|Year : 2016 | Volume
| Issue : 3 | Page : 216-220
Personal vis-a-vis social responsibility for disparities in health status: An issue of justice
Ayan Jha1, Madhumita Dobe2
1 Clinical Research Fellow, Health Education and Research Institute, Charleston Area Medical Center, Charleston, West Virginia, United States
2 Director-Professor (Public Health) and Head, Department of Health Promotion and Education, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
|Date of Web Publication||24-Aug-2016|
Prof. Madhumita Dobe
Department of Health Promotion and Education, All India Institute of Hygiene and Public Health, 110 Chittaranjan Avenue, Kolkata - 700 073, West Bengal
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Health inequities are disparities which can be avoided through rational actions on the part of policymakers. Such inequalities are unnecessary and unjust and may exist between and within nations, societies, and population groups. Social determinants such as wealth, income, occupation, education, gender, and racial/ethnic groups are the principal drivers of this inequality since they determine the health risks and preventive behaviors, access to, and affordability of health care. Within this framework, there is a debate on assigning a personal responsibility factor over and above societal responsibility to issues of ill health. One school of philosophy argues that when individuals are worse-off than others for no fault of their own, it is unjust, as opposed to health disparities that arise due to avoidable personal choices such as smoking and drug addiction for which there should (can) be a personal responsibility. Opposing thoughts have pointed out that the relative socioeconomic position of an individual dictates how his/her life may progress from education to working conditions and aging, susceptibility to diseases and infirmity, and the consequences thereof. The existence of a social gradient in health outcomes across populations throughout the world is a testimony to this truth. It has been emphasized that assuming personal responsibility for health in public policy-making can only have a peripheral place. Instead, the concept of individual responsibility should be promoted as a positive concept of enabling people to gain control over the determinants of health through conscious, informed, and healthy choices.
Keywords: Health disparities, health ethics, health inequities, personal responsibility in health, social determinants of health, social gradient
|How to cite this article:|
Jha A, Dobe M. Personal vis-a-vis social responsibility for disparities in health status: An issue of justice. Indian J Public Health 2016;60:216-20
|How to cite this URL:|
Jha A, Dobe M. Personal vis-a-vis social responsibility for disparities in health status: An issue of justice. Indian J Public Health [serial online] 2016 [cited 2020 Aug 5];60:216-20. Available from: http://www.ijph.in/text.asp?2016/60/3/216/189020
| Introduction|| |
Health inequalities exist due to differences in health status or unequal distribution of health determinants between different population groups. Mortality among elderly varies with mortality among young population, also it varies among different social classes. Health inequalities are attributable to biological variations; some are attributable to external environmental conditions. In the first case, health inequalities are inevitable, as it is impossible or ethically unacceptable to change health determinants. However, in the second, uneven distribution may be avoidable and unfair so that the resulting health inequalities also lead to inequity in health. Hence, it is important to distinguish between inequality in health and inequity.
| Inequality and Inequity|| |
The Commission on Social Determinants of Health,  under chairmanship of Sir Michael Marmot, unambiguously defined all such health disparities which are avoidable by rational actions to be health inequities (meaning unjust or unfair). They further emphasized that health disparities demand our urgent intervention, both from the viewpoint of ethical imperativeness and social justice. Margaret Whitehead defines health inequalities as inequities if they are "unnecessary, avoidable, unfair, and unjust."  The WHO, drawing a similar definition, has stressed that such avoidable inequalities in health exist within and between social groups, populations, and countries. The social and economic determinants are understood to be the principal drivers of this inequality since they determine the health risks and preventive behaviors, access to healthcare, and of course, the affordability of it. 
At global level, the infant mortality rate varies from 2/1000 live births in Iceland to over 120/1000 live births in Mozambique; 1 out of 8 mothers die in Afghanistan, whereas only 1 in 17,400 has that risk in Sweden. Even within a country, sharp demarcations exist between health status of the rich and the poor, the educated and the illiterate. In Bolivia, over 100 infants born to every 1000 uneducated mothers die, whereas this rate drops to 40/1000 with secondary level maternal education. 
Worldwide, societies have gradually evolved hierarchical patterns, based on factors such as education, occupation, income, race, ethnicity, and gender. The relative socioeconomic position of an individual dictates how his/her life may progress from childhood education to adult working conditions and aging: Moreover, in our context, the susceptibility to diseases and infirmity, and the consequences thereof. As of 2005, the richest countries, home to 10% global population, have a combined gross national income which is 122 times that of the poorest countries with an equal population share - a disparity that has doubled it since 1985. It is even more disturbing to understand that the poorest population quintile in the underdeveloped world has suffered rapidly declining shares in national growth and consumption over the last 15 years; Kenya being a good example. A similar story is repeated when one considers gender as the determining factor to health and well-being. 
