## 1. Introduction



One possible explanation for health disparities among the rich and
poor is that the rich can afford better health care. Were this
explanation correct, questions regarding the justice of health
inequalities could be answered by resolving familiar debates about
access to health care.



While unequal access to health care certainly contributes to health
inequalities, epidemiologists argue that the principal causes of these
inequalities lie outside of the health care system. These inequalities
are largely due to the "social determinants of health",
which we will understand as the socially controllable factors outside
the traditional health care system that are independent partial causes
of an individual's health status. Candidate examples of the
social determinants of health include income, education, occupational
rank, racism, and social class (for a brief corrective against the
natural tendency to reserve a privileged position for health care
here, see Marmot 2005).



In this entry, we provide an overview of the empirical literature
regarding the social determinants of health, and the philosophical
literature concerning the justice of health inequalities. Although the
health care system is itself a determinant of health, we largely set
aside questions regarding access to health care for it is covered
elsewhere (see entry on
 justice and access to health care).
 We begin with a discussion of the social gradient in health, proposed
social determinants of health, and possible causal pathways by which
these socially controllable factors could affect people's
health. We also discuss the normative question of whether health
inequalities should be understood and measured as differences among
*social groups* or differences among *individuals*.



We then address the central question of this entry: what makes a
health inequality unjust, when it is unjust? We first focus on the
justice of domestic health inequalities, providing an overview of
prominent theoretical approaches to this question. Since many propose
that health inequalities are not unjust when due to the voluntary
choices of individuals, we next explore the issue of individual
responsibility for health and its implications for health policy. We
conclude with a discussion of the justice of global health
inequalities.


## 2. A Social Gradient in Health



The empirical literature's most significant and powerful
reported finding can actually be replicated with *a number of
the* listed candidate social determinants of health, including
income, education, occupational rank, and social class. This is the
existence, within a given society, of a *social gradient* in
health. The most significant evidence on the relation between a
socially controllable factor and health comes from the Whitehall
studies, conducted in England by Michael Marmot and his colleagues
(1978). In these studies, the candidate social determinant of health
is occupational rank.



Between 1967 and 1969, Marmot examined some 18,000 male civil servants
aged between 40 and 69 years old. By placing a flag on their records
at the National Health Service (NHS) Central Registry, Marmot was able
to track the cause and date of death for each subject who later died.
His data are unusually good data. To begin with, they are generated
from data-points on specific individuals. Each datum reports the
relation between the occupational rank of a particular person and the
life-span (and cause of death) of the very same person. By contrast,
almost every other study begins from aggregate data. In addition, a
number of important background factors are held constant for this
study population. Notably, all the subjects in this study are stably
employed, they live in the same region (greater London), and all have
free access to health care provided by the NHS.



![a bar char: link to extended description below](fig1.png)

Figure 1. Social gradient in total
mortality, Whitehall 25 year follow-up. (van Rossum et al. 2000: 181)
[An
 extended description of figure 1
 is in the supplement.]




Figure 1
 presents the Whitehall data after 25 years of follow-up. It reports
age adjusted all-cause mortality rate ratios by employment grade, for
three periods of follow-up. A mortality rate ratio reports the
proportion of deaths in a given group divided by the proportion of
deaths in the reference group. There are four grades in the British
Civil Service employment hierarchy: administrative (highest),
professional/executive, clerical, and "other" (lowest).
The professional/executive grade has been used as the reference group,
so its mortality rate ratio is 1.0 by definition.



![a bar char: link to extended description below](fig2.png)

Figure 2. Risk factor adjusted social
gradient in CHD mortality, Whitehall 25 year follow-up. (Marmot 2000:
363, fig. 10) [An
 extended description of figure 2
 is in the supplement.]




The striking and important feature of these data is that the
relationship between employment grade and mortality exhibits a marked
*gradient*. It is natural to think that, below some threshold
of deprivation, there will be disproportionate ill-health. Yet, in
this study population, there is no deprivation, not even in the lowest
grade (where everyone is still a government employee with free access
to health care). Furthermore, and notably, there is no threshold.
Rather, there is a *step-wise* improvement in health outcomes
as one climbs the employment grade ladder. In addition, these
gradients persist even after the mortality rates have been adjusted
for standard risk factors. For example, coronary heart disease (CHD)
accounted for 43 percent of the deaths in the Whitehall study at 10
years of follow-up (Marmot, Shipley, & Rose 1984: 1003). Standard
risk factors for CHD include smoking, blood pressure, cholesterol and
blood sugar levels, and height.
 Figure 2
 presents the Whitehall data on mortality from CHD after 25 years of
follow-up. It reports relative rates of death from CHD by employment
grade, with administrators having a rate of 1.0 by definition. The
left bar in each pair displays the relative rate adjusted for age
alone, while the right bar adjusts it for all the standard risk
factors. Correcting for standard risk factors does explain some of the
gradient in CHD mortality, but no more than a third. The remaining
gradient is still marked.


## 3. Other Social Determinants of Health



The existence of a social gradient in health certainly suggests that
*something* in addition to health care exercises a powerful
influence on an individual's health--something, moreover,
that at least correlates with a social variable. However, it is not
clear exactly what this something is. To begin with, similar domestic
gradients in individual life expectancy can be found when the social
variable is *income* (Chetty et al. 2016; Case, Lubotsky, &
Paxson 2002; McDonough et al. 1997); when it is *education*
(Mackenbach et al. 2008; Huisman et al. 2005; Crimmins & Saito
2001; Elo & Preston 1996; Kunst & Mackenbach 1994); when it is
*social class* (Wilkinson & Marmot 2003); and, in the U.S.
context, when it is *race* (Arias 2016; Braveman, Cubbin, et
al. 2010).



By itself, therefore, the surface fact of a social gradient in health
is compatible with quite different accounts of the underlying causal
influences on individual health. Each distinct social variable might
function as a "marker" for a different underlying causal
factor, different social variables might function instead as
alternative markers for the same underlying causal factor, or there
may be some mixture of both. It is also possible that some social
variables--e.g., education (see Cutler, Lleras-Muney, & Vogl
2011)--function as a relatively direct causal factor.



Furthermore, it is not clear how much of the correlation between
health and a given social variable is properly causal in the first
place. In some cases, there is clearly some "reverse
causation" between health and a social variable, notably from
poor health to lower income (Bleakley 2010; J. Smith 2009; Deaton
2002) and from poor health to less education and lower occupational
rank (Case, Fertig, & Paxson 2005). Similarly, there is evidence
of a bidirectional relationship between income and mental illness
(Ridley et al. 2020). In addition, there is plainly some causation
among social variables, notably from education both to higher income
and to higher occupational status. Similarly, while there is evidence
that racism contributes directly to poorer health outcomes among
racial and ethnic minorities, for example, by means of racism-related
stress, it also contributes to racial and ethnic minorities having
lower incomes, worse educational outcomes, and lower occupational
status (Williams, Lawrence, & Davis 2019).



The choice of the social variable in terms of which to describe some
social gradient in health can be made on a number of different
grounds. One obvious ground would be to choose the variable(s) that
came closest to conveying the operative causal mechanism(s). Another
ground would be to choose the variable(s) that have independent moral
and/or political significance, such as race and gender. These grounds
need not exclude each other and there may be a case for choosing the
same variable on both grounds. The second ground acquires a special
relevance if health inequalities suffered by individuals who also
suffer, for example, from racial discrimination are more unjust than
health inequalities (of the same magnitude) suffered in the absence of
racial discrimination. If one injustice can compound another, then the
choice of social variable may affect the *kind* of inequality
in health at issue, and not simply its magnitude.



