Health Inequalities, Social Justice, and the Limits of Liberalism

This path-breaking volume compiles a wide variety of research from numerous disciplines—spanning sociology, anthropology, philosophy, bioethics, public health, and medicine—inserting these disparate fields into “conversation with each other to illustrate how different vantage points and starting assumptions can complicate widely accepted views on health inequality and justice” [1]. The volume offers a compelling interdisciplinary analysis surrounding issues of social justice, equality, and healthcare reform, particularly in the USA, at a time of growing inequalities [2, 3]. By articulating the connections between unequal social resources, health inequalities, and justice, this volume also has broad relevance in urban settings in the USA and worldwide, where rates of poverty and inequality are often most pronounced and linked with health disparities [4, 5].

The book’s first section highlights the dominant normative debates surrounding health inequalities and establishes the intellectual terrain of the book. In chapter one, Paula Braveman defends the significance of conceptualizing health inequalities as a matter of social justice, employing a rights-based approach. In chapters two and three, Jennifer Ruger and J. Paul Kelleher advocate new frameworks to approach health inequalities and conceptions of justice in health, advancing theories of “provincial globalism” and “relational egalitarianism,” respectively. In the final chapter of the section, Eva Kittay offers a compelling challenge to conventional assumptions of autonomy, which underpin liberal frameworks of justice. The second section includes three case studies that engage with specific instances of health inequalities, situating the previous conceptual debates within concrete examples. These include oral health disparities in the children of migrant workers in California, conceptions of risk in pregnancy, and forms of (dis)respect and involuntary treatment in mental health services. Finally, the third section unpacks policies within the US healthcare system as well as contentious methodological approaches in interdisciplinary research. The discussion ranges from analyses of patient-centered care and the Affordable Care Act (ACA) to racial disparities in the Healthy People Act, applying the central debates of the book to existing legislation.

What is most notable about this volume is the dialog it generates between chapters, unpacking fundamental issues in philosophies of justice and key methodological issues in research related to health inequalities. From this dialog, a central theme arises related to the limitations of liberal theories of justice in defining, measuring, and addressing health inequalities. Throughout the volume, a divide emerges between the differing ways that authors interpret liberal theories of justice and inequality [6–10], and more radical social theories [11–15], to explain how gendered, racial, and class-based inequities within society shape health outcomes. In the volume’s two most compelling essays, Eva Kittay and Janet K. Shim et al. problematize assumptions of individual autonomy and rationality within liberal theories of justice. As Kittay notes, “the normative set of assumptions that accompany the principle of autonomy has its own difficulties,” which obfuscates the social, economic, and political resources with which particular groups are endowed in society, and which are instrumental in shaping health treatment and outcomes [1]. Liberal theorizations, such as Rawls’ notion of justice as fairness, offer useful conceptual tools to assess the moral imperatives of improving social inequities in a hypothetical society; however, because they rely on idealized conceptions of autonomous, rational citizens, when applied to issues of health inequalities, they often have the effect of “skewing the distribution of health resources in favor of those who are most likely to fit that norm” [1]. Kittay draws on a case study from New York [16], comparing the stratified treatment of three individuals of differing social classes and ethnicities suffering from the same heart disease to powerfully illustrate how the “higher a person sits on the socioeconomic pyramid, the more advantageous is the valuing of autonomy” [1].

In similar fashion, in chapter nine, Shim et al. employ the Bourdieusean inspired concept of “cultural health capital” to analyze patient-centered care and the ACA, noting how patients’ and providers’ “cultural assets and interactional styles,” which are the product of numerous intersecting social forces, “problematize the embrace of individual autonomy so prevalent in discourses on patient-centred care” [1]. By demonstrating the “uneven playing field” and “underlying architecture” of power relations in society that shape interactions in public health and healthcare, the authors question the validity of assumptions relating to individual autonomy, capabilities, and responsibility, which underpin many of the theories of justice and inequality employed throughout the book, particularly in chapters two and three [1]. These liberal theorizations of justice continue to have considerable influence in shaping public policy, and the radical critiques offered in this volume demonstrate the importance of questioning some of the uncritically accepted assumptions within them.

In chapter two, Ruger offers an interesting framework to analyze global health inequalities; however, her fixation on individual “capabilities” in relation to global health outcomes at times glosses over the contextual specificity and socio-economic complexity of health outcomes in particular regions [1]. Advancing a framework of “provincial globalism,” Ruger’s analysis derives from a universal ethical norm based on individual flourishing in achieving health outcomes in which “individuals must use their health agency to improve their own health” [1]. The way in which Ruger applies Sen’s “individualist focus of the capabilities approach” leads her to underemphasize the role of prevailing political and economic ideologies embedded in international organizations, the ability of local and transnational corporations to structure global health outcomes, and key differences between urban and rural health across the West and the Global South [1]. One only has to consider the profound influence of lobbying and campaign financing by pharmaceutical and insurance companies in the USA, or the role of intellectual property rights in limiting global drug availability, for example, to note the significance of large transnational corporations and investors in inhibiting health reform [17–20]. While Ruger’s analysis understandably cannot engage with the vast complexity of health reform in the global economy, which she analyzes in detail elsewhere [21, 22], mentioning the barriers to reform posed by powerful business interests, the contextual differences in urban and rural health globally, and the dominant political-economic paradigm of neoliberalism would have elevated her argument. The more critical approaches advanced in this volume, especially those by Kittay and Shim et al., demonstrate the importance of recognizing the social specificity of health inequalities and problematize global frameworks based on abstract concepts of individual capability.

