Equal Health?
By Ezio Di Nucci
Should we aspire to a society in which everybody is equally healthy? More precisely, is it not unfair that in many societies, people are not equally healthy, through no fault of their own? After all, the Constitution of the World Health Organization (WHO) states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.”
Doesn’t the “highest attainable standard of health” for “every human being” mean everybody ought to be equally healthy? In the case of the WHO constitution, technically, it does not. In fact, the WHO does not seem to be interested in equality at all, as the “highest attainable standard of health” will vary greatly between different human beings (given, for example, their genetic makeup). Indeed, while the WHO declaration does go on to speak about not distinguishing between race, religion etc., it is otherwise very neoliberal in launching a health rat-race for the highest attainable standard. Health-capitalism at its worst from a most unexpected source.
What the WHO declaration does remind us of though, is that equal health for all might be not just an empty slogan, but a meaningless one too. Different people can simply not be equally healthy. Some people are born with severe genetic conditions that will cause them great suffering and greatly shorten or impair their lives. Other people live long healthy lives without ever experiencing anything remotely comparable to a serious genetic condition. What does it even mean to talk of equal health between two such individuals?
It might be unrealistic to wish that everybody was equally healthy, but that does not make it fair. As in, it does not make it “fair” that people diverge massively in their level of health. Yet the basic unfairness of some people being very sick and others very healthy does not mean that the only fair distribution would be one in which everybody was equally healthy.
Here we should distinguish two different points:
(i) The first regards health and disease being unequally distributed. Is that fair?
(ii) The second point is that health might not be equally distributable — but maybe healthcareis? And — crucially — should it be?
Those two points are related by the following hypothesis: an equal distribution of healthcare may contribute to diminish the unequal distribution of health and disease.
Despite the simplicity of this hypothesis, various research suggests an equal distribution of healthcare will do everything butdiminish the unequal distribution of health and disease, because what an unequal distribution of health and disease calls for in order to be compensated is actually an unequal distribution of healthcare. There is great inequality in our world between health and disease that calls for corresponding inequality in the distribution of healthcare resources and services. This means that whatever the answer is to the question of “is it fair that health and disease are unequally distributed?” — equal healthcare cannot be the solution. And the reason for that is pretty simple: healthcare needs vary greatly(for more on this, see Norman Daniels’ research).
The question, really, is what a fair distribution of healthcare resources and services given great differences in needs would look like. This question does not settle the basic moral issue of whether it is fair that there is such unequal distribution of health and disease (as in, such unequal health needs).
We should be careful, here, not to get things backwards: the pressing practical question — let’s call it the politicalquestion — is what a just (or, as non-philosophers say in this debate, equitable) distribution of healthcare resources and services should look like. Yet, that issue alone cannot settle our basic philosophical question; whether it is fair or not that some people are sick and others healthy, given that individual genetics create a distribution where not all differences between the sick and the healthy can be traced back to less-than-just healthcare distributions of the past, nor be corrected by future just/equitable healthcare distributions.
Indeed, the relationship between our basic philosophical question and the political issue about healthcare distributions is rather that the moral urgency of just/equitable healthcare distributions (also) depends on the basic unfairness of some people being very sick and others very healthy. Even though there are good reasons for just/equitable healthcare distributions that go beyond whether or not the natural lottery is unfair.
This is important because it means that the health equity debate does not answer our question (i)but only, at best, question (ii). A consequence of this is some critics of the “needs approach” within this debate propose, as an alternative, principles for the distribution of healthcare resources and services that are supposed to redistribute health and disease so that there is more equality between the sick and the healthy. These approaches are very much in our own spirit, but we should be careful not to confuse them with an answer to (i), as that would be begging the question. It is on the other hand the basic unfairness of unequal natural distributions that motivate these approaches, so that they too need an answer to our question (i) beyond what they are currently able to provide.
In certain circles, there may be something repugnant about achieving totalhealth equality. The easiest mathematical way to get there, after all, would be either to make everybody as sick as the world’s sickest person or to kill off everyone but the two people whose level of health is most similar. You should have known by the time that ugly word “total” came along that this paragraph was not going to be any fun.
Which brings us back to square one: is it unfair that some people are very sick and some very healthy (and all the diversity in between)? Given the inherit challenges of the question, one might ask for a little help from the Luck Egalitarian discipline. Luck Egalitarianism is the theory that “it is unjust for some to be worse off than others through bad luck. However, to the extent that they are worse off than others but not through bad luck their disadvantaged position might not be unjust” (xi).
Luck Egalitarianism asks us to distinguish between different ways in which people come to be sick or healthy — some of that is through luck, some through autonomous (and thereby responsible) behavior, and most of it a mash of the two, luck and responsibility. The idea would then be that those differences in health which are due to luck and luck alone are unjust but other differences — in as much as they are due to one’s autonomous and thereby responsible actions — are not necessarily unjust.