When the social variable is *income*, there is an important
further definitional dispute to consider. Income appears to have a
significant effect on life expectancy, even controlling for education
(Backlund, Sorlie, & Johnson 1999). However, there is an on-going
debate about which definition of "income" is adequate to
capture the contribution individual income makes to individual life
expectancy (see the sample of articles collected in Kawachi, Kennedy,
& Wilkinson 1999). According to the *absolute income
hypothesis*, the contribution income makes to individual life
expectancy is entirely a function of the individual's
non-comparative income. By contrast, the *relative income
hypothesis* holds, roughly, that an individual's life
expectancy is also a function of the *relative* level of her
income--that is, its level compared to others' income in
her society--and not simply of its non-comparative level
(Wilkinson 1996). To make this second hypothesis precise requires one,
among other things, to specify the reference group to which the
individual's income is compared and also the nature of the
comparison (for examples, see Deaton 2003). For an overview of this
debate and the state of evidence, see Sreenivasan (2009a) and Pickett
and Wilkinson (2015).


## 4. Groups or Individuals?



Our discussion thus far has implicitly proceeded on the assumption
that inequalities in health are defined in terms of membership in some
social *group* or other. An "inequality" in health,
so defined, is a difference between the health status of two groups,
with the identity of the group following from the choice of the social
variable with which health is correlated. For example, we note above
that in 2019, the life expectancy was 78.8 years for non-Hispanic
white Americans, and 74.7 years for non-Hispanic Black Americans.
While this is how most of the discussion in the literature on health
inequalities is actually structured, the definition is controversial.
Notably, Murray, Gakidou, and Frenk (1999: 537) argue in favor of an
alternative methodology, in which "health inequality"
refers to "the variation in health status across individuals in
a population", rather than to a difference in health status
between social groups.



Stimulated in large part by their article and the reaction to it,
another lively debate considers the basic conceptual question of how
health inequalities should be defined in the first place (for a nice
overview, see Asada 2013). Should they be defined across social
groups? Or across individuals instead? It helps to consider this
question on two separate levels. Let us call the first one the
"fundamental moral level" and let us assume that, on this
level, the individual is the basic unit of concern. The question at
this first level asks whether it is health inequalities across
individuals or health inequalities across groups which matter from the
standpoint of justice.



Now it may seem as if the assumption that individuals are the basic
units of moral concern compels us to define "health
inequality" across individuals as well, i.e., to reject the
conventional definition at the fundamental moral level, but that is a
mistake. Daniel Hausman's (2007, 2013) position in the debate
illustrates this point well. Despite affirming that the individual is
the fundamental unit of moral concern and taking as his starting point
the claim that what matters most for egalitarians like him is
inequalities in welfare or standing among individuals, he still
opposes defining inequalities in health across individuals.
Hausman's (2013: 95) central claim is that "[individual]
health inequalities are not themselves pro tanto
injustices".



For ease of exposition, let us follow Hausman in assuming, more
specifically, that what is of fundamental concern to justice is
individual *well-being*. Hausman's main point can then be
formulated as follows: Even though health is both an important
component and cause of well-being, if two individuals are unequal in
health, it does not follow that they are unequal in well-being. For
obviously, the same two individuals may also be unequal in some other
component of well-being, and the individual who is less healthy may
not have less well-being overall. For example, *A* may be
healthier than *B*, but *B* may have more friends or be
more accomplished than *A* (or both), and the latter inequality
may have a greater magnitude than the former (or a greater importance
to well-being), so that the less healthy *B* may still be
better off overall than *A* (cf. Hausman 2007: 52). The health
inequality between *A* and *B* is therefore fully
consistent with there being no fundamental complaint of justice about
their comparative situation (at least, not on behalf of the less
healthy *B*). Hence, if permission to infer that an injustice
obtains is built into the classification "inequality", as
Hausman at least implicitly supposes, we should not classify any
health difference between *A* and *B* (or, more
generally, between individuals) as an inequality. While Hausman
focuses on well-being moreover, this point generalizes to many
non-welfarist egalitarian views of justice too, for example, a
resourcist view which understands health to be one among a number of
resources.



Of course, even on its own terms, the logic of this argument admits of
an important exception: anytime an inequality in health between
individuals is such that it *cannot* be counter-balanced by any
complementary inequality in (one or more) other components of
well-being--for example, because it is too large (Hausman 2007:
54)--then that inequality in health does permit us to infer that
the less healthy individual also has less well-being overall. Hausman
calls these special health inequalities "incompensable"
and he accepts that they are immune to his objection:



> 
> 
> Data concerning incompensable health inequalities do permit inferences
> concerning inequalities in welfare or standing, and they thus provide
> relevant information for egalitarians. (Hausman 2013: 98)
> 
> 
> 



Accordingly, he restricts the scope of his official argument, so that
it only concerns *compensable* health inequalities between
individuals.



By contrast to (compensable) health inequalities between individuals,
health inequalities between social *groups* typically do, in
Hausman's view, permit inferences about inequalities in overall
well-being. Since that is his argument for defining "health
inequality" across social groups, it actually relies on the
assumption that individual well-being is the fundamental unit of moral
concern.



> 
> 
> Information about social group health differences will thus often be
> relevant to conclusions about justice, not because group differences
> matter and individual differences don't, but because information
> about differences in QALYs between well-studied social groups will
> often license conclusions about the fundamental inequalities that
> egalitarians care about. (Hausman 2007: 50)
> 
> 
> 



An important implication of Hausman's argument, which we shall
see independent reason to affirm later, is that it is artificial and
over-simple to put very much weight on mono-factor normative
principles, such as "equality of health-by-itself".



Iris Marion Young (2001) provides a more direct reason for focusing on
inequalities across groups at the fundamental moral level. She agrees
with Hausman that individuals are the basic unit of moral concern, but
argues that when claims of justice concern equality, the appropriate
focus is inequalities across groups. The cause of morally troublesome
inequalities, she argues, lies with social structures, where
structures



> 
> 
> refer to the relation of basic social positions that fundamentally
> condition the opportunities and life prospects of the persons located
> in those positions. (Young 2001: 14)
> 
> 
> 



Since structures constitute and relate to individuals as members of
social groups, group-conscious practices of assessing inequalities are
necessary to identify *structural inequalities*: inequalities
in people's freedom or wellbeing that are the cumulative effect
of social institutions, policies, and the decisions of officials
(Young 2001: 15). The social groups to focus on, Young (2001: 15)
argues, are those



> 
> 
> which we already know have broad implications for how people relate to
> one another--class, race, ethnicity, age, gender, occupation,
> ability, religion, case, citizenship status, and so on.
> 
> 
> 



Such structural inequalities are unjust since societies should not
structure their social institutions and policies in ways that
disadvantage people in the exercise of their freedom or flourishing on
the basis of factors beyond their control (Young 2001: 16).



Young does not focus exclusively on health but Paula A. Braveman,
Kumanyika, et al. (2011) provide an account of unjust health
inequalities that is structural in nature. While we use the concept of
*health disparities* above as a stand-in for *health
differences*, Braveman et al. (2011: S150) understand health
disparities as those health differences among groups that are
systematically tied to their social disadvantage (Braveman et al.
2011: S150):



> 
> 
> Health disparities are systematic, plausibly avoidable health
> differences according to race/ethnicity, skin color, religion, or
> nationality; socioeconomic resources or position (reflected by, e.g.,
> income, wealth, education, or occupation); gender, sexual orientation,
> gender identity; age, geography, disability, illness, political or
> other affiliation; or other characteristics associated with
> discrimination or marginalization...Health disparities do not
> refer generically to all health differences, or even to all health
> differences warranting focused attention. They are a specific subset
> of health differences of particular relevance to social justice
> because they may arise from intentional or unintentional
> discrimination or marginalization and, in any case, are likely to
> reinforce social disadvantage and vulnerability.
> 
> 
> 



To put this in Young's terms, health disparities are
*structural health inequalities*: health differences due to
social institutions and policies (see also Goldberg 2012; Powers &
Faden 2006, 61).



