social justice in healthcare essay

• Annual Meeting

• Generation Public Health
• Public Health Thank You Day
• Who is public health?
• Climate, Health and Equity
• Racial Equity
• Environmental Health
• Gun Violence
• Health Equity
• All Topics and Issues
• Advocacy for Public Health
• Policy Statements
• American Journal of Public Health
• The Nation's Health
• Fact Sheets
• Reports and Issue Briefs
• Advertising
• Public Health Buyers Guide
• Publications Contacts
• Continuing Education
• Public Health CareerMart
• Internships & Fellowships
• Careers at APHA
• Policy Action Institute
• National Public Health Week
• APHA Calendar
• News Releases
• Social Media
• Brand Guidelines
• Member Sections
• Student Assembly
• Member Perks
• Membership Rates
• Agency Membership
• School-Sponsored Student Membership
• Special Member Savings
• Early-Career Professionals
• Gift Membership
• APHA Your Way
• Member Directory
• What is public health >
• Generation Public Health >
• Our Work >
• Social Justice

Social Justice and Health

• What is public health?

Why should I care?

Social justice is the view that everyone deserves equal rights and opportunities — this includes the right to good health. Yet today, there are inequities in health that are avoidable, unnecessary and unjust. These inequities are the result of policies and practices that create an unequal distribution of money, power and resources among communities based on race, class, gender, place and other factors. To assure that everyone has the opportunity to attain their highest level of health, we must address the social determinants of health AND equity.

Racism and other forms of structured inequity sap our potential to become the healthiest nation. Racism is a system of structuring opportunity and assigning value to individuals and communities based on race that unfairly disadvantages some individuals and unfairly advantages others. Racism and other “isms” are forces that determine the distribution of the social determinants of health, including:

Health care —  More than 30% of direct medical costs faced by U.S. Blacks, Hispanics and Asian-Americans can be tied to health inequities. Because of inequitable access to care and other health-promoting resources, these populations are often sicker when they do find a source of care and incur higher medical costs. That 30% translates to more than $230 billion over a four-year period. In addition, studies have shown that clinicians tend to have more negative attitudes toward people of color, and unconscious racial bias among clinicians has been shown to lead to poorer communication and lower quality of care.

Criminal justice — Thirty years of “tough on crime” and “war on drugs” public policies have resulted in mass incarceration of primarily Black and Hispanic males. This discrimination and inequity undermines the social and community fabric that is so vital to public health, narrowing opportunity, disrupting families and social cohesion, and preventing civic participation.

Voting rights —  In recent years, there has been a resurgence of activities that make it harder for people to exercise their right to vote, especially in communities of color. Since 2010, about half of the states have passed new laws making it more difficult for voters to access the ballot box.

What can I do?

Name and address racism . Acknowledge racism as a system of structured inequity and not an individual character flaw. Name racism as a determining force in the distribution of the social determinants of health and equity. Identify the structures, policies, practices, norms and values in which racism may be operating.

Start a conversation about health equity  within your agency or organization. Health equity is more than one intervention; it’s a lens through which all of your work should be viewed. Foster an open and honest dialogue within your agency (and ideally with your community partners) about historical injustices and present-day racism, bias and inequity and how they contribute to disparate health outcomes. Use tools such as the documentary “Unnatural Causes: Is Inequality Making Us Sick?” to jumpstart the conversation.

Promote a health-in-all-policies approach and ensure an equity lens. Seek partnerships across sectors such as transportation, housing, education and law enforcement. Work with these partners to ensure that health and equity are embedded in their decision-making process. All of these sectors and many more have a role in creating the conditions that enable all people and communities to attain and sustain good health.

Demand the fair allocation of community resources. Creating health equity requires targeted investment in marginalized and under-resourced communities. Ensure representation of these groups in decision-making processes.

Fight against the trend of growing voter restrictions. Everyone needs a voice in improving our communities, and such community participation is intrinsic to achieving health equity. Educate community members about the importance of civic engagement and encourage their participation in grassroots advocacy efforts.

SIGN OUR PLEDGE to create the healthiest nation in one generation!

Join generation public health.

Help us create the healthiest nation in one generation.

Share this infographic!

• What is public health
• Topics and Issues
• Policies and Advocacy
• Publications
• Professional Development
• Events and Meetings
• News and Media
• APHA Communities
• Privacy Policy

2024 © American Public Health Association

August 3, 2020

Health Care Is Long Overdue for a Social Justice Reckoning

Biases in the system put the lives and well-being of women and minorities at risk

By Stacey Rosen , Jennifer Mieres & Beth Nash

Kelly Davidson Getty Images

With protesters in many American cities marching for justice, and with the Supreme Court delivering a historic ruling protecting gay and transgender workers from workplace discrimination, this summer is shaping up to be a watershed moment for equality in America. But while much of our national conversation is focused on urgent issues like police brutality, it’s time we acknowledged that American health care, too, is long overdue for a reckoning with systemic forms of discrimination that have a detrimental effect on the health and well-being of tens of millions of American women.

Take, for example, heart disease. It’s the leading cause of death among women—but a 2012 survey conducted by the American Heart Association (AHA) found that 44 percent of women were unaware of this, with the highest percentages of unawareness among Blacks and Latinas. Why this discrepancy? Why are so many women more concerned with, say, breast cancer than they are with heart disease, a condition that kills six times as many women each year?

The AHA has explored that question, too, and found that many women reported that their physicians seldom if ever talked to them about heart health, and, in some cases, misdiagnosed obvious symptoms of heart disease as panic, stress or even hypochondria.

On supporting science journalism

If you're enjoying this article, consider supporting our award-winning journalism by subscribing . By purchasing a subscription you are helping to ensure the future of impactful stories about the discoveries and ideas shaping our world today.

That is a blatant example of how inherent biases put women’s lives at risk, but it’s not the only one. Gender, the socially constructed roles and behaviors associated with being male or female, is very much a part of the so-called “social determinants of health,” which researchers now believe play a large part in determining a patient’s well-being.

How do these factors—which include everything from poverty and literacy rates to social relations and expectations—affect men and women (including transgender individuals) and people of color differently? Why is one group more susceptible than another? The reasons include racist and sexist barriers embedded in our institutions and communities, whether we are aware of them or not.