The Luck Egalitarian principle is helpful to those with the basic moral intuition that it is unfair that some people are sick and others healthy because it restricts that intuition in a way as to make it more plausible. It is not that all differences between the sick and the healthy are unfair, but those due to pure luck definitely are. Obviously, such unfair differences in health can be caused by social injustice, such as discrimination of particular minorities, as well as environmental and natural causes (such as genetics). For the purpose of this discussion, I will focus in particular on unfair health distribution due to genetic distribution (or, “natural” causes).
One initial problem with the basic Luck Egalitarian principle is that, however plausible it might sound, its application is messy. One might think that genetics would be a standard bearer for luck (and thereby unjust health issues), and smoking (or heavy drinking, or too much sugar, or no exercise) a standard bearer for reckless behavior — the consequences of which are thus not unjust. The reality is it would be pretty naïve to think that the fact that smokers smoke is a luck-free choice, and there is extensive debate and research around various social determinants of health.
What is helpful about the Luck Egalitarian approach (and I recommend Shlomi Segall’s book Health, Luck and Justicefor further reading on the subject) is that it gives us the beginning of an argument for the initial intuition that it is not fair that some people are very sick and some healthy. Namely, that the difference is down to luck, and that’s not fair. Indeed, according to Luck Egalitarianism (and this is the further argumentative step), it is also unjust.
Unfortunately, as is so depressingly often the case in philosophy, that’s not the end of the discussion. A skeptic of luck egalitarianism will want to know exactly why it is that such lucky occurrences of health and disease are supposedly not fair. That’s the lottery that Robert Nozick popularized with reference to American basketball player Wilt Chamberlain. How dare philosophers take away from Wilt Chamberlain (or Serena Williams, Usain Bolt or Cristiano Ronaldo) the fruits of their natural talents through a form of health taxation?
Thankfully, one does not have to look too far to find an argument for the initial intuition that massively unequal distributions of health and disease are unfair, and that they are so even when their causes are ‘natural’. Luck Egalitarianism is a useful tool one can build upon to respond to such skeptics. Despite this, there are downfalls (as there always are) to the Luck Egalitarianist stance that need to be addressed.
If we adopt luck egalitarianism in order to ground our intuition that unequal natural distributions of health and disease (in general, distribution caused by biological diversity) is unfair, the package comes with two added conditions that we might not be so delighted about:
(1) the claim is not only that they are unfair but also that these lucky occurrences are thereby unjust — as in, they call for corrections by society;
(2) one must simultaneously accept the luck egalitarian idea that if those occurrences were not the result of luck, then they are not unfair (such as smoking, lack of exercise etc.).
The first condition we can live with. After all, what better way to make our intuition about the unfairness of differences in health and disease real than to demand for it to be addressed by societies, states and healthcare systems? But what about the second condition?
Sure, we can appeal to the social determinants of health literature to try and reduce its impact, but a theoretical (and not necessarily ethical) point would remain: if you are responsible for your disease, then it is notunjust that as a result of your disease you are worse off than someone who was say, raised in a difficult environment.
Which brings us to the resulting outcome of certain forms of luck egalitarianism, the bit which is hard to swallow; if it is not unjust that you are worse off as a result of that self-inflicted disease, then this will have to be taken into account in the distribution of healthcare resources and services.
All things considered, the solution seems to have gone awry in the face of ethical interrogation. For the challenging ambition of everybody being equally healthy, motivated by the basic unfairness of some people being very sick and others very healthy; luck egalitarianism seems a suitable legitimate philosophical argument to back up a potential solution. But the theoretical result of introducing this philosophical framework in the discussion? Prioritizing non-smokers over smokers when distributing healthcare resources and services. That’s hardly the Russian Revolution, is it?
But then maybe communism and the abolition of private property was never what we should have aspired to for healthcare. And that’s simply because while ‘health’ and ‘wealth’ might sound vaguely similar, they shouldn’t really be compared. For one thing, as we have seen, there is no such thing as equal health and there ought to be no such thing as equal healthcare. Also, wealth might well survive an individual and further entrench privilege, but health most certainly won’t. In the end the best we might be able to say, when it comes to healthcare distributions, pace Luck Egalitarianism, still comes from good old beardy Karl Marx: “jedem nach seinen Bedürfnissen!”.[1]
About Ezio di Nucci
Ezio Di Nucci is Associate Professor of Medical Ethics at the University of Copenhagen. His latest book is Ethics in Healthcare: A Philosophical Introduction, was published in 2018 by Rowman & Littlefield International.
[1]Thanks to Ina Willaing Tapager for comments.