On the other side of the debate, Kasper Lippert-Rasmussen (2013)
argues that we should define "health inequality" across
individuals at the fundamental moral level. He first raises two
related objections to social group definitions which together advance
the point that any group definition will be inherently arbitrary.
Lippert-Rasmussen's first objection is the "intra-group
inequality" challenge, according to which there is no reason to
treat health inequalities between groups as being any more unjust than
health inequalities *within* groups. Yet,



> 
> 
> for any selection of groups such that [health] inequalities between
> two groups matter, intragroup [health] inequalities may exist. (2013:
> 57)
> 
> 
> 



Lippert-Rasmussen's second objection is the
"group-identification" challenge. There are any number of
ways to sub-divide a given population into groups. Holding the
underlying health facts fixed, different choices of group definition
will correspond to different inequalities in health (of different
magnitudes) inhering in the same population. Some explanation is
called for, then, of the significance in justice of the particular
character of one's favored group definition. What is the
relevance to justice, for example, of the apparently artificial
boundary demarcating the top 1% of the income distribution in the U.S.
from the bottom 1% (our opening illustration of an inequality in
health)?



Now, as Young (2001) and Braveman, Kumanyika, et al. (2011)
illustrate, one obvious option for discharging this explanatory
burden, which Lippert-Rasmussen (2013: 58) also recognizes, is to
define the groups so that they "echo the major social causes of
health equality". He rejects this response however on the
grounds that there is likely to be a mismatch between "groups
identified by the social causes of health" and "groups
among whom there are morally relevant health inequalities"
(Lippert-Rasmussen 2013: 58). A focus on the former will therefore
fail to recognize some number of unjust group health inequalities.



Lippert-Rasmussen (2013: 58) also attacks a central premise that he
takes to underlie arguments for group measures of health inequalities,
namely, that



> 
> 
> only health inequalities that are the causal result of social factors
> are unjust, and only group-based measures of health inequality fit
> unjust health inequalities.
> 
> 
> 



In contrast to this view, Lippert-Rasmussen argues that there is such
a thing as natural injustice, for example, health inequalities due to
biological processes for which no one is responsible, and individual
measures of health inequalities are necessary to capture them. We
discuss this point in more detail below.



Nir Eyal (2018) rejects many of the arguments in support of focusing
on health inequalities among groups. However, he offers a number of
moral reasons to identify and address "status group
inequalities", that is, health inequalities "between
groups that are defined along lines of social advantage and
disadvantage" (Eyal 2018: 150). He takes these reasons to be
compatible with, if not supported by, Lippert-Rasmussen's
inter-individual egalitarianism. We discuss two here. First, although
status group inequalities are not inherently unfair, they are often
"rough indicators" of underlying moral problems, including
injustices such as racial discrimination or failures of social
solidarity (Eyal 2018: 159). Eyal argues, second, that status group
inequalities may sometimes function as a proxy for luck egalitarian
injustices. Where status group inequalities exist, for example,
inequality in life expectancy between low-income and high-income
groups, it is likely that members of the disadvantaged group are
subject to circumstances that lessen their responsibility for the
outcomes in question (Eyal 2018: 161-162). Since luck
egalitarians hold that inequalities due to unchosen circumstance are
unjust, status-group inequalities may often function as proxies for
luck egalitarian injustice.



Earlier we said that it was helpful to consider the question of
defining health inequalities on two levels, where the first level is
the fundamental moral level. The main point behind distinguishing
levels here is simply to clarify that the fundamental moral level is
separate from other levels at which the question can be considered and
also more basic than them. In the first instance, then, it does not
matter much how exactly we describe the second level. We need only
describe it as "not the fundamental moral level". How the
other level(s) should be described more specifically will depend on
one's purposes. For example, Yukiko Asada (2013) describes a
"policy" level and Lippert-Rasmussen (2013) describes a
level of "principles of regulation".



At the level of policy-making, Asada (2013: 40-41) reviews two
considerations that favor defining health inequalities across
individuals and one that favors defining them across social groups.
She also proposes a novel approach that attempts to combine the merits
of both. A definition across individuals is favored by the fact that
data collected on that basis lends itself easily to international
comparisons (see also Murray, Gakidou, & Frenk 1999), whereas data
on health inequalities defined across groups can only be compared
between two countries if both countries have conceived and
operationalized the relevant groups in the same way (which they often
have not). Furthermore, defining health inequalities across
individuals does not require any balancing or summary operation in
order to yield conclusions about overall inequalities in health,
whereas a definition across groups only yields conclusions about
overall inequalities when combined with data from other relevant
groups (e.g., when health inequalities across income groups are
combined with health inequalities across educational groups). On the
other hand, a definition across groups is favored by the fact that the
social variable defining the group (e.g., income or education) often
naturally suggests a target for policy intervention, whereas a
definition across individuals suggests no such target and is thus
"one step removed from policy" (Asada 2013: 41).


## 5. Causal Pathways



The strategy of aligning the social groups used to define inequalities
in health with the major social causes of health evidently presupposes
that one knows what those causes are. To determine whether any of the
previously discussed correlations between individual life expectancy
and a social variable is causal, one needs some account of the
*causal pathways* between candidate social determinants and
specific mortality risk factors. Unfortunately, these pathways are not
well understood (Mackenbach 2019: 49-55; Adler & Newman
2002; Adler & Ostrove 1999; R. Evans, Hodge, & Pless 1994).
While research in this area remains preliminary, it may be useful to
describe some of the possibilities.



Johan Mackenbach (2019: 62-73) helpfully identifies three groups
of causal pathways between social determinants and health outcomes.
The first is childhood environment. Socioeconomically disadvantaged
mothers are more likely to have impaired health, have greater
psychosocial stress, and to engage in unhealthy behaviors during
pregnancy (Mackenbach 2019: 66). Their children are therefore more
likely to experience impaired fetal growth, low birth weight, and
premature birth. Children with disadvantaged parents are also more
likely to be exposed to unfavorable conditions after birth, including
inadequate nutrition and harmful levels of air pollution, which may
explain why they have worse health outcomes compared to children of
high-income parents (Currie 2009; Case, Lubotsky, & Paxson
2002).



A second group of causal pathways is lifelong material living
conditions (Mackenbach 2019: 68). Certain conditions of absolute
material deprivation constitute well-recognized risks for ill health
and mortality, including inadequate nutrition, lack of clean water and
sanitation, and poor housing. A very plausible causal pathway runs
from low levels of non-comparative individual income through these
material risk factors to poor health outcomes (Aldabe et al. 2011).
Low-income people are also more likely to work physically demanding
jobs which expose them to dangerous chemicals (Clougherty, Souza,
& Cullen 2010), and reside in neighborhoods featuring poor access
to amenities and increased exposure to environmental risks such as air
pollution and toxic waste sites (Brulle & Pellow 2006; Pickett
& Pearl 2001).



A third group of causal pathways between social determinants and
health outcomes is social and psychological factors (Mackenbach 2019:
72; Marmot 2004). This group is important for it can explain the above
cited social gradients in life expectancy which were mainly observed
in highly developed societies, where the prevalence of absolute
material deprivation is fairly low. In particular, a significant
social gradient was observed in the Whitehall studies, where the
occupants of even the lowest occupational rank were nevertheless all
stably employed civil servants with free access to health care.



One of the most prominent specific risk factors envisaged as the
terminus for a psychosocial pathway is (the effects of)
*stress*. As Eric Brunner and Michael Marmot (2006) explain,
the long-term effects of stress differ importantly from its short-term
effects. In the short-term, an individual's fight-or-flight
response to external stressors is beneficial insofar as it enables
them to cope with threats and challenges. Among other things, this
acute stress response involves the activation of neuroendocrine
pathways, along which adrenaline and cortisol (e.g.) are released into
the bloodstream. These hormones stimulate psychological arousal (e.g.,
vigilance) and mobilize energy, while simultaneously inhibiting
functions irrelevant to immediate survival (e.g., digestion, growth,
and repair). An optimal reactivity pattern is characterized by a sharp
increase in levels of circulating adrenaline (and later, cortisol),
followed by a rapid return to baseline once the challenge has passed.
Sub-optimal patterns are characterized by elevated baseline levels and
slower returns to baseline.