We at Northwell Health have created our Center for Equity of Care that includes the division of Diversity, Inclusion and Health Literacy (DIHL), which establishes networkwide policies and procedures to ensure meaningful access to services, programs and activities to incorporate health literacy, language access and cultural competency as integral parts of the delivery of safe, quality patient-centered care. And at the Katz Institute for Women’s Health, we address decades of sex- and gender-based disparities in health and health care delivery through a new model: one based on unique clinical programs, sex- and gender-focused research and community partnerships. Many other health systems have similar programs to tackle these issues.

Preliminary data, for example, suggest that women have been more economically disadvantaged than men as a result of the COVID-19 pandemic. That makes sense: Women are overrepresented in service-related jobs such as retail and hospitality, face higher risk of layoffs because of those jobs, and also tend to fill more marginal and lower-authority jobs. The closure of schools and day care centers has massively increased childcare needs, which has largely impacted working mothers.   Gender-based domestic violence has increased as a result of heightened tensions in households at the same time that essential health support services are being disrupted or made inaccessible as a result of the need to socially isolate.

Gender also plays a role in the scientific study and management of the pandemic. Most alarmingly, women scientists are underrepresented among investigators studying COVID-19—presumably in part because women scientists and physicians also have to manage household issues like homeschooling their children—making it less likely that representative research questions are being asked.  Preliminary data also suggest that countries with female leaders have been especially successful at managing the pandemic. We need more of these female leaders at the table to make decisions globally, whether it’s through the WHO or in talks with scientists working on vaccines.

When it comes to fighting disease and maintaining health, sex, gender and race matter. We need to design the right COVID-19 studies now to identify the reasons for the sex, gender and race disparities—and develop appropriate interventions. And we need to ensure that women, and communities of color are represented in designing and implementing solutions.

Equitable health outcomes and the health of our society depend on it.

• Table of Contents
• Random Entry
• Chronological
• Editorial Information
• About the SEP
• Editorial Board
• How to Cite the SEP
• Special Characters
• Advanced Tools
• Support the SEP
• PDFs for SEP Friends
• Make a Donation
• SEPIA for Libraries
• Entry Contents

Bibliography

Academic tools.

• Friends PDF Preview
• Author and Citation Info
• Back to Top

Justice and Access to Health Care

Many societies, and nearly all wealthy, developed countries, provide universal access to a broad range of public health and personal medical services. Is such access to health care a requirement of social justice, or is it simply a matter of social policy that some countries adopt and others do not? If it is a requirement of social justice, we should be clear about what kinds of care we owe people and how we determine what care is owed if we cannot possibly meet every health need, as arguably no society can. We should be clear about what constitutes appropriate access to that care, given that there are diverse barriers to access. We must also be able to say why we owe these things as a matter of justice, and, of course, different accounts of social justice will bake and serve this cake in different ways.

In what follows, we shall address these questions in the following order. In Section 1, we describe briefly what some societies actually do to assure universal access to health care. Although health care is more equally distributed in these societies than other social goods, nevertheless health inequalities persist across demographic groups. This implies a question we shall have to address: if universal access cannot assure equality in health status, because there are other important social determinants of population health and its distribution, then is universal access a requirement of justice after all? We shall also examine some of the consequences of unequal access to care, for these may compound the effects of inequitable distributions of other determinants of health. In Section 2, we examine more carefully the concept of access to care. How, for example, do we actually tell if access to care is equal or equitable? The problem of measuring access to care aside, we might think that the concept of equal access is straightforwardly analyzed, and the concept of equitable access depends in a more complex way on what inequalities in access are permissible. We shall see, however, that considerations of justice bear on judgments about equal access as well as on those about equitable access. In Section 3, we examine three different lines of argument for universal access. In Section 4, we consider what kinds of care these views, especially the opportunity-based account, imply that we owe each other. In Section 5, we consider whether we have a right to health or health care, in light of those views of justice, and what entitlements follow from such a right if there is one.

1. What Societies Do About Access to Care

2.1 when is access to care equal, 2.2 conceptualizing and measuring equity of access to care, 3.1 health, opportunity, and universal access, 3.2 universal access to prudentially defined care, 3.3 access to a decent minimum of health care, 3.4 lessons about rationales for universal access, 4. what kinds of health care do we owe each other, 5. is there a right to health or health care, other internet resources, related entries.

We might seek guidance from how some societies assure access to care, keeping in mind that what societies actually do may not coincide with what they should do as a matter of justice. If, however, there is widespread belief that people owe each other access to certain kinds of care, and this belief is embodied in institutions that attempt to do that, it may give us some evidence about what people think they owe each other. Of course, we find different institutional provisions of access in different settings, and the differences may not reflect differences in belief as much as differences in resources or social history.

Nearly all developed countries provide all their residents with access to a broad set of public health and individual medical interventions. In these countries access to care is assured despite income and wealth inequalities through universal coverage health systems. The method of financing these universal access systems, as well as their organizational structure, varies considerably. Some systems are funded through general tax revenues as in Canada; others through payroll taxes, as in several European countries; and others through a mix of public and private insurance schemes, as in Germany. Thus some systems are more progressively financed than others, since general tax revenues are more progressive than social security or payroll taxes, and these in turn are more progressive than insurance premiums. (In a progressive tax scheme, the rate increases as the amount that is taxable increases.) Some systems have public ownership of hospitals, with physicians and nurses as salaried employees of the public system, as in the United Kingdom or Norway. Others contain a mix of public and private institutions, though with extensive public regulation of the benefit packages available to people, as in Germany. Some systems allow no insurance schemes except the universal coverage scheme, as in Canada and until recently Norway; others allow supplementary insurance, as in the United Kingdom.

