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When are health inequalities a political problem?

Signild Vallgårda
DOI: http://dx.doi.org/10.1093/eurpub/ckl047 615-616 First published online: 6 April 2006


Is it possible to define criteria by which a political decision on which inequities in health should be addressed can be made? It has been suggested that differences which are unnecessary and avoidable and those which are unfair and unjust are inequalities which should lead to political action. In the article it is argued that it is not possible to make a clear distinction between avoidable and unavoidable differences, and that the extent to which differences are considered unfair depends on political and normative standpoints, and generally acceptable criteria can therefore not be established.

  • ideology
  • inequity
  • policy

Is it possible to establish some indisputable criteria by which inequalities in health can be categorized as problems, which should be dealt with? Researchers studying inequalities in health generally share an ambition not only to describe and explain the disparities but also to contribute to reducing them. Therefore, they take on the task of trying to define criteria by which to make a political decision as to which inequities should be addressed. This comment should not be seen as a critique of researchers dealing with the issue but as a discussion of the grounds on which judgements can be made.

My starting point is Margaret Whitehead's oft-quoted article about ‘concepts and principles of equity in health’. According to Whitehead, ‘the term “inequity” has moral and ethical dimensions’,1 i.e. it is about unfair inequalities. Inequities are ‘differences which are unnecessary and avoidable, but in addition are considered unfair and unjust’.1 Whitehead argues that some differences should not to be classified as inequities: those caused by biological, natural variation, effects of freely-chosen, health-damaging behaviour and transient health advantages where one group adopts a health-promoting behaviour before others. Is it possible to establish common criteria as to which differences are inequitable, as Whitehead seems to claim? Or will the judgement inevitably depend on and be guided by certain assumptions about the world and the nature of man, which may be discussed but the validity of which may not be proven?

What is avoidable and unnecessary?

Whitehead considers health differences caused by biological or natural factors as unavoidable while those caused by social factors are not unavoidable. The question, however, is whether it is feasible to clearly distinguish between social and biological factors and if biological factors necessarily are unavoidable. Social conditions create or contribute to differences between biological categories, such as gender and age groups. Or, phrased differently, age and gender are both biological and social categories. The fact that the gap in life expectancy between men and women varies over time indicates that it cannot be caused by biological differences alone. Different gender and age groups live under different and changeable social conditions. Living and working conditions furthermore influence the effect caused by differences related to gender and age. For instance, if the labour market is adjusted to people with different biological characteristics, then health effects of these differences will be smaller.2 In practice, discrimination between what is social and biological or natural is not possible, and it is thus not possible to define what is unavoidable with this criterion. Furthermore, some biological differences, and most likely an increasing number, are amenable: ‘as medical technologies advance, the borderline between avoidable and unavoidable inequalities is moving’.3 A biological cause is, therefore, not the same as an unavoidable effect.

What is unjust or unfair?

Inequalities are, according to Whitehead, considered fair if the individual can avoid the health-damaging influence. She asserts that the ‘crucial test’ of something as unfair is ‘whether people chose the situation that caused ill health or whether it was mainly out of their direct control’,1 or in the words of Peters and Evans, whether it is a result of a ‘free and informed choice’.4 This leads to the fundamental question of freedom of will, whether and to what extent people's behaviour is determined by factors beyond the reach of the influence of the individual and to what extent they can make their own sovereign choices. Whitehead maintains that skiing injuries are viewed as the result of a voluntarily chosen activity, while smoking of poor people is, at least partly, the result of advertising targeted at those groups. A similar distinction can be seen in a report from the Swedish Folkhälsokommittén (National committee on public health): ‘When analysing different behaviours, it is wise to distinguish between individual, relatively freely chosen behaviours and structurally determined behaviours. In the first case, which often characterizes the life situation of the more privileged groups, it is often possible through well-framed health information to reach people and create a basis for healthier choices. In the second case, there is a strong association between living conditions and behaviour, which implies that public health work needs to entail intervention targeting both society and individuals in order to become effective.’5 The possibility of choosing behaviour, and hence the responsibility for said behaviour, apparently depends on the social position of an individual or group. Privileged groups are expected to make free choices and to govern themselves, while other groups are seen as limited by their social conditions. People in higher positions are not expected to be influenced by social circumstances when they ski to the same extent as people in lower social position when they smoke. Naturally there are choices that may be dependent on people's available resources, such as good quality housing and food. But what is at stake here is a general perception that wealthy people can choose more freely and are less dependent on influences, e.g. from advertisements and peers, than poor people. The limited range of choices open to poorer social groups thereby justifies more active intervention from authorities in order to influence their behaviour. Since it is not likely that those who hold this view actually believe that rich people are fundamentally different from poor, when it comes to the question of freedom of choice, one might get the impression that it is a wish to help the poor, rather than an idea of their abilities to exercise free choice, which is the main argument for maintaining that their unhealthy behaviour is not their own responsibility The argument about responsibility is, however, considered more acceptable and, therefore, put forward. This is not to say that there is a problem in taking care of poor fellow humans, but rather that the argument for doing so ought not to be whether their choices are free and informed or not.

