Injustice and Inequalities in Health

Abstract

Serious inequalities in health abound the world over. For example, there are marked differences in average life expectancy both between and within countries. Individual life expectancy varies by more than 30 years between the highest national average and the lowest. Even worldwide, average life expectancy lags more than 10 years below the highest national average. Within single countries, inequalities in life expectancy between the top and bottom groups of men, for example, have been recorded at 7 years in England and Wales and at almost 15 years in the United States, albeit using rather differently constituted groups. Intuitively, these inequalities in health will strike many observers as unjust. But why are they unjust, if they are? Are inequalities in health unjust per se? If not, what makes some inequalities in health unjust, but not others? According to an influential analysis, inequalities in health are unjust when they are avoidable, unnecessary, and unfair. Thus, if an inequality in health is inevitable, it is not unjust. Following this analysis means that answering these questions requires a combination of empirical and normative understanding. On the empirical side, some understanding of the socially controllable causes of health is required. On the normative side, various dimensions of fairness have to be understood. In addition, some appreciation of the interaction between these two sides is needed.. Each side of the question is fairly complicated. With respect to the requirements of fairness, three subsidiary controversies can be distinguished. To begin with, should a general principle of equality be applied directly to the case of health? An alternative approach traces the injustice of avoidable inequalities in health to the independent injustice of their social causes instead. Next, should inequalities be defined across social groups (such as class or race within countries or, indeed, countries themselves)? If so, which groups? An alternative is to define inequalities across individuals. Finally, should equality be defined in comparative terms (as is traditional)? An alternative is to define the requirements of fairness non-comparatively (as a matter of “priority” to the worst off). Even if a given inequality in health is avoidable, some resolution of all three controversies is needed to decide whether that inequality is unfair.