Though all of these health care systems assure universal access to all citizens, their benefit packages vary. Sometimes, the variations occur at the level of specific treatments. For example, one system might decide a particular drug for Alzheimer’s is not cost-worthy, whereas other systems might provide it. Sometimes the differences involve whole categories of service. For example, the Canadian national law requires coverage only for inpatient drugs, not outpatient ones; different provinces provide different levels of coverage for what is omitted from the national schemes. Similarly, long-term care is not part of the national Canadian system, though some Canadian provinces, but not all, provide long-term care. The U.S. Medicare system provides nearly universal coverage to the American elderly, but until 2006, when the 2003 Medicare Modernization Act became effective, it excluded drugs from its benefit package (Medicare 2003). All universal coverage systems exclude certain categories of service, such as cosmetic surgery (as opposed to reconstructive plastic surgery). In general, then, where systems provide universal access, it is access for all to a specific set of benefits that varies from country to country, not to every service people may need or want.

It is not only the wealthy, industrialized countries that assure universal access to a broad range of personal medical services. Recently, middle-income countries such as South Korea and Taiwan have adopted universal coverage insurance schemes. Thailand and Mexico have also added insurance schemes aimed at covering the nearly half of their populations that had not been covered in the social security schemes and other insurance schemes that are used by civil servants or large employers. The benefit package in these different schemes is often not equal across these components of the health system, but the avowed goal is to close gaps in access and incrementally to approach equality of access.

The WHO advocates universal coverage in low- and middle-income countries as well as in richer countries (WHO 2010). A key issue in these efforts is the comprehensiveness of the benefit package, which in some reforms is a “thin” benefit package that may not cover many needed services and that requires significant out-of-pocket payments even for covered services. An ongoing policy debate will have to address efforts to “thicken” the benefit package along the three dimensions that define it: the number of people covered, the types of services covered, and the amount of co-pays or deductibles for covered services. Disagreements with the ethical guidance WHO (Ottersen, Norheim, et al. 2014) has provided about how to “thicken” the benefit package will no doubt be part of that policy debate. Reasonable people will disagree how to trade improvements on each dimension against the others, and a process will be needed to resolve these disagreements. A related issue is whether the health system can sustainably deliver the benefit package the insurance scheme is committed to deliver.

For many years, the United States stood alone among wealthy developed countries in not providing universal coverage through some form of health-care insurance. Nearly 50 million people, mostly the employed poor and near poor (Selden and Sing 2008), were uninsured as of 2010 (we note that he number is greater than the population of S. Korea, which has universal health care coverage). The uninsured are not shut out of health care altogether, since they obtain some care at public hospitals (EMTALA 1986) and neighborhood clinics, but, according to the Institute of Medicine (IOM 2002), the medical care they receive is “too little, too late.” Being sicker when care is obtained, or getting inadequate continuity of care has a significant impact on their health outcomes, leading to higher morbidity and mortality rates, to say nothing of the greater cost of care.

In 2010, however, The Patient Protection and Affordable Care Act (ACA) passed into law through a reconciliation act. It contains an individual mandate requiring all individuals to purchase health care insurance on penalty of a having to pay a special tax, expands Medicaid (which is a means-tested health insurance program for the poor jointly funded by states and the Federal government) coverage to an intended 16 million people, establishes insurance exchanges to sell insurance, much of it subsidized, to another intended 16 million people, prohibits insurers from denying coverage because of prior medical conditions, and allows children to be on their parents’ insurance until age 26. A U.S. Supreme Court decision (National Federation of Independent Business vs Sebelius, Secretary of Health and Human Services, 2012) upheld the individual mandate, but ruled that states had the prerogative to expand Medicaid and that such expansion could not be a requirement of the ACA. The failure to expand Medicaid in some states and their ongoing opposition to the ACA meant that the expansion of coverage did not reach the 32 million estimated. The increased coverage of the ACA never included the estimated 12 million unauthorized immigrants (Daniels and Ladin 2014), who are also excluded from universal coverage plans in most countries). Given that many of the estimated 12 million long-term unauthorized immigrants in the U.S. count as members of the society, even if they are not citizens, coverage in the U.S., even if the PPACA is fully implemented, will not be truly universal. Nevertheless, unauthorized immigrants still have access to emergency care at all U.S. hospitals because of EMTALA.

One of the largest groups of people excluded from access to insurance coverage under the ACA is the group comprised of unauthorized immigrants (who are also excluded from universal coverage plans in most countries). Given that many of the estimated 12 million long-term unauthorized immigrants in the U.S. count as members of the society, even if they are not citizens, coverage in the U.S., even if the ACA is fully implemented, will not be truly universal. To be sure, unauthorized immigrants still have access to emergency care at all U.S. hospitals because of EMTALA.

After the Trump Administration took office in 2017, there was an effort by it and the Republican Congress to repeal and replace the ACA. The House, with a significant Republican majority, narrowly passed the American Health Care Act of 2017. The Senate version of it failed to receive a majority of votes, and the efforts to repeal the ACA and replace it later with a plan to be worked out also failed to pass. Because President Trump has continued to threaten the ACA and the Republican leadership in both houses put replacing the ACA high on their list of goals, arguably the victory of the ACA and its goal of reducing significantly the number of uninsured is not secure as of the summer of 2017. (We return in Section 2 to discuss further the Republican model of universal access, resting as it does on the “choice” to be uninsured.)

Aside from financial barriers to access, there are several important kinds of non-financial barriers to access. These include forms of discrimination and exclusion, such as racism and gender-bias; geographical barriers; and language and cultural barriers, including cultural attitudes toward disease and medical care. In the United State, for example, we know that the prevalence of certain health conditions is much higher among African Americans than whites. Controlling for insurance coverage, income, and educational differences, African-Americans are still less likely to receive important treatments for a range of serious illnesses, including heart disease and certain kinds of organ failure (IOM 2002). Just how to explain these utilization disparities is a matter of ongoing research, some of which focuses on conscious and unconscious attitudes and racial stereotypes. Until advocacy groups for women, such as the National Breast Cancer Coalition, lobbied successfully to alter research funding policy, some women’s diseases were systematically under funded in the U.S. Similarly, there are significant differences in access to care that derive from the geographical maldistribution of providers, including physicians, and services. Thus physicians concentrate their practices in wealthier urban and suburban areas, leaving poor urban and rural areas underserved. Many hospitals face the problem of overcoming language barriers because of the large and diverse immigrant populations that they serve, and striking examples abound of failures to meet health needs because of cultural views about disease and medical care (Fadiman 1997).