Stemming from their normative understandings of justice and inequality, the authors employ different ways of defining and measuring health inequalities, which in turn shapes their analyses of the social determinants of health. In chapter one, Braverman argues that health inequality ought to be measured by the “distribution of health across social groups,” determined by comparing disadvantaged populations’ health with the most socially privileged in society [1]. Health inequalities, defined as “potentially avoidable differences in health that adversely affect socially disadvantaged groups,” are thus analyzed through the lens of socially underprivileged groups in society [1]. Foregrounding the plight of socially, economically, and racially disadvantaged populations and groups in society, and the degrees to which they are relatively underprivileged, plays a central role in the essays by Braveman, Shim et al., and Kittay.

By contrast, in several chapters, authors promote the importance of individual responsibilities, as well as absolute, rather than relative, inequalities in society. In chapter eight, King offers a critique of what he calls “The Argument” in which it is assumed that there is a moral imperative to address the social determinants of health and redistribute resources more equitably. King argues that this position is based on several fallacious assumptions, including the supposed value neutrality of data, which he illustrates by suggesting that our perceptions of inequality are shaped by how we measure them: absolutely, or relatively. Braveman counters by noting that “equality is a matter of relative deprivation” and, by measuring health outcomes against the most privileged social groups, the goal of obtaining the highest attainable standard of health for everyone can be reserved on the agenda for future reform [1]. Employing a framework that is attentive to the importance of relative forms of inequality, Braveman insightfully notes that notions of minimum thresholds and absolute gains in health outcomes across entire populations are not sufficient as objectives for a democratic society that strives for social justice and equality.

King provides a critique of Bravemen, Kittay, and Shim et al. by suggesting that the proponents of “The Argument” fall prey to counterfactual traps by “misreading observational evidence for associations” between social issues and health as causal claims, and by adhering to the “consonance of the good,” which is defined as the belief that what is fair in one domain will lead to fairness in another [1]. While King’s attempts to heighten the rigor of interdisciplinary research related to the social determinants of health are welcome, he neglects to consider how strong correlative trends between social factors and health outcomes with considerable evidence can warrant interventions to remedy them [23]. Braveman provides a strong rebuttal to the notion that there is not robust evidence linking social disadvantage, such as economic resources and levels of education, with health outcomes, noting that these factors have been “repeatedly demonstrated to be tightly associated with health” [1]. Further, she notes that “absolute certainty is not an appropriate standard” in assessing the moral significance of connections between social injustices and health inequalities [1]. Throughout his critique, King makes generalizations about the field of epidemiology and offers a narrow construal of what constitutes causality. Asserting that epidemiologists have merely been demonstrating associations between health disparities and the distribution of social goods, and that few have demonstrated “causal mechanisms explaining these associations,” King downplays the abundance of strong evidence linking the availability of social resources with health inequalities [1, 24–26]. King relies on a limited understanding of causality, albeit one which he never fully articulates in the chapter. He does not engage critically with numerous theorists who have convincingly advocated more pluralistic approaches to causal inference in epidemiology [27–29]. While King’s essay is certainly provocative, the utility of his skepticism toward remedying health inequalities seems unhelpful.

Scholars and policymakers must scrutinize research methods in order to base public health interventions in robust evidence; however, pursuing certainty in causal inference surrounding social determinants of health is epistemically misguided and is often neither feasible nor ethical, only serving to delay meaningful action. Approaches to this problem, such as using pluralistic methods to link causes of health outcomes at multiple levels within causal chains, have been offered by Bravemen and others [24, 30, 31]. As she does elsewhere, in this volume, Braveman convincingly defends the social determinants of health and provides a strong backdrop on which other chapters base their analyses about health inequalities. These authors’ focus on the social determinants of health is especially relevant for studies of urban health, which analyze heavily populated urban centers where social resources and urban poverty are critical in structuring health outcomes [32]. Defending the conceptual links between social resources, health inequality, and justice is increasingly important in urban contexts, particularly at a time when growing numbers of people are concentrated in urban and low-income urban areas around the globe [4, 5].

As the editors assert in the introduction, “[i]nterdisciplinary work is not easy” [1]. Any attempt to cross academic disciplines to engage with highly complex social issues requires “bracketing, questioning, and justifying” the numerous assumptions endemic to each method of inquiry and discipline [1]. Bringing together diverse perspectives from numerous fields, and conjoining philosophical, empirical, and policy-based discussions, the essays in this volume expand conceptual horizons and offer a compelling defense for the moral import of the social determinants of health. Moreover, the contributors vigorously debate the importance of various methodologies and challenge readers to question some of the fundamental assumptions underpinning mainstream theorizations of justice. Overall, this book is an indispensable read for anyone interested in contemporary philosophical and empirical debates surrounding health inequality, justice, and healthcare reform. The volume represents a critical scholarly achievement, demonstrating how comparative study and interdisciplinary work can “inspire important conjunctures and novel analyses as well as offer significant implications for health policy” [1].