It has been a matter of much debate so as to which health disparities should be considered as inequities, and should be dealt as a matter of priority under the broad schools of ethical justice. Temkin views inequality as a multidimensional concept, varying according to our conceptualization of inequality between the worst-off and best-off or the worst-off and average; Atkinson raises the contrast between absolute and relative scales of measurement of health outcomes.  One can also look into the healthy life expectancy over total life expectancy in understanding the existence of true health disparities across groups.
In general, one can argue that not every inequality in health parameters demands an ethical concern. We need to be focused on health disparities arising from the social context, or in other words, rooted in the social determinants of health - "the circumstances in which people are born, grow, live, work, and age."  We may be less concerned about health inequalities that have basis in the human genetic predisposition, that is to say, are of more biological in origin. 
Braveman et al.  defined health disparities between populations to be of social origin when they are defined by social characteristics such as wealth, income, occupation, education, racial or ethnic groups, sex, rural, or urban residence. They argued that scientific literature provides enough evidence of strong associations between health outcomes and these social variables. Marchand and Wikler have noted that health disparities arising out of social inequalities are not only critical but also difficult issues. 
Thus, for the purposes of this discussion, we may accept that it is when health inequality becomes a social inequity, we should be concerned. Indeed, in almost every society and every country across the world (rich or poor), it has been observed that there is a social gradient in health outcomes across populations. A good example would be the well-established association of under-five mortality with household-level wealth, where not only the bottom stratum suffers the highest death rate, but also the second-highest quintile has higher childhood mortality compared to the highest quintile. 
Health inequity is a true global phenomenon that affects everyone. Almeida et al.  have also argued that "equity is not the absence of all disparities;" but rather, an absence of "systematic disparities between social groups." Within this framework, we can explore the debate between assigning personal responsibility as opposed to a social responsibility of such health disparities.
| The Contrasting Viewpoints|| |
Buchanan in his essay on "autonomy, paternalism, and justice"  notes that a significant school of public health professionals does believe in personal accountability for making unhealthy/risky choices. Under this philosophy, a higher health insurance premium for the healthy population to support the high-risk group is unjust, as nobody is ever "forced" to start smoking, drugs, or eat unhealthy food. This view often finds popularity with the general public, who might also prefer assigning a "moral responsibility" for risk-prone choices, and not be subject to additional financial burden toward the health and well-being of people who make such choices.
Segall, Le Grand, and Temkin have argued that when individuals are worse-off than others for no fault of their own, it is unjust; as opposed to health disparities that arise due to avoidable personal choices.  Seagull in fact has proposed a revised version of the luck-egalitarian principle, the luck-prioritarian view (prioritarianism believes in maximizing goodness for all individuals, with extra weight given to the worse-off), according to which, provided that individuals have invested equal or more effort to maintain health but still are worse-off, they should be accorded priority. 
Sen  has treaded a cautious approach in disentangling purely voluntary personal choices in complete disregard of health consequences as opposed to those arising from discriminatory and unjust social arrangements. A cause of ill-health which is not addressed because of social reasons, in his opinion, is negative social justice.
The relationship between socioeconomic status and health is indeed reciprocal and dynamic across the life course. Deaton  categorically establishes the role of income, occupation, and education in predisposing to severe health inequalities between the rich and poor populations in a country, and even between wealthy nations and their less well-off counterparts. The poorer sections of the society, he argues, are more likely to smoke and drink, become obese, be exposed to occupational hazards, live in polluted residential colonies in the outskirts of the cities (hence affordable). However, this is hardly a matter of choice, rather than being a matter of compulsion. Even being aware of the health consequences, there are minimal possibilities of avoiding these options. Hence, to argue that such health disparities may not be unjust is an extremely superficial proposition. Parallels can be drawn with children who die from childhood respiratory, diarrheal, and other infectious diseases in developing countries, as opposed to identical counterparts in the "first" world, who are protected by an overall superior health-care system which has successfully eradicated many such causes of childhood mortality. Our natural intuition about equality and justice (provided we value health as an issue of human rights) guides us to promote measures addressing the poor health conditions of the developing world so that children are not lost to the preventable causes of death. It becomes unexplainable why a similar sense of goodwill and justice should not prevail in empathizing with social inequalities that give rise to absolutely remediable health disparities.
Egalitarians (egalitarianism means "equalism" - all humans are equal in fundamental worth or social status) such as Hausman and Daniels have argued that inequalities are unjust regardless of their source when we could ameliorate them by intervening, and they lay minimal importance on personal responsibility to health.  Furler and Palmer  have noted that the socially-based health inequality among the population is a reality that cannot be ignored in imparting health care. They opine that beneficence means ensuring health care to individuals regardless of the limitations imparted by their position in the social hierarchy and disregarding the social context is actually doing harm. Schrecker et al.  have warned that contrary to common belief, globalization tends to increase health disparities, and health policies should unequivocally address the social determinants of health through principles of redistribution, regulation, and rights. Marchand and Wikler  have strongly argued that in almost all nations, the socioeconomically worst-off suffer at least twice more, on an average, in terms of morbidity and mortality than the best-off. They have noted the existence of health disparities across the social gradient, both in absolute and relative terms. Marmot  presents compelling evidence from the Whitehall studies, justifying why minimal priority should be accorded to individual responsibility in health disparities. About 30-60% of the social gradient in mortality may be explained by individual-level behavior toward cardiovascular risk factors, but this fails to explain the very existence of such social gradient. Contradictory trends showing a steady decrease in the prevalence of smoking in Britain against the rising obesity epidemic cannot certainly be explained by personal behaviors unless we agree that the same population can be selectively healthy! More than an individual-level phenomenon, the decline in smoking has been a result of purposeful public health policy adopted by the Government (such as prohibition of smoking in public places, increased taxation, and regulatory control on industry.). To assume an overwhelming concept of personal responsibility in complete disregard of the social context would hence be a brutal injustice. Marmot has hence advocated the principle: "Opportunities lead to health."