All of these kinds of barriers to access act as obstacles to providing adequate health care both in the U.S and in many developing countries. If justice requires providing universal access to health care, then these barriers must be addressed as a matter of justice. Some of these barriers to care, such as geographical and cultural barriers, remain as such even in systems that aim to provide universal access. All of them would have to be specifically addressed by any effort to move the U.S. system toward the provision of universal access.

It might be thought that the provision of universal access to a range of public health and personal medical services would go a long way toward reducing health inequalities among different social groups, whether ethnic or divided by socio-economic status. But, careful studies in many countries, most dramatically in the United Kingdom, have shown that health inequalities by class have not been reduced by the presence of universal coverage through the British National Health Service (Marmot 2004). Two longitudinal studies of British civil servants, known as the Whitehall Studies, have shown a pronounced socio-economic gradient of health across different categories of workers: the higher a worker’s occupational status, the longer and healthier her life. In addition, this difference is not explained by risk factors associated with occupational status, such as smoking rates or lipid levels or other “lifestyle choices.” Nor is the gradient simply a result of “deprivation”—for none of the civil servants are poor, lack basic education, or medical care—and the gradient is present across all occupational levels.

The Whitehall results are very robust and reveal a strong gradient of health across a wide range of morbidity and mortality measures. They are also consistent with findings found in many countries, both with and without universal coverage. All these findings show a strong impact of non-health care determinants of health: income and wealth, education, inclusion and exclusion, including discrimination against women and L.G. B. T. groups, social cohesiveness, and others. An important focus of research is to explain the mechanisms that might be at work in creating these health inequalities. The WHO Commission on the Social Determinants of Health issued a final report in 2008 that called for various policy measures that improve daily living conditions and distribute more equitably money, power, and resources, as well as research aimed at better measuring the influence of these factors and evaluating the impact of measures to redistribute these determinants of health more fairly (CSDH 2008).

For our purposes, however, the lesson to be drawn from the literature on the social determinants of population health is that we cannot expect health inequalities to disappear solely as a result of providing universal access to care. Health care is not the only socially controllable factor affecting population health and its distribution. This leaves us with a question we shall have to address: if other factors besides health care are important determinants of health, then is the focus on providing universal access to health care misplaced? Even if justice requires us to promote or protect health, does it require us to do so through the provision of access to health care, or should we now modify our view of the importance of health care in light of what we have learned from social epidemiology? We return to address this issue in Sections 3 and 4.

It will help to summarize the key points that emerge from this sketch of what different societies do to provide access to care.

• If we focus on developed countries, we find a nearly universal commitment to assuring universal access to care in the form of universal coverage. The methods of financing and organization may differ, and the actual kinds of care provided may vary somewhat, but there are avowals that universal access is a social obligation, even a right, and there are institutions that approximate such coverage. To be sure, some barriers to access remain even in these countries, especially geographical maldistribution of services and inequalities in access for some indigenous or minority groups.
• Serious limitations on access remain in developed and developing countries alike. In some, there remain financial barriers, for example the 12 million unauthorized immigrants in the U.S. and elsewhere who cannot buy insurance assured to others; in all countries, there are non-financial barriers to care, often geographical, but also in many there are racial barriers as well.
• The commitment to universal access is hardly limited to developed countries, for various middle income countries have recently provided universal access (such as Taiwan and Mexico) or attempted to do so incrementally, and there is a recent effort to include low-income countries in the effort to secure universal coverage.
• Nevertheless, the actual explanations of why institutions have been developed that provide approximations to universal access may be as varied as the local social histories of these countries, and there is no simple way to infer from the presence of these institutions to the conclusion that these are all efforts to promote conceptions of social justice.
• Despite the belief that probably accompanied the introduction of universal access, namely that it would reduce health inequalities in the population, we know from the social epidemiology literature that health inequalities persist, that they are correlated with the distribution of a wide set of non-health care goods, and that they are present across a broad spectrum of the population.

2. Conceptualizing and Measuring Access to Care

Arguably, the goal of universal access to health care, as embodied in health systems in nearly all developed countries, is to secure equal or at least equitable access to needed care. How can we tell whether or not access to care is equal? What should we count as equitable access, if this involves departures from equal access? We might hope that it is relatively unproblematic to determine when access to care is equal, as it is, for example, with income, and that equitable access would then consist of allowable or justifiable inequalities in access. As we shall see in this Section, giving an account of equal access, let alone equitable access, is not so easy.

Conceptualizing and measuring access to care is more complex a task than it might seem at first. In part, this is because health care is non-homogeneous in its function, for it does quite different things for us. In addition, there is disagreement about the nature of health care as a social good: some think it is just a commodity, to be purchased in a market like other commodities; others claim it has a special moral importance that distinguishes it from some other market goods. If we are to make sense out of claims that we owe each other equal or at least equitable access to care, and this means we must overcome various barriers to access to care that create inequitable access, then we need to be clear how to determine when access is unequal or unjustifiably unequal.

It is tempting to think that we can give a completely non-controversial definition of equal access to health care—much as we can do for equality of income—and reserve all controversy for debates about which departures from equality conform to acceptable principles of justice. If A earns $10,000 less than B , the inequality might be thought equitable by some if B works longer or harder than A , by others if B ’s skills have a higher market value than A ’s, and by others if B needs more than A does. Here our moral disagreements about appropriate distributive principles show up as disagreements about just or equitable income distribution, though there is no controversy about whether incomes are equal.

The situation is arguably different for the notion of equal access to health care: to arrive at a notion of equal access, we must already have made various decisions about what considerations ought to count in judging when access is equal. These decisions reflect our purpose or interest in making the judgment about equality, and some of these discriminations are themselves moral. So moral considerations are already embedded in the specification of equal access and are not held at bay until we get to decisions about equity.

