov VM, Wirth M.
view. Measuring disparities in health: methods and indicators. In: Evans
T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, eds.
Acknowledgments
Challenges inequities in health: from ethics to action. London:
I thank Amartya Sen, Sudhir Anand, Michael Marmot, and participants Oxford University Press, 2001.
in the workshop on Rights, Dignity, and Inequality at Trinity College,
23 Ruger JP. Health, health care, and incompletely theorized
Cambridge, UK, for helpful comments. I also thank Washington agreements, mimeographed. Harvard University, 1995.
University School of Medicine and Center for Health Policy for support.
24 Sunstein C. Incompletely theorized agreements.
J P Ruger is supported in part by a Career Development Award (grant Harvard Law Review 1995; 108: 1733.
1K01DA016358–01) from the US National Institutes of Health.
25 Horton R. North and South: bridging the information gap. Lancet
References 2000; 355: 2231–36.
1 United Nations Development Programme. Human development 26 Chen LC, Berlinguer G. Health equity in a globalizing world. In:
reports, 2003.http://www.undp.org/hdr2003/indicator/ Evans T, Whitehead M, Diderichsen F, Bhuiya A, Wirth M, eds.
indic_70_1_1.html (accessed Oct 27, 2003). Challenges inequities in health: from ethics to action. London:
2 Beauchamp TL, Childress, JF. Principles of biomedical ethics. 4th Oxford University Press, 2001.
edn. New York: Oxford University Press, 1994. 27 The Rockefeller Foundation. Program in health equity. http://
3 Gold MR, Siegel JE, Russel LB, Weinstein MC. Cost-effectiveness www.rockfound.org/display.asp?Context=3&SectionTypeID=
in health and medicine. New York, NY: Oxford University Press, 18&Preview=0&ARCurrent=1 (accessed Oct 10, 2003).
1996. 28 Stiglitz JE. An agenda for development in the twenty-first century.
4 Emanuel EJ. The ends of human life. Cambridge, MA: Harvard In: Pleskovi B, Stiglitz JE, eds. Annual World Bank conference
University Press, 1991. on development economics 1997. Washington, DC: World Bank,
5 Rawls J. A theory of justice. Cambridge, MA: Harvard University 1998.
Press, 1971. 29 Wolfensohn JD. A proposal for a comprehensive development
6 Daniels N. Just health care. New York: Cambridge University framework. Washington, DC: World Bank mimeograph, 1999.
Press, 1985. 30 Rodrik D. Making openness work: the new global economy and the
7 Aristotle. The Nicomachean ethics. Translated by Welldon JEC. developing countries. Washington, DC: Overseas Development
Amherst, NY: Prometheus Books, 1987. Council, 1999.
31 Ruger JP. Changing role of the World Bank in global health.
Am J Public Health (in press).

1080 www.thelancet.com Vol 364 September 18, 2004

For personal use. Only reproduce with permission from Elsevier Ltd

View publication stats