By contrast, the long-term effects of stress--either from over
frequent provocation of acute stress or from chronic stress--can
be physiologically harmful (Brunner & Marmot 2006). Stress-induced
damage is mediated, among other things, by prolonged elevation of
adrenaline and cortisol levels in the blood. Elevated cortisol can
lead to the accumulation of cholesterol (e.g., by raising glucose
levels even during inactivity); and elevated adrenaline increases the
blood's tendency to clot, which can add to the formation of
arterial plaques and thereby lead to increased risk of heart disease
and stroke. Other risks that may be increased by stress-induced damage
include risks for cancer, diabetes, infection, and cognitive
decline.



A psychosocial pathway running from stress-induced damage--or
"allostatic load" (B. McEwen 1998)--has next to be
traced to some social factor, preferably one amenable to policy
manipulation. Four factors that have attracted considerable attention
are "social rank", "job control",
"racial discrimination", and "poverty".



The most specific evidence on the role of *social rank* in
producing stress-induced damage comes from studies of non-human
primates (Brunner & Marmot 2006; R. Evans, Hodge, & Pless
1994). In various primate species, social life is organized in terms
of clear and stable dominance hierarchies. Robert Sapolsky and Glen
Mott (1987) found that hierarchies of free-ranging male baboons
exhibit an inverse social gradient both in cortisol elevations and in
adverse cholesterol ratios. Manipulating the dominance hierarchy of
captive female macaque monkeys, Carol Shively and Thomas Clarkson
(1994) similarly found that dominant monkeys who became subordinate
had a five-fold excess of coronary plaques as compared to those who
remained dominant. (Part of this excess was due to the stress
associated simply with a *change* in social rank [as distinct
from a demotion], since subordinate monkeys who became dominant also
had more atherosclerosis [albeit, only twice as much] compared to
those who remained subordinate).



Evidence on the role of *low job control* in producing
stress-induced damage comes from the Whitehall II study (Marmot,
Bosma, et al. 1997). "Job control" refers to an
individual's level of task control in the workplace,
operationalized here in terms of a questionnaire concerning decision
authority and skill discretion. One of the principal diseases for
which stress-induced damage increases the risk is coronary heart
disease (CHD). In Whitehall II, there was an inverse social gradient
in age-adjusted CHD incidence: Compared to their high grade
counterparts, intermediate grade male civil servants were 1.25 times
more likely to develop a new case of CHD in a five year interval,
while low grade men were 1.5 times more likely. For women, the odds
ratios were 1.12 and 1.47. Marmot and his colleagues also found an
inverse social gradient in low job control. Among men, 8.7 percent of
high, 26.6 percent of intermediate, and 77.8 percent of low grade
civil servants reported low job control; for women, the percentages
were 10.1, 34.8, and 75.3. But their key finding was that a
substantial part of the gradient in CHD incidence could be attributed
to the differences in job control. Controlling for low job control
reduced the low grade (e.g.) men's odds ratio for new CHD from
1.5 to 1.18 and the women's from 1.47 to 1.23. By comparison,
known CHD risk factors only reduced the same ratios from 1.5 to 1.3
and from 1.47 to 1.35, respectively.



There is also evidence that experiences of *racial
discrimination* may contribute to racial disparities in health.
While some racial health disparities are explainable by appeal to the
lower average socioeconomic status of racial minorities, racial health
disparities persist at every level of socioeconomic status (Braveman,
Cubbin, et al. 2010). There is increasing evidence that such residual
disparities may in part be the result of experiences of
individual-level racial discrimination which produce stress-induced
damage (Williams et al. 2019; Colen et al. 2018). Indeed, a recent
study suggests a causal pathway between these factors, finding an
independent association between discrimination exposure and higher
levels of spontaneous amygdala activity and
connectivity--processes linked to higher levels of stress,
physiological arousal, vigilance, and negative health outcomes (Clark,
Miller, & Hegde 2018).



Finally, there is increasing evidence that children raised in
*poverty* are often exposed to adversities that produce
"toxic stress". Such stress "involves the frequent
or sustained activation of the biological stress system" and is
often the result of adverse events that are more likely to exist in
low-income households, including maternal depression, child abuse and
neglect, and spousal violence (C. McEwen & B. McEwen 2017: 448).
Toxic stress in turn negatively affects children's early
physical and cognitive development, with likely negative consequences
for their later health, educational, and occupational outcomes (C.
McEwen & B. McEwen 2017; Boyce, Sokolowski, & Robinson
2012).



In sum, there is a reasonable case to be made that many health
inequalities are caused by a number of socially controllable factors
outside of the traditional health care system. Such social
determinants of health may include income, occupational rank,
education, social status, and racial discrimination. We would caution,
however, that more evidence is needed to establish the proposed causal
pathways, and that some of the evidence we discuss is contentious. For
example, Anne Case and Christina Paxson (2011: F185) argue that much
of the gradient Marmot, Bosma, et al. (1997) attribute to job control
in Whitehall II can be explained by participants' early life
health and socioeconomic status, suggesting that "occupational
grade may be more of a marker of poorer health than a cause of poorer
health".



In addition, while the above evidence regarding causal pathways is
arguably sufficient for normative theorizing, things may be different
for the purposes of *designing policy* remedies. As Angus
Deaton (2002: 15) puts it, "policy cannot be intelligently
conducted without an understanding of mechanisms; correlations are not
enough". It is not clear that our existing understanding of the
causal pathways between socially controllable factors and specific
mortality and morbidity risks is sufficiently well-developed to
underwrite concrete policy proposals. Moreover, even if it were, it
would still be a further step to *license implementation* of
some such proposal. Among other things, a license of this kind
requires an account of the comparative effectiveness of a proposed
reform in relation to salient alternatives.


## 6. Justice and Domestic Health Inequalities



We turn now to a discussion of the normative dimension of health
inequalities. We begin in this section with a look at health
inequalities among residents of the same state. We first examine the
concept of *health equity* which is often employed as a
normative standard in the public health literature for evaluating such
inequalities. We then turn to the philosophical literature, providing
an overview of the most prominent accounts of the justice of health
inequalities. In the two remaining sections of this entry, we first
discuss the relevance of individual responsibility for health justice
before concluding with a discussion of the justice of global health
inequalities.


### 6.1 Health Equity



The concept of *health equity* is often used to refer to just
distributions of health, where health inequities are understood to be
differences or disparities in health that are avoidable, unnecessary,
and unfair (Whitehead 1992). Health *inequalities* are
therefore in principle observable differences in the health among
individuals and groups. Health *inequities* are health
inequalities that are unjust. (For discussion of the ways in which
health inequality metrics may themselves be value-laden see King 2016;
see Asada 2019 for a good discussion of challenges in measuring health
inequities).



While the concept of health equity is frequently invoked as a
normative standard by scholars, policymakers, and public health
practitioners, there is a good deal of disagreement regarding its
meaning. There is disagreement, first, on which health differences are
*avoidable*. Some suggest that health differences are avoidable
only if they are caused by social processes rather than natural or
biological processes (Chang 2002; Whitehead 1992). Others argue that
this understanding is too constrained (Preda & Voigt 2015; Wilson
2011). Even if health differences caused by natural processes are not
avoidable in the sense of being preventable, these critics suggest,
they may be avoidable in the sense of being treatable. Moreover, if
inequalities in health are inequitable in part because they are
unchosen, as luck egalitarians claim, then it makes sense to identify
avoidable health inequalities as those that are amenable to
intervention (Preda & Voigt 2015: 30).