To see the point, consider what may seem to be a trivial example. Is there equal access among department colleagues to the coffee in the lounge not far from Prof. A ’s office? If there is no wheelchair access to the lounge, then a paraplegic colleague can readily claim unequal access—and this claim has force even if she drinks as much coffee as she wants because someone is willing to fetch it for her. What should we say about the fact that the coffee is only ten feet from Prof. A ’s office, but thirty from her junior colleague’s? Does it matter if one colleague hates the color of the paint in the lounge but others do not? Does it matter that one colleague has had negative experiences in the coffee lounge on a previous job but other colleagues have not? If we view access to coffee as meeting an important need, then we might worry about the unequal distances or the psychic burden of seeking the coffee, but if we think coffee is only an amenity (leave aside addiction), then we might not care about these other issues, even if they lead to differences in preferences for obtaining coffee and in coffee consumption. How we think about the importance of drinking coffee matters to us when we consider whether access to it is equal.

The same point applies to judgments about equal access to health care: such judgments presuppose some view about the moral importance of health care. Nevertheless, it is probably fair to say that all that most people have in mind when they talk about equal access to health care is a negative criterion, specifically that certain traditional constraints on access, mainly financial, geographical, or discriminatory, should play a minimal role in determining whether people who need health care get it. There may be implicit in this negative characterization a positive ideal—for example, “any any two persons of comparable health status who want appropriate care have an equal chance of getting it.” But nothing so schematic may be in anyone’s mind at all; there may be only a moral complaint against a particular inequality. Thus in many cases there is agreement about what to call equal access only because there is agreement not to accept a particular kind of inequality.

The dominant conceptualization of equitable access to health care among health service researchers builds on the idea that the utilization of services should reflect actual needs for care (Aday and Anderson 1974, 1975, Aday 1975, Aday, Anderson and Fleming 1980, Aday 2001, Aday et al. 2004). A prominent competing view, especially in the United States, is a modified market view that focuses on the availability in the market of a decent basic minimum of care (cf. Enthoven 1980). This modified market account is not to be confused with a pure market view that allows all care to be determined by market forces, which might mean that some people do not even get a decent basic minimum of care. However, even the modified market view allows for many inequalities of access to care that would be judged inequitable by the use-per-need view. A third model of equal, universal access can be derived from some things that have been said by Republicans determined to advance a model of universal access that rests on the “choice” to buy coverage (Bump 2017). Rather than taking all to have insurance coverage as the model of universal and equal access to care, on this model the “choice” to buy coverage is the key determinant of universality. It will be useful to examine the implications of these three prominent views of equity of access.

Consider first the use-per-need view. On this view, use-per-need should not be distorted by certain structural features of the health system, such as the distribution of providers or facilities or exclusionary attitudes they harbor, or by inappropriate disposing or enabling factors of individuals, such as their information about health care or their inability to communicate with providers, or their income, or by such “process variables” as travel and waiting time. The approach allows us to test whether or not a factor potentially affecting access, such as waiting time, actually does, for example, if it produces an effect on actual utilization of the services where need is held constant. Where distorting factors mean that utilization of services is not determined by need, the use-per-need view judges the access inequitable. In this way, the view can be used analytically to test how important certain potential access factors are, and it can be used normatively to make judgments about equity of access.

The use-per-need approach is quite sensitive to what actual measures of both need and utilization are used. A process variable—for example, time spent in a waiting room—may have a significant effect on measures of satisfaction with care (a subjective measure of actual access), but have relatively little effect on utilization rates (an objective measure of actual access). So the choice of objective or subjective measures of realized access may yield different assessments of the importance of a process variable and, ultimately, of the equity of access to health-care services. Even if we are inclined to use an objective measure, however, it matters which one. For example, cultural attitudes toward entering a sick role might have a greater impact on disability days, as a measure of need, than they do on the more serious level of need, bed-disability days.

Critics of the use-per-need account argue that some process variables are important determinants of equity of access even if they do not have a significant impact on utilization of services (Sloan and Bentkover 1979). For example, even if waiting time does not interfere with utilization, it may impose a significant burden on those seeking care, and that burden may be inequitable. Another criticism of the use-per-need account is the claim that uniformity in utilization rates is not even a necessary condition for equity of access. If some people are informed, yet averse to the utilization of medical services, then differences in their utilization rate from others should not count as an inequity of access. A further objection is that the approach abstracts from the effectiveness of care—it does not look at health status as an outcome, only the utilization of services. People with different utilization rates may have the same health status as an output simply because the care was ineffective, so measuring its rate of utilization does not tell us what really matters.

The rationale for the use-per-need view might appeal to an argument from function of the following sort: “The (main) function of health-care services is to prevent and cure illness, i.e., to meet health-care needs. A distribution of health-care services that is not determined by the distribution of health-care needs is therefore unreasonable in some important sense. One sense in which it is unreasonable is that it would defeat the purpose of meeting health needs to provide access in ways not determined by the level or kinds of need people have. Another sense in which it is unreasonable is that it ignores similarities and differences—here in health status—between persons which, given the function of health care, ought to be relevant to establishing its reasonable distribution. Ignoring such relevant similarities and differences is what it means for a distribution to be inequitable.” A version of this argument is clearly foreshadowed in Bernard Williams’ (1971: 27) now classic discussion of equality in which he concluded that, “leaving aside preventive medicine the proper ground of distribution of medical care is health; this is a necessary truth.”

Unfortunately, this argument from function falls short of providing a basis for the use-per-need view. The function of food processors is to meet food processing needs, but no one believes that willingness to pay for food processors is an inappropriate basis for distributing them and that we must do so in proportion to the presence of vegetable-slicing needs in the population. The problem here is that meeting some needs, but not others, matters as a concern of justice or equity. In the next section, we shall return to seek more persuasive foundations for the use-per-need view.

Consider next the modified market view, according to which we have equity of access to health care when a decent minimum is available to all in a market. Unlike the utilization rate approach, the market view is not really a position represented in the empirical literature on access but rather a composite abstracted from views that are common in the economics and health planning literature. Its interest lies in the quite different limits it places on the notion of equitable access and because of the quite different underlying view of health care and distributive justice.