Marchand et al.  view class inequalities in health as a matter of justice, independent of the allocation of health-care resources, or distribution of income and wealth. Offering empirical evidence from the days of the Black Report, they opined that health inequality is a fundamental violation of everyone's equal right to health. They emphatically point to research evidence that majority of ill-health does not have a causal behavioral origin, and even beyond that class inequalities in health are present independent of the behavioral risk patterns.
These evidences underline the importance of understanding and incorporating the social responsibility to address health disparities, whereas formulating public health policies. A criterion to judge the true progress of society, be it in the rich or the poor worlds, would be the extent of fair distribution of health rights across the social spectrum. 
| Considerations in Policy-making|| |
Wikler elaborates the dangers of assuming personal responsibility for health in public policy-making, arguing that this notion should have but a peripheral place in our considerations. For example, global efforts in addressing mortality and morbidity due to tobacco products have been criticized, often to an extreme as by Scruton, of unwisely focusing on an area which is extremely related to voluntary personal choices and independent risk-taking attitudes. However, then in the same light, we may not be spending a penny for the control of sexually transmitted infections, or even, distribute insecticide-treated bed nets free-of-cost to the poor in Asia and Africa since all these can be traced down to some personal behaviors! At a time when noncommunicable diseases are on the rise globally, we must tread extreme care in arbitrarily assigning a personal responsibility to health, in complete disregard of the prevailing scientific evidence which directs us in the opposite. 
It has been aptly observed that empowerment of individuals and groups across four principles dimensions-political, economic, social, and cultural is intricately linked to addressing the issues of health inequity. These four dimensions together represent a continuum and largely contribute to inclusion or exclusion of the needy population.  More recently, Bircher and Kuruvilla , have strongly argued for the adoption of a more holistic and measurable definition of health (as compared to the WHO definition) which incorporates the contribution of socioenvironmental determinants in shaping individual health status. The Meikirch Model of Health conceptualizes health as a "state of well-being" resulting from interactions between these determinants and individual-level demands and potentials.
Policy should necessarily focus on a positive assignment of the concept of a personal responsibility in self-health by providing more information toward building a healthy life style, initiating health promotional measures aimed at harm reduction, and addressing social inequalities that predispose unjust health disparities. The same philosophy has been echoed by Marmot and Deaton that public health policy must look beyond the realm of assigning individual responsibility for ill-advised choices, more so when the social circumstances have instigated such risky behaviors. 
In the realm of decision-making and implementation, quality information about actual health status of the social subgroups (racial, ethnic, gender, economic, etc.) remains of paramount importance. Petticrew et al.  have advised that future research should focus carefully on collecting health data across the social subgroups to generate valid evidence to address the social determinants of health and health inequalities through informed policy-making. In absence of such data, Rabinowicz argues that the egalitarian principle of equal treatment should be upheld as it ensures maximum equality in outcome, minimizing the "moral cost." 
| Conclusion|| |
Thus, in all fairness, it shall be apt to conclude that while considering disparities in health status that have a deep-rooted social origin, it shall only be prudent not to impart any undue importance to personal responsibility for health. The concept of individual responsibility should be viewed as a positive concept of enabling people to gain control over the determinants of health through making conscious, informed, and healthy choices. The society bears an undeniable responsibility of addressing the unjust health inequalities due to financial position, racial disposition, or any such factors.
It is in this spirit that the Commission on Social Determinants of Health  has proposed three areas of principled action, - improving the conditions of daily life; addressing inequitable distribution of power, money and resources at global, national, and local levels; and understanding the social basis of ill health while assessing the impact of our actions. One hopes that our understanding of ethical approaches shall always guide us to make the most just decision in addressing health disparities, instead of inculcating a culture of avoiding our responsibility as public health professionals by conveniently blaming individuals for choices that they had little control over.
This paper was initially developed by AJ as part of coursework under Prof. Daniel Wikler, Professor of Ethics and Population Health, Department of Global Health and Population, Harvard T. H. Chan School of Public Health. The author expresses regard for Prof. Wikler's teachings and inspiration behind this article.
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Conflicts of interest
There are no conflicts of interest.
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