There is also disagreement regarding whether avoidability is a
distinct and necessary condition of unjust health inequalities. Sudhir
Anand and Fabienne Peter (2000) suggest that unfairness entails
avoidability and so is not really separate from it. But avoidability
is cleanly separable (in the other direction) from unfairness, and
that can be an analytic advantage. For example, it allows the justice
of inevitable inequalities in health to be decided without having to
engage the issue of fairness at all. Others question whether health
differences must be avoidable if they are to count as unjust
(Lippert-Rasmussen 2013: 59-60; Wilson 2011: 216). For luck
egalitarians, health differences due to natural processes can be
unjust regardless of whether they can be prevented or treated. Even if
person *A* has lesser mobility compared to person *B*
due to a genetic condition that is neither preventable nor treatable,
the difference between *A* and *B* is unjust and
*A* has a claim on society to rectify it, for example, through
the provision of a mobility aid or the restructuring of the social
environment. Such inequalities are examples of *natural*
injustices--injustices caused by natural processes--rather
than *social* injustices--injustices caused by social
processes (Lippert-Rasmussen 2013: 59-60). (For a contrary view,
see Wester 2018).



One way to save the avoidability condition--understood as
amenability to intervention--is to stipulate that the concept of
health equity is only concerned with *social* injustices
(Sreenivasan 2015: 54). But, while luck egalitarianism is
controversial, James Wilson (2011: 216) cautions that it would be a
mistake to define the concept of health equity in a way that
presupposes its falsity. Wilson (2011: 217) therefore concludes that
health inequities are simply those health differences that are unjust
(for an excellent overview of these and other debates regarding the
concept of health equity, see M. Smith 2015).



While these debates regarding the avoidability condition implicitly
raise questions of justice, the fairness condition does so explicitly.
If the concept of health equity is to function as a defensible
normative standard, we need an account of justice in the distribution
of health.


### 6.2 Free-Standing Approaches



We can distinguish two fundamentally different approaches to bringing
verdicts of fairness or justice to bear on a given health inequality.
On the *free-standing approach*, the injustice of an unjust
health inequality is the primary injustice, although a verdict of
injustice can also be spread *backwards* from this primary
injustice to its causes. By contrast, on the *derivative
approach*, the injustice of an unjust health inequality is not the
primary injustice. Rather, the primary injustice is some unjust cause
of a health inequality, although a verdict of injustice can also be
spread *forwards* from this primary injustice to the health
inequality itself. In this way, the injustice of an unjust health
inequality derives from the primary injustice of its cause(s). (This
distinction between free-standing and derivative approaches closely
matches Peter's [2004: 94-95] distinction between direct
and indirect approaches). Suppose, for example, that part of the
difference in life expectancy between white and Black men in the
United States is caused by racial discrimination. On the derivative
approach, this part of that inequality in health is unjust because its
*cause* is unjust, and this verdict holds even if inequalities
in health are not otherwise unjust (e.g., even if no valid principle
of equality applies directly to health). On a free-standing approach,
by contrast, this difference in life expectancy may itself be unjust,
regardless of its cause. We discuss each approach in turn.



The simplest example of the free-standing approach applies a general
principle of equality directly to the case of health. (For general
discussion of the grounds of egalitarianism, as well as of the
character of different versions, see the entry on
 egalitarianism.)
 With some qualifications, the resultant requirement of
"equality of health" is affirmed, for example, by Anthony
Culyer and Adam Wagstaff (1993). This implies that *any*
avoidable inequality in health is unfair or unjust.



Luck egalitarians object to the strict equality view on the grounds
that inequalities are not unjust if they are the result of voluntary
and informed choices (Segall 2010; Le Grand 1987). While it is unjust
for one person to be worse off than another because of *brute*
luck--i.e., factors beyond a person's control such as their
natural or social circumstances--inequalities due to
*option* luck--i.e., factors within a person's
control--are just. For luck egalitarians therefore, not all
health inequalities are unjust, only those due to unchosen
circumstances (Voorhoeve 2019; Albertsen & Knight 2015; Temkin
2013; Segall 2010: 99).



A problem for both strict and luck egalitarian views, however, is that
they are subject to the leveling down objection, for unjust
inequalities in health may be addressed either by improving the health
of those who are unfairly worse off or leveling down the health of
those who are unfairly better off (Segall 2010). If *A*'s
life expectancy is 10 years shorter than *B*'s due to
cancer, this inequality may be addressed either by treating
*A*'s cancer or damaging *B*'s health.
Similarly, if one holds that health inequalities between social groups
are unjust, one may be committed to the conclusion that deteriorations
in the health of members of advantaged social groups are good--at
least in one respect--when they reduce such inequalities. For
example, one may be committed to the questionable claim that the rise
of "deaths of despair" among white Americans in the
twenty-first century (see Case & Deaton 2015, 2020) is in one
respect good since it reduced inequalities in life expectancy among
white Americans and Black Americans (for a thoughtful discussion of
this issue, see Blacksher 2018).



Eyal (2013) offers the most promising response to the leveling down
objection in this context, pointing to a number of cases where it is
plausible to prefer outcomes that are more equal, even if less equal
alternatives are available where some are better off and no one is
worse off. Luck egalitarians also soften the force of this objection
by adopting pluralist views, arguing that comparative fairness is not
the only relevant value (see Voorhoeve 2019; Temkin 2013).



Segall (2010) opts instead for a luck prioritarian account,
*prioritizing the opportunity for health of the worse off*.
According to this principle,



> 
> 
> Fairness requires giving priority to improving the health of an
> individual if she has invested more rather than less effort in looking
> after her health, and of any two individuals who have invested equal
> amounts of effort, giving priority to those who are worse off
> (health-wise). (Segall 2010: 112)
> 
> 
> 



On Segall's (2010: 119), view therefore, justice demands, first,
that we improve the health of those who have been most prudent in
taking care of their health, that is, whose health deficits are most
due to brute luck. For individuals who have exercised equal prudence
regarding their health, justice demands, second, that priority be
given to those whose health deficit is greatest--i.e., are worse
off (Segall 2010: 119). In contrast to a luck egalitarian view,
Segall's (2010: 120) luck prioritarian view is not concerned
with realizing equality in health, but rather with "prioritizing
the opportunity for health of the worse off".



Some scholars avoid the leveling down objection by opting for social
or relational egalitarian alternatives to luck egalitarianism. On this
view, health inequalities are unjust if they undermine citizens'
ability to interact with each other as equals (see Voorhoeve 2019;
Kelleher 2016; Voigt & Wester 2015; Hausman 2012; Pogge 2004). For
example, Alex Voorhoeve (2019) suggests that social egalitarians have
special reason to be concerned with health deficits that make people
vulnerable to domination or exploitation in private life as well as
domination or marginalization in public life. Proponents of this view
argue that it addresses a significant problem with luck egalitarian
approaches since it holds that health inequalities due to
people's voluntary and informed choices are nonetheless unjust
if they undermine their standing as equals. A challenge to social or
relational egalitarian views, however, is that they are vague on which
health inequalities undermine equal relations among citizens (Hausman
2019; Voigt & Wester 2015).



In contrast to those who see luck egalitarian and relational
approaches as competing views, Voorhoeve (2019) argues that each has a
compelling basis and may be combined in a complementary way. Social or
relational egalitarianism recognizes that there is "reason to be
averse to choice-based inequalities that threaten people's
status as equal citizens" while the luck egalitarian approach
offers a reasonable interpretation of the vague relational requirement
of the principle of equal consideration (Voorhoeve 2019:
154-155).



Others avoid the leveling down objection by defending sufficientarian
approaches to health justice (for comprehensive discussions of
sufficientarian approaches, see Fourie 2016; Rid 2016). Madison Powers
and Ruth Faden (2006: 15-29) argue that social justice requires
that people be secured a sufficient level of wellbeing where wellbeing
is understood to have six essential dimensions: health, personal
security, reasoning, respect, attachment, and self-determination.
Justice does not therefore demand equality in health outcomes, but
rather that people have "enough health over a long enough life
span to live a decent life" (Powers & Faden 2006: 95).
Jennifer Prah Ruger (2010) similarly develops a capabilities approach
to health justice, according to which people are entitled to a
threshold level of certain core health capabilities, that is,
abilities to be healthy. The focus of public policy, Prah Ruger (2010:
88-90) argues, should be to reduce "shortfall"
inequalities--i.e., to bring people as close to the requisite
threshold as is possible.