I earlier noted that one objection to the utilization rate approach is that similarity in intergroup use-per-need rates is not even a necessary condition for equitable access (or distribution). One rationale for this claim is the view that health-care services are commodities like any others. On this view, there is nothing so ‘special’ about these services that cannot be accommodated by allowing a market for them to respond to people’s preferences for them. On such a view, equity of access is assured if three main conditions obtain: (1) the commodity must be available at something like “true social cost;” (2) individuals are capable of making rational (informed) decisions about using the system; (3) income distribution must be (approximately) equitable. The second condition requires that information about alternatives—for example, therapies or insurance schemes—is available and that people are competent and informed enough to make use of the information. Some access inequities arise when this condition is not met and these must be addressed by public policy. (We shall see how these conditions affect the philosophical arguments about prudential insurance in the Section 3.)

Aside from the problem of subsidies to the poor to guarantee equitable income distribution, the central problems of access are those brought about by departures of the medical market from the ideal of a truly competitive market (Arrow 1963). In particular, there may be various distortions on the supply side which amount to the market’s not delivering services at their “true social cost.” For example, rural populations or inner city minorities may not be able to get the care they want and can afford. They may not be able to get it in the desired quantities, or at the desired times with the characteristics they desire.

Viewed in this way, the problem is that the market is unresponsive to consumer preferences on the supply side and interventions may be needed to correct the problem, generally by addressing structural problems in capital expenditure policy. A central problem here is the way in which the choice of a health insurance plan is tied to features of employment and the unavailability of an adequate range of plans—for example, ones that cover people between jobs. The central issues of access and equity of access are concerned with these supply malfunctions of the market. (In Section 3, we shall see how Dworkin (1994, 2000) attempts to avoid these market limitations.)

The third condition, about equitable income distribution, is rarely addressed in the literature. Obviously, if income redistribution brings people only to the officially defined poverty level, it is inadequate to cover the costs of a decent basic minimum of care (this notion is discussed further later in this section). If the transfer falls short of this, we have an inequitable transfer. So the modified market view I am sketching is not that of the pure libertarian who might reject all such transfers, but rather one in which there is implicit acceptance of some important moral claims that might loosely be characterized as “welfare rights.”

Assuring equitable access in the ways defined by the market approach leaves extensive room for all sorts of departures from equitable access as defined by the use-per-need approach. Surely, there may be variations in the amenities that accompany healthcare services, if that is how we want to look at (some) process variables such as waiting time. Equal quality in these dimensions is surely not required, any more than everyone prefers equal quality in, say, automobiles. Similarly, use-per-need rates may vary with suspect variables like income or race and yet not indicate any inequity of access, contrary to the use-per-need formulation. Rather, the unequal distribution of health care in quantity and quality can be viewed merely as the expression of different preference curves, just as food budgets might vary among a welfare recipient, a factory worker, and a wealthy industrialist. If we take the underlying income distribution to be morally acceptable, its expression in terms of utilization of health services need indicate no inequity.

Put succinctly, then, the market approach I am considering here comes to this: access to health care is equitable if and only if there are no information barriers, financial barriers, or supply anomalies that prevent access to a reasonable or decent basic minimum of health-care services. How plausible such an account is depends on the characterization of such a decent minimum and the moral arguments maintaining that provision of such a minimum is all that justice or equity demands. The problem facing the ‘market’ proponent thus appears to be the other side of the coin from the problem facing the use-per-need account. If the market view suggests we owe each other on grounds of justice only a decent minimum, the use-per-need view suggests we owe much more—both require clear rationales. One central problem with that account was its simplifying assumption that health care is relatively homogeneous in function and that the proper basis for its distribution must be the realization of that function. A related problem for that account is its working assumption that access can be equitable only if services of all kinds that happen to be offered in the system are distributed according to need. If, however, we want to treat health-care services as non-homogeneous in function, and we are willing to ground equity claims only by reference to some features of some of those services, we owe an account of how to draw the lines.

There are three ways to elucidate the notion of a decent basic minimum: (1) the provision of a general criterion by reference to which we can tell if services are within the minimum or are above it; (2) the simple listing the types of services included; or (3) the description of a fair procedure for determining the minimum. In the market literature—indeed in much of the literature—there is little attempt to give a general criterion or describe an appropriate, fair procedure. What attempts we get are far too vague. Charles Fried, in an early effort at characterization (1976:32), suggests that the “decent minimum should reflect some conception of what constitutes tolerable life prospects in general. It should speak quite strongly to things like maternal and child health which set the terms under which individuals will compete and develop.” The characterization is not developed enough to tell when prospects are tolerable and for whom.

Efforts to specify a decent basic minimum more commonly appeal to a list of categories of services or to some “average” level of services in a particular health system. Neither of these approaches provides a criterion that clarifies why these services are viewed as decent and basic. Where there is appeal to a list, as in an early proposal by Enthoven (1980), the Consumer Choice Health Plan that significantly influenced the Clinton Administration efforts at health reform, it may derive from an earlier effort at regulation, such as the 1973 HMO Act. It is typical of such appeals to lists that there is no rationale offered for why items are on the list. If mental health services are included, we are often not told which ones; and there may be categorical omissions, such as dental care, without explanation.

Appeals to an “average” insurance package similarly provide no clear basis for deciding whether a set of benefits is truly appropriate to a decent minimum. For one thing, the average may reflect many features of a market that is not working well, capturing much that is wasteful, ineffective, or inappropriate in a system providing care. It may also be the case that an average package omits some crucial features of care, for example, certain mental health services. Indeed, by focusing on services provided within a given system to “average” users, the concept of what we owe people, that is, what counts as equitable treatment, is turned into a completely “interstitial” notion. We are told, “within the confines of this system, equity requires making this package available, since it happens to be available on average” but we are not in a more general way told that the system provides people with what they should get, as a matter of justice. We are, in effect, told that a system that aims to meet certain needs should treat people equitably in addressing those needs, but we are not told that a system that is fair to people should perforce meet certain health needs. Nor are we given a process that might help us decide what to provide as a matter of justice where there may be disagreement about equitable coverage. In short, neither lists nor averages substitute for an appeal to a defensible rationale or to a fair process for determining what should be covered. (We shall consider in Section 3 how the insurance approaches of Dworkin (1994) and Gibbard (1982) address these issues, since each approach is part of an argument to justify the appeal to equal access; the choice model takes equal access for granted and does not make an attempt to justify it, and so we do not discuss it in Section 3.)

