Public Health Ethics and the Social Determinants of Health by Daniel S. Goldberg

Author:Daniel S. Goldberg
Language: eng
Format: epub
Publisher: Springer International Publishing, Cham

2.personal security

3.reasoning

4.respect

5.attachment

6.self-determination

The criteria for social justice is the extent to which a society provides to its members the social conditions necessary for its members to achieve a sufficient amount of these six essential dimensions of well-being. The theory places a lot of weight on the idea of sufficiency, so much so that Powers and Faden’s theory of justice has been termed a “sufficientarian” account. So, how do we know whether a given health intervention comports with mandates of social justice? If the intervention helps to create or sustain conditions that enable people to obtain sufficient amounts of the six essential dimensions of well-being, it satisfies Powers and Faden’s framework of social justice.

The fact that Powers and Faden’s model of social justice is based on sufficiency highlights the importance of densely-woven patterns of disadvantage. For, as Powers and Faden point out, those caught within these webs or clusters of disadvantage are disproportionately likely to experience insufficient amounts of the six essential dimensions of well-being. That is, people belonging to groups that are subject to compound social disadvantage are less and less likely to be able to achieve a sufficient level of health or personal security or a sufficient opportunity to determine the course of their own lives (self-determination). This claim in turn is at least partly supported by the epidemiologic evidence regarding the clustering of disadvantage and its impacts on stress and health. But it should not take too much imagination to understand how, for example, people who are persistently exposed to violence (a form of social disadvantage) are in the aggregate less likely to achieve sufficient levels of personal security.

Because compound disadvantage poses immense difficulties for health sufficiency , it becomes a priority in Powers and Faden’s theory. One of the most difficult questions with which theorists of justice grapple is ordering ethical priorities. This problem is of particular importance to public health; some argue that priority-setting is the central ethical question in the entire field of public health ethics. Priority-setting issues are extremely common in public health, in multiple ways and at multiple levels. For example, when a state government cuts appropriations to local health departments, the leadership of the latter face difficult decisions regarding how to revise and realign their priorities in the face of less resources. And in pandemic or disaster planning, it is crucial to determine which public health workers should enjoy priority in receiving prophylactic antibiotics or antivirals, not to mention which patients are of highest priority for receiving different kinds of interventions.

But, and as we will see in Chap. 5, issues of priority-setting go beyond the individual cases mentioned above. Priority-setting is also a vital component in determining what problems, policies, and categories of interventions are favored and implemented at global and domestic levels. Public health leaders, for example, face difficult choices in deciding whether to prioritize interventions that address public health problems higher up the causal pathway (often referred to as upstream, distal, or structural factors) or that operate lower down the pathway (downstream or proximal factors).

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