While these sufficientarian approaches avoid the leveling down
objection, they nonetheless face two significant challenges. First,
should governments be indifferent regarding health disparities above
the threshold identified by sufficientarian views (Arneson 2002)? If
the threshold is set too low, such a view may regard significant
disparities in morbidity and mortality as not unjust. Second, among
those who fall below the threshold, who should be prioritized (Fourie
2016)? Should policymakers focus on maximizing the number of people
who meet the threshold, even if this means helping those who are
better off? Or should they prioritize the worse off, even if this
means using significant resources to only marginally improve their
health? (For a discussion of possible solutions to these problems, see
Shields 2016).



Some commentators criticize free-standing views' tendency to
focus on or prioritize *health* inequalities to the exclusion
of other normative considerations. Hausman (2007, 2013, 2019) argues
that health inequalities among individuals are not pro tanto unjust
since such inequalities (among individuals) do not permit inferences
regarding inequalities in wellbeing or moral standing which are of
real moral concern. Daniel Weinstock (2015: 438) cautions against
"health consequentialism", the view that all social
determinants of health should be arranged to achieve some preferred
distribution of health--e.g., health equality. He argues instead
in favor of pluralistic approaches to distributive justice which
recognize that the distribution of many of the social determinants of
health--e.g., income and education--should also be governed
by additional, non-health related principles of justice (see also
Wester 2018). Powers and Faden's (2006) view avoids these
problems by positing six dimensions of wellbeing, though this approach
faces the challenge of how conflicts among these dimensions ought to
be adjudicated.


### 6.3 Derivative Approaches



In contrast to free-standing approaches to the justice of health
inequalities, derivative approaches locate the injustice of unjust
health inequalities with their unjust causes. Norman Daniels (2008)
offers the most prominent example of this approach (see also Daniels,
Kennedy, & Kawachi 2000; and Peter 2004). His central claim is
that, by a happy coincidence, John Rawls' principles of justice
regulate all of the principal social determinants of health (Daniels
2008: 82 and 97). Compliance with these principles, Daniels (2008: 82)
claims, "will consequently flatten the socioeconomic gradient of
health as much as we can reasonably demand" with the result that
"*social justice in general is good for population health and
its fair distribution*".



To begin with, *income* and *workplace organization* are
regulated by the difference principle: inequalities in income and
hierarchies in the workplace are permitted only to the extent that
they work to the greatest benefit of the least well off.
*Education* is regulated by the principle of fair equality of
opportunity, which requires "equitable public education"
as well as "developmentally appropriate day care and early
childhood interventions" (Daniels 2008: 96). *Political
participation*, which Daniels (2008: 95-6) regards as a
social determinant of health, is regulated by the principle of equal
basic liberty: among other things, this principle safeguards the fair
value of the right to participate politically. Finally, reaffirming
his earlier work (1985), Daniels maintains that fair equality of
opportunity also requires universal access to comprehensive *health
care* (broadly construed to include public health).



To the extent that these social variables are causal determinants of
health, and to the extent that their distribution in society
*fails* to conform to the corresponding principle of Rawlsian
justice, the resultant health inequalities will be unjust and unjust
because their causes are unjust. The flip-side of this point is that
the implementation of Rawls' principles will tend--again,
insofar as the relevant determinants are causal--to reduce
existing inequalities in health (Daniels 2008: 82).



As Daniels notices, observing Rawlsian justice may flatten the social
gradient in health without eliminating it altogether. For example, the
difference principle may permit certain inequalities of income, which
are nevertheless *possible* to eliminate. If income is a causal
determinant of health, these permissible income inequalities will
(continue to) generate health inequalities if they are left in place.
(This scenario is actually only coherent if the *relative*
income hypothesis is the correct account of the causal mechanism. For
the explanation, see Sreenivasan 2009b). Daniels holds that the
persistence of avoidable health inequalities does not give us reason
in justice, independently of the difference principle, to eliminate
their underlying cause. In his view, justice permits some avoidable
inequalities in health:



> 
> 
> The residual inequalities that emerge with conformance to
> [Rawls'] principles are not a compromise with what justice
> ideally requires; they are acceptable as just. (2008: 99)
> 
> 
> 



Anand and Peter (2000) criticize Daniels' account on the grounds
that there is a tension between two different uses Daniels makes of
Rawls' second principle of justice. On the one hand, they argue,
Daniels treats its two parts as simply regulating certain specific
social determinants of health--the fair equality of opportunity
principle regulates education (e.g.), while the difference principle
regulates income. On the other hand, his account of health care treats
the fair equality of opportunity principle as regulating
*health* itself directly. But the latter employment of fair
equality of opportunity, which Anand and Peter actually prefer (2000:
52), threatens to contradict Daniels' treatment of residual
health inequalities. If fair equality of opportunity requires (some
kind of) egalitarianism about health, then residual health
inequalities that remain after the difference principle is fully
implemented may still fall within *its* scope. In that case,
Rawlsian justice may well command their reduction.



To avoid this problem of inconsistency, Jayna Fishman and Douglas
MacKay (2019) and Johannes Kniess (2019) rework Rawls's theory
of justice, developing a Rawlsian conception of the social
determinants of health--the *social bases of
health*--and arguing that it should be considered a social
primary good. Fishman and MacKay (2019) and Kniess (2019) disagree
however on which Rawlsian principle should govern the distribution of
this good. Fishman and MacKay (2019) argue that the parties to the
original position would choose an additional principle of justice to
govern the distribution of the social bases of health and assign it
lexical priority over fair equality of opportunity and the difference
principle. According to this principle, the



> 
> 
> social bases of health are to be arranged so as to have the greatest
> positive impact on the health status of those least advantaged on the
> social health gradient. (Fishman & MacKay 2019: 616)
> 
> 
> 



The social bases of health deserve this priority, Fishman and MacKay
(2019: 615) suggest, since health is necessary if people are to
realize their highest order interests in developing and exercising
their two moral powers. Inequalities in the distribution of the social
bases of health, and so inequalities in health status resulting from
such a distribution, are just if the least advantaged on the social
health gradient have a higher expected health status than they would
under an equal distribution (Fishman & MacKay 2019: 616). Kniess
(2019: 418), by contrast, argues that the social bases of health
should be governed by the difference principle, though he concedes
that this complicates the indexing problem, namely, that there is no
obvious way to rank different distributions of income and wealth, the
powers and prerogatives of offices and positions of responsibility,
and the social bases of health. Kniess (2019: 420) concludes that such
tradeoffs must be decided through the democratic process. While
Fishman and MacKay (2019) avoid this problem by prioritizing the
social bases of health, as Kniess argues (2019: 418-420), his
approach may be preferable since it permits tradeoffs between health
and income and also leaves more room for political communities to set
priorities.



One remaining problem with Fishman and MacKay (2019) and
Kniess's (2019) reworking of Daniels' (2008) approach is
that they too are silent on the justice of residual health
inequalities. This question is important, for while we have presented
the free-standing and derivative approaches as alternatives, it is
possible for the two approaches to be combined. Holding that
inequalities in health are unjust because of their unjust causes does
not preclude holding that they are unjust simply qua inequalities.


## 7. Individual Responsibility and Health Behaviors



In
 section 5,
 we identified three groups of possible causal pathways between social
determinants and health outcomes: childhood environment, material
living conditions, and social and psychological factors. A central
contributing factor to poor health outcomes, however, has an ambiguous
relation to social determinants. There is strong evidence that
*health behaviors*, including smoking, excessive alcohol
consumption, poor nutrition, and lack of physical exercise are key
contributors to morbidity and mortality (Petrovic et al. 2018). Some
find, moreover, that health behaviors explain much of the social
health gradient in high-income countries, since harmful health
behaviors are more prevalent in groups with lower socioeconomic status
(Petrovic et al. 2018). For example, Silvia Stringhini, Sabia, et al.
(2010) argue that when superior measures of health behaviors are
employed, much of the health gradient identified in the Whitehall II
study can be explained by a social gradient in harmful health
behaviors (though Stringhini, Dugravot, et al. [2011] did not
replicate this finding in a study of employees of the French national
gas and electric company, suggesting that whether health behaviors
contribute to the social gradient may depend on social context).