Consider now the third model of what we should count as equal access, which we refer to as the choice model. Actually, this model is couched as a version of universal access (as opposed to universal coverage), and we shall have to infer the notion of equality. So what is its commitment to equality of access? The foundational intuition behind it can be found in Paul Ryan’s words that no one should be forced to do what they don’t want to do. If the intuition focuses on what anyone wants to do, then there is a concern about equality after all. It cannot be an intuition that focuses only on what some people want to do if they are rich enough to have certain choices. It rules out choice that is forced on individuals by their being unable to afford to do what they prefer to do. Such a forced choice was typical of what people faced on the individual insurance market before the ACA if they bought skimpy but affordable health insurance (e. g., high deductible plans that are cheaper because they do not cover certain needed services). For a choice to buy or not buy insurance coverage to be a real choice on this view, both choices have to be ones people could select, if they wanted to. This feature rules out a choice between a health care insurance scheme people cannot afford vs one that they can afford. Subsidies must be available to those with limited resources that make their choices real. This requirement makes the model more expensive to implement than the Republican plans allowed. Real choice has costs given the income inequality that prevails in the U.S. The costs have a compensation that has a bearing on “equality,” for everyone is equal in the choices that are possible for purchasing insurance, and individuals have more room to express other priorities than the purchase of health care.

The real choices of some people to forego coverage actually make things worse for those who need insurance and prefer to buy it, and they create the need to fund subsidies for the foregone insurance purchase. We shall call “free riders” those who—for whatever reason—do not share in the cost of the health system but can share its benefits (needed health care) when ill. Suppose further that free riders can share the benefits of the health system by meeting some modest penalty for remaining uninsured. In short, free riders can pocket the cost of insurance minus the penalty, but still get care when they need it. Put another way, the health system must be ready to treat all people, free riders or not, because that is the choice of society. (We are assuming that few people would allow Free Riders to die in the streets, which would happen if they are not allowed to get care when they need it and have not purchased health care insurance.) Free riders thus get a good bargain—some might say an incentive to free load—if they are given needed care when they join a system they did not contribute to, except for facing a modest punishment for not joining earlier.

Free riders raise the costs of keeping the system ready for them, a cost that is paid by all who contribute to it by obtaining coverage in it. So the “real choice” of those who forego coverage (and become free riders) harms those who “choose” to pay for coverage each year. These harms to others are encouraged whenever such a choice is allowed. The replacement plans for the ACA in promoting such choices are premised on allowing these harms to third parties. The price of encouraging some people to forego coverage is to encourage free riding and the resulting harms to third parties.

To conclude this section, we shall briefly consider what each of these three approaches to access has to say about some race inequalities in health and health care that are found in the U.S. A first point to note is that these accounts of access to health care do not inform us about the origins of some important inequalities in health. For example, certain health conditions, such as high blood pressure, diabetes, and asthma are more prevalent among African Americans than among other racial groups in the U.S. However the differences are best explained—by income differences, educational differences, lifestyle choices, some other environmental exposure to risks, or biological differences in the susceptibility to those illnesses—if the difference is not the result of differences in access to preventive services or treatments, then inequity in access to care is not the source of the health difference. A higher prevalence rate—or need—should lead to a higher utilization rate for relevant services, or else the use-per-need rates would differ between African Americans and other groups. What the use-per-need approach counsels us to do is to consider whether differences in the use-per-need rate are best accounted for by certain structural features of the system (e.g. inadequate supplies of providers in the areas where the population in need resides, organization of care that induces discontinuity of care, discriminatory attitudes of providers, including conscious or unconscious stereotyping), or by enabling or disposing features of the individuals (income differences, insurance level differences, educational differences, age differences, attitudes toward disease and treatment). If factors other than differences in need affect the use-per-need rate, then we have strong grounds for thinking there is an unfair inequality in access to care.

How would the modified market view judge such differences? Differences across types of insurance coverage (above the decent basic minimum level) that the use-per-need view would judge problematic might be dismissed as preference differences by the modified market view. Just as the household preferences and budget for food or clothing might differ across income and education levels, so too utilization of health services might differ—above the decent minimum—without the raised eyebrows evoked by unfair inequalities. If there is a quality difference—which might even take the form of additional protection against health risk through better diagnosis or more continuous care—that might not be problematic for the modified market view when it would be for the use-per-need view.

On the third view that subsidizes all choices to buy insurance, the higher prevalence of illness among some minorities in the U.S. would presumably lead them to make fewer choices to forego coverage and thus to purchase needed coverage more. That result might be explained, as it was on the market view, as a difference in preferences across groups. In any case, it would not lead to the claim of unfairness. The opposition from the choice view is to the full range of subsidies that make real choice possible.

3. Does Justice Require Universal Access to Health Care?

In this Section we shall examine three lines of argument that aim to show that universal access to (at least some forms of) health care is a requirement of justice. If one or more of these views establishes its claim, then the practice we have noted in many countries of financing institutions aimed at providing such access can be construed as an effort to meet, however imperfectly, a requirement of justice. We shall not spend time, however, assessing views that deny such claims altogether—noting only that some libertarian accounts of justice would reject redistributive efforts to promote health just as they would redistributive efforts to promote other social objectives.

One prominent line of argument in favor of universal access to some forms of health care builds on the contribution made by health—and derivatively by health care—to the opportunities people can exercise. The most explicit version of this argument extends Rawls’s appeal to a principle assuring fair equality of opportunity (Daniels 1981, 1985, 2008). Variants on that argument can be extrapolated from Sen’s (1980, 1992) work on capabilities or from Arneson’s (1988) and Cohen’s (1989) versions of “equal opportunity for welfare or advantage,” though there will be differences among these variants in what kinds of care are covered and under what conditions.