When religious groups ‘freely choose not to use a particular health service’1 and therefore become sicker, it is not considered unfair, according to Whitehead. Consequently, health effects of all forms of behaviour related to one's religion, which may impact one's health, e.g. eating and dress codes, are considered fair. There are good reasons to ask how freely one chooses one's religious affiliation. In most cases one is born into it, and it may require a most independent action to opt out.

The point is that deciding what is caused by choice as opposed to external determinants is to some extent an ideological question. The view of human nature differs. From a liberal standpoint, people are able to act rationally and in their best interests. People with a socialist persuasion, meanwhile, see people as being more related to and dependent on their fellow human beings as social creatures.6 These views obviously influence interpretations of human behaviour as more or less free and independent.

Gakidou et al. argue that claiming some behaviours may be labelled ‘fully informed choices of individuals’ is ‘a very slippery slope’.7 They ask if any choices can be said to be made on the basis of complete information about the consequences. In that case, we will scarcely ever be able to make a clear distinction between freely chosen behaviours and others. It is more accurate to say that all behaviour is influenced by at least three factors: choice, social context, and individual characteristics, inherited or acquired. The importance attached to each will depend, among other things, on one's philosophy of man as well as one's political standpoint, and that goes for researchers as well as for politicians.

When is inequity a political problem?

Three American researchers consider additional research as one way of reaching an agreement on what unjust inequalities actually are: ‘In any case, the analysis of inequity is only as good as our understanding of what is unavoidable or unnecessary.’8 As I have tried to argue, knowledge alone is not enough to decide what is unavoidable and unfair. The decision cannot be reached solely on the basis of logical or empirical studies—it must necessarily depend on a political judgement. If you cannot determine whether a certain behaviour has been chosen freely, and this is the sole responsibility of the acting person, then it is not straightforward to decide whether it is unfair, and whether it consequently should be a political task to deal with the inequalities that result from the behaviour. The same researchers, who seem to accept some of Whitehead's argument, criticize her for leaving us ‘with an unresolved complexity of judgements about responsibility, and as a result, with disagreements about fairness and avoidability’.8 Perhaps the problem is not complexity, but the difficulty in accepting that there is in fact no technical solution. The judgement can only be made on value or political grounds. Researchers should produce as much knowledge as possible about causes of inequities in morbidity and mortality, to give politicians a better foundation for making decisions. Policy making needs evidence, but evidence cannot replace political judgements. Like politics, research will always be guided by certain ideas about politics and the nature of man. It will thus always be a politically or morally guided decision whether inequalities are considered unfair, unnecessary, and possible to avoid. Ideological beliefs also influence the extent to which inequalities are seen as a problem. To those with a liberal standpoint a certain inequity in health may not be desirable, but may be considered an inevitable effect of the desirable individual freedom of action. Securing this freedom and autonomy limits possible state interventions in the life of the individual.6 To people valuing solidarity and equality, inequalities are a sign of society's failure in the task of creating reasonable conditions for all citizens, i.e. treating all citizens with equal concern and respect.6,9

Neither the question of what inequity is, i.e. what is avoidable, unnecessary, and unjust, nor the question as to what extent inequities are problems that need to be dealt with can be solved by more research alone, the answer will always also depend on the political and philosophical standpoint of the observer.

Key points

  • Can we determine which health differences are inequitable by determining what is avoidable and unfair?

  • There are no indisputable definitions of the differences that are unnecessary or avoidable, nor is it possible to establish a clear distinction between social and biological factors.

  • What are considered unfair or unjust differences will always depend on the political ideology one adheres to.


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