When harmful health behaviors are more prevalent among people with
lower socioeconomic status, one might argue that the consequent health
inequalities are simply the result of social factors over which one
has no control--i.e., as akin to one's childhood
environment. This is too quick, however, for people
*decide*--at least in some sense--to smoke, to drink
alcohol excessively, or to eat a poor diet, and such decisions may not
always be determined by social factors--e.g., material
constraints on access to healthy food. This matters for evaluations of
justice, since, as we saw above, some argue that health inequalities
are not unjust if they are the result of voluntary choices. If
decisions to engage in harmful health behaviors meet the appropriate
threshold of voluntariness, therefore, one may plausibly argue that
there is nothing unjust about that portion of the social gradient in
health that is due to them.



The question of individual responsibility is also relevant for a
number of areas of health policy. If individuals are responsible for
the downstream consequences of their harmful health behaviors,
policymakers may be justified in withholding care or assigning such
patients lesser priority in the allocation of scarce resources (see
Voigt 2013). Policymakers may also be justified in designing public
health strategies that encourage people to make better choices
regarding diet and physical exercise as opposed to addressing the
structural circumstances within which people make choices.



To begin, luck egalitarians would seem to be committed to the view
that health inequalities due to voluntarily chosen health behaviors
are not unjust. While luck egalitarians hold it is unjust for one
person to be worse off than another because of brute luck,
inequalities due to option luck--i.e., factors within a
person's control--are just. Applied to health and health
care, luck egalitarianism would seem to imply that people should be
compensated for inequalities in health due to brute luck--e.g.,
genetic factors and the social determinants of health--but held
responsible for health outcomes due to option luck--e.g.,
voluntary decisions to drink excessively or eat a poor diet (see,
e.g., Le Grand 1987, Segall 2010, and Cavallero 2011).



For example, if someone has a treatable case of lung cancer, we might
ordinarily reasonably presume that it would be unjust to deny him
medical care. However, if his cancer is due to a heavy, life-long
smoking habit, the question arises of whether the ordinary presumption
is defeated or diminished in strength. For instance, if there is a
choice to be made (say, because of resource scarcity) between treating
him and treating another lung cancer patient who is in no way
responsible for her lung cancer, does justice require preferring the
second patient? A simple application of luck egalitarianism would hold
that it is just to deny treatment to the smoker, as long as his
"decision to smoke" qualifies as a "voluntary
choice" according to some suitable criteria.



Many find this implication of luck egalitarianism to be objectionable,
with Elizabeth Anderson (1999: 296) calling it "the problem of
*abandonment of negligent victims*". Some luck
egalitarians respond that their view, properly understood, is not
committed to this implication. For example, Alexander Cappelen and Ole
Norheim (2005) and Julian Le Grand (2013) suggest that differences in
option luck--i.e., differences in how the voluntary choices of
people play out--are themselves unjust, and so policies should be
implemented to ensure that the lucky help the unlucky, such as taxes
on cigarettes with the revenues used to provide care to smokers who
develop lung cancer. Eric Cavallero (2011: 393-396) takes a
stronger line, arguing that luck egalitarianism provides no support
for holding individuals accountable for the outcomes of health
behaviors. Cavallero (2011: 393) distinguishes between socially
detectable and socially undetectable risky behaviors, with smoking an
example of the former and poor stress management an example of the
latter. He argues that it is not necessarily more fair, by luck
egalitarian lights, to only hold people responsible for the former
behaviors than to simply refrain from holding people responsible for
their choices (Cavallero 2011: 395).



Segall (2010), by contrast, accepts that luck egalitarians cannot
avoid the abandonment objection by appeal to egalitarian
considerations, but can do so if they appeal to moral considerations
unrelated to distributive justice--e.g., meeting people's
basic needs. Voorhoeve (2019: 155) similarly adopts a pluralistic
view, arguing that a luck egalitarian approach should be combined with
a social egalitarian approach since the latter



> 
> 
> specifies that one has reason to be averse to choice-based
> inequalities that threaten people's status as equal citizens and
> social cohesion.
> 
> 
> 



Others address the question of harmful health behaviors by developing
Rawls's (1982) concept of the *social division of
responsibility*. According to Rawls (1982 [1999: 371]), society is
responsible for securing people's basic liberties and providing
each with a fair share of opportunities and income and wealth, while
individuals are responsible for setting goals and projects in light of
the legitimate claims they may make on social institutions. Applying
this concept to health inequalities, Kniess (2019: 115) argues that
people are responsible for the health outcomes of choices made under
conditions of social justice, but not those outcomes due to choices
made under conditions of social disadvantage. As Kniess puts it,



> 
> 
> where there is no justice, there is no (substantive)
> responsibility...the disadvantaged in an unjust society are
> therefore let off the hook, so to speak, no matter what they do or
> don't do to look after their health. (2019: 116)
> 
> 
> 



Even if people's choices to drink excessively, eat an unhealthy
diet, or fail to exercise are voluntary, on this view, if such choices
are made under conditions of unjust social disadvantage, people are
not responsible for the downstream consequences. Daniels (2011)
develops a similar Rawlsian view, but emphasizes that even under
conditions of social justice, policymakers should be wary of holding
individuals accountable for the costs of their health behaviors. We
all have an interest, Daniels argues, in having the freedom to make
choices regarding sport, sex, and diet without the fear of social
sanction when our choices turn out to be "bad" ones (see
also Fleck 2012).



Ben Davies and Julian Savulescu (2019) provide an alternative argument
for holding individuals responsible for the health behaviors. They
argue that where healthcare systems are grounded in solidarity, people
have obligations to fellow members of the system to protect their
health and may be held responsible for some or all of the costs of
treatment that result from a failure to do so. Solidarity, Davies and
Savulescu (2019: 135) argue, is a two-way street, meaning that members
of a system founded in solidarity not only have claims on other
members of the system, but also obligations to them. These obligations
include a duty not to impose *unreasonable* costs on members of
the system, with such costs being the result of refusals of
"Golden Opportunities", that is, refusals to make
realistically adoptable, health promoting behavioral changes, which
are performed under conditions conducive to responsible choice (Davies
& Savulescu 2019: 139-140). Davies and Savulescu (2019, 141)
caution however, that it is only permissible to hold people
responsible for refusals of Golden Opportunities if solidarity is
practiced in the broader social system, meaning that all people are
held responsible for failures of solidarity--e.g., including the
rich for tax avoidance.



In sum, although the claim that inequalities due to voluntary chosen
health behaviors are not unjust is prima facie plausible, few are
willing to endorse it and/or its policy implications without
significant qualification. Luck egalitarians either reject it by
appealing to further egalitarian considerations or opt for a
pluralistic view that enables them to avoid its counter-intuitive
policy implications. Similarly, those who adopt either Rawlsian or
solidaristic approaches hold that people are only responsible for the
outcomes of their voluntarily chosen health behaviors in the context
of a just society.



Others reject the idea that people are responsible for health outcomes
due to harmful health behaviors. Daniel Wikler (2004) offers a
sustained critique of the unmodified luck egalitarian view, pressing
the abandonment objection but also raising a number of practical
problems regarding the view's applications, including the
difficulty of identifying voluntary actions and the arbitrariness of
finding fault with some choices but not others (see also Fleck 2012).
He concludes that personal responsibility should only be employed in
health policy as an ideal in health promotion campaigns to motivate
and encourage people to take an active role in living healthy
lives.



Neil Levy (2019) similarly rejects the idea of personal responsibility
for health by focusing on the greater prevalence of harmful health
behaviors among people with low socioeconomic status. The explanation
for this disparity, Levy (2019: 106-107) argues, is that such
people, due to their circumstances, have reduced agential capacities,
lower education, and make choices under the stressful conditions of
poverty. For many, these challenges are significant enough to render
them non-responsible for the behaviors that contribute to ill health.
Since most people who are causally responsible for their ill health
are morally non-responsible in this way, Levy argues (2019: 109),
health policy should not be designed on the premise that people are
responsible for their ill health. Instead, since the distribution of
agential capacities and the circumstances of choice is the result of
public policy and the actions of large corporations, it is these
latter actors who bear responsibility for the health outcomes in
question (Levy 2019: 110).



Others are skeptical of this line of argument. Ben Schwan (2021)
cautions that the mere fact that people's choices are influenced
by the social determinants of health does not mean that they are not
responsible for them--some social determinants of health are
"responsibility-preserving". Cavallero (2019) argues
similarly that the health-related choices of people with low
socio-economic status satisfy widely accepted criteria of responsible
choice, namely, that they are made in the context of reasonable
alternatives and are not coerced. He argues further that questioning
the autonomy and responsibility of people of low socioeconomic status
is incompatible with the liberal ideal that all competent adults are
deserving of equal respect and opens the door to paternalistic
restrictions of people's liberty (Cavallero 2019). This does not
imply, however, that society is not *also* responsible for the
disparate health outcomes of low SES individuals. Cavallero (2019:
378) agrees that the pattern Levy (2019) identifies is morally
troubling and argues that governments have an obligation to ensure
that people do



> 
> 
> not face unequal health opportunities simply in virtue of their
> socioeconomic status of origin if those inequalities are remediable
> through reasonable public interventions.
> 
> 
> 



Finally, others argue that the focus on personal responsibility in
debates regarding priority setting and health promotion is misplaced
or even fundamentally mistaken. Phoebe Friesen (2018: 56) makes a
strong case that the behaviors policymakers wish to hold people
responsible for--e.g., excessive drinking, smoking, and poor
eating habits--are stigmatized. She challenges proponents of
considering personal responsibility in health policy to either explain
their focus on socially undesirable behaviors, or to extend their
arguments to include behaviors that contribute to ill health, are
known to be risky, and that are under people's
control--e.g., living in a city with high levels of air
pollution, engaging in a dangerous sport, or spending too much time in
the sun (Friesen 2018: 56). Others worry that a focus on individual
responsibility may distract policymakers from the more urgent need to
address the social determinants of health and may also stigmatize
people who act "irresponsibly" (Voigt 2013; Goldberg
2012). Since socio-economic conditions are the principal determinants
of health outcomes, these critics argue, such structural factors ought
to be the focus of public policy.


## 8. Justice and Global Health Inequalities



Discussions of justice and health inequality often focus on
inequalities among members of the same polity. However, scholars have
also addressed the justice of international health disparities, which,
depending on the countries of comparison, can be drastic. As we note
above, life expectancy in low-income countries in 2016 was 62.7 years,
compared to 80.8 years in high-income countries, a gap of 18.1 years
(WHO 2020). These disparities are no doubt driven by the wide income
differences among these countries, and so questions regarding their
justice are tightly connected to questions of global distributive
justice (see entries on
 international distributive justice
 and
 global justice).
 However, global health inequalities are also driven by war, climate
change, healthcare worker migration, and the funding decisions of
sponsors of medical research, among other factors. Positions regarding
the justice of global health disparities may therefore have
far-reaching implications for a diverse set of policy spheres.



Given the tight connection between global health justice and global
distributive justice, it is no surprise that approaches to the former
piggy-back on approaches to the latter. Briefly,
*cosmopolitans* start from the premise that all humans are
moral equals and argue on this basis that high-income states have
robust distributive obligations to people regardless of their
nationality or relation to them. Some cosmopolitans defend a
sufficientarian position (Brock 2009), while others argue that global
justice demands equality since national membership is a morally
arbitrary factor on the basis of which people should not be
disadvantaged (Caney 2005). *Institutionalists* do not reject
the claim that all humans are moral equals but argue that robust
distributive obligations--as opposed to a duty of
assistance--are contingent on the existence of certain types of
institutions, whether a coercive legal system (Nagel 2005; Blake 2001)
or institutions establishing substantial economic interdependence
(Sangiovanni 2007; J. Cohen & Sabel 2006).



Turning to theories of global health justice, a number of scholars
defend sufficientarian accounts, according to which all people are
entitled to some minimum level of health or opportunity to be healthy.
Sridhar Venkatapuram (2011: 224) defends a cosmopolitan account of
global health justice according to which all people have an
entitlement to the capability to be healthy, secured at a threshold
sufficient to ensure their equal human dignity. Jennifer Prah Ruger
(2018: 82) defends an institutionalist sufficientarian approach,
"provincial globalism", according to which states and the
broader global community have an obligation to ensure that all people
enjoy a threshold level of central health capabilities. Others defend
the human right to health, understood as a right to "protection
against 'standard threats' to health" (Wolff 2012:
27), or as a right to those things necessary for a basic minimum of
health and so for a minimally good life (Hassoun 2020; see also Powers
& Faden 2006: 85).



Segall (2010) defends a cosmopolitan luck prioritarian account of
global health justice. National membership is a morally arbitrary
feature of one's identity, Segall argues, and so disadvantages
in people's opportunities for health that are due to national
membership should be addressed, with priority given to those who are
worse off. While luck egalitarian or prioritarian positions often
permit deficits in health due to voluntary choices in the domestic
context, Segall (2010) rejects appeals to national responsibility to
justify global health disparities on the grounds that not all
residents of a polity can be held responsible for national policies.
Even in an ideal world of democratic countries operating in the
context of a just global economic order, policy decisions will be made
on behalf of children and against the wishes of dissenters.



Hausman (2012) criticizes luck egalitarian and prioritarian accounts
on the grounds that they may imply policies that exacerbate
international inequalities in income or opportunity. Since citizens of
some low-income countries experience better health than citizens of
some middle- and high-income countries, policies aimed at addressing
the poor health outcomes of the latter may exacerbate income
inequalities among these countries. Luck egalitarian and prioritarian
views therefore face difficult questions regarding the prioritization
of health equality over equality of income or equality of opportunity.
As an alternative to these accounts, Hausman (2012: 45) proposes a
relational egalitarian account of global health justice, positing that
some health inequalities across borders may be drastic enough to



> 
> 
> render individuals in one nation vulnerable to domination by other
> nations and diminish their voice in international co-operation.
> 
> 
> 



Although Hausman's proposal is more of a sketch than an account
of global health justice, it faces the above-mentioned problem with
domestic relational egalitarian approaches, namely, identifying the
health inequalities which in fact undermine equal relations. For
example, when are the difference in life expectancy among citizens of
two countries large enough to imply that they do not have equal status
when representatives negotiate a trade deal?



Daniels (2008) develops an institutionalist approach to global health
justice. He rejects the cosmopolitan idea that national membership is
morally arbitrary on the grounds that co-nationals stand in a morally
relevant set of institutionally mediated relationships which establish
sustainable claims of egalitarian justice. Co-nationals are subject to
the same coercively enforced rules of social cooperation of which they
are the putative co-authors (see Nagel 2005). While Daniels (2008)
rejects Segall's claim that global inequalities due to national
membership are unjust, he follows Joshua Cohen and Charles Sabel
(2006) in arguing that international organizations and agreements
establish morally relevant relationships and so must be designed in
accordance with principles of justice. Thus, Daniels (2008) argues,
the World Health Organization must show equal concern to all in its
distribution of public health expertise and technology, and
international property rights regimes must be designed to better
address the global burden of disease.



Gopal Sreenivasan (2007b: 221) side steps the above-mentioned debates
in global distributive justice, and instead offers a non-ideal account
of global health justice, one which anticipates the "minimum
requirements that *any plausible and complete* ideal theory of
justice will include". He argues that the richest nations have
an obligation to transfer 1% of GDP to the poorest nations with
priority given to spending it on the determinants of health, including
health care and public health, income and nutrition support, and
education. This transfer is neither too demanding, nor, if spent on
the determinants of health, too minimal for it promises to
substantially improve the life expectancy of the world's poorest
people (Sreenivasan 2007b).