The fair equality of opportunity argument for universal access can be sketched as follows:

• Suppose health consists of functioning normally for some appropriate reference class (e.g. a gender specific subgroup) of a species; in effect, health is the absence of significant pathology.
• Maintaining normal functioning—that is health—makes a significant—if limited—contribution to protecting the range of opportunities individuals can reasonably exercise; departures from normal functioning decrease the range of plans of life we can reasonably choose among to the extent that it diminishes the functionings we can exercise (our capabilities).
• Various socially controllable factors contribute to maintaining normal functioning in a population and distributing health fairly in it, including traditional public health and medical interventions, as well as the distribution of such social determinants of health as income and wealth, education, and control over life and work.
• If we have social obligations to protect the opportunity range open to individuals, as some general theories of justice, such as Rawls’s justice as fairness, claim, then we have obligations to promote and protect normal functioning for all.
• Providing universal access to a reasonable array of public health and medical interventions in part meets our social obligation to protect the opportunity range of individuals, though reasonable people may disagree about what is included within such an array of interventions, given resource and technological limits.

Some comments will clarify the main points in this sketch. First, the narrow concept of health does not preclude the broad range of determinants of health noted in (3), yet the narrower notion is about what epidemiologists and public health planners measure and care. This narrower concept of health avoids conflating health with well being more generally, which the WHO definition of health arguably does (“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity”) (WHO 1948). Obviously, though, normal functioning includes cognitive and emotional functioning and not just physical health, for we are complex social animals. Health remains a “limit” or “ceiling” concept, unlike income, for we cannot increase health indefinitely but must aim only for normal functioning for all.

Second, protecting and promoting normal functioning is not the only factor affecting the range of opportunities open to people. Income, education, and basic liberties, as well as other factors, do so as well. Nevertheless, the loss of functioning or premature death that may come with ill health clearly diminishes the range of plans of life people can reasonably choose among in a given society. Accordingly, protecting health protects opportunity, even if it is not the only thing that does so. A crucial feature of the argument is that we are concerned about the health of all because we are concerned about protecting the opportunity range of all.

Third, we have learned much in the last several decades about the broader social determinants of health (see entry by Sreenivasan on Health Inequalities and Justice), especially that the presence of universal access in a society does not eliminate or significantly reduce health inequalities in it. Does the importance of other socially controllable factors that affect population health and its distribution mean that providing universal access to an appropriate set of public health and personal medical services is less important (see Sreenivasan 2007)? Suppose we learn that some expensive individual interventions contribute less to protecting the opportunity range of individuals than redistributing some other important goods that are determinants of health. That might well mean that we should spend less on health care and redefine the benefit package we provide in a universal access system. But it should not mean that we abandon universal access to care, even if it means we ought to shrink the range of medical services open to people in light of other ways to reduce risks of loss of functioning. No matter how justly we distribute the broader determinants of health, some people will become ill and others not. Universal access to reasonable care (given its relative effectiveness compared to other things we may do) is still the only way to assure people that certain health needs can be equitably met.

Fourth, the extension of Rawls’s theory introduces some modification in the account of opportunity, but the modification is not inconsistent with the thrust of justice as fairness. Justice as fairness abstracts from health status differences in its assumption that agents are choosing principles to govern people who are fully functional over a normal lifespan. This simplification drew criticism from Arrow (1973) and later Sen (1980), for it means the method of judging inequality, the index of primary social goods, would fail to account for the inability of people in some health states to convert those goods into the same level of well-being as people functioning normally. Rawls’s (1971) notion of opportunity is primarily geared to the strategic importance of access to jobs and offices; health, viewed as normal functioning, clearly has a bearing on access to jobs and offices, but we also need a broader account of opportunity if we are to address the impact of health on other important aspects of life. In borrowing justification for a principle assuring fair equality of opportunity, then, and then using it to apply to a broader notion of opportunity, the argument involves a modification of Rawls’s own arguments. Nevertheless, he seems to have adopted this view of how to extend his theory (Rawls 1995: 184, n.14; Rawls 2001: 175, n.58).

Despite this modification, the approach preserves a key feature of Rawls’s original idealization away from consideration of health states: in aiming to keep all in a population functioning normally over a normal lifespan, we aim to keep the real world as close to the idealization as possible. A crucial consequence of this is that we are not simply focused on equalizing opportunity, but on promoting the broadened range of opportunity that comes with normal functioning for everyone. The view aims at promoting population health and not simply equalizing it: equally bad health is not the goal of the argument. Put another way, the ultimate goal of health policy is that all people function normally: but that means the ultimate goal is both egalitarian and maximizing (though short of the ultimate goal, we face important trade-offs).

Finally, we must consider how we can meet health needs fairly when we cannot meet them all. The question is especially difficult because we have reasonable disagreements about what interventions to include in a universal access system, as we noted earlier when we noted how reasonable disagreements will arise about the tradeoff between improved financial protection, say by reducing the co-pays or deductibles a benefit involves, and coverage of more types of services during deliberations about the comprehensiveness of a universal coverage benefit package. This is true even if we accept the principle of fair equality of opportunity principle as the appropriate principle to govern health and health care.

The problem is that the fair equality of opportunity principle is too general and indeterminate to address a family of “unsolved rationing problems” (Daniels 1993). For example, when we are thinking of investing in a new service or technology, we may agree that we should give those who are worst off in their health some priority over those who are better off. But we may wonder how much priority we should give them if we can produce much bigger improvement in health for those who are somewhat better off. Similarly, we may agree not to allow many trivial benefits to outweigh significant ones, but we may still disagree about when do modest benefits for larger numbers of people outweigh significant benefits for fewer people. In these and other problems, reasonable people—people seeking reasons that can form the basis for a mutual justification of policy—will disagree about how to make the tradeoffs among the competing values at issue, even if they agree that the overall goal of health policy should be to protect opportunity. We lack prior agreement on more fine-grained principles that tell us how best to protect opportunity in this context. Because we lack a consensus on such principles, we should engage a form of procedural justice or fair process to yield fair outcomes.

One version of such a process is called “accountability for reasonableness” (Daniels and Sabin 2008). It requires a search for mutually justifiable reasons, publicity about the grounds for decisions, revisability of decisions in light of new evidence and arguments, and assurance that the process is adhered to. The specific features of such a fair process would have to be adapted to the institutional level at which it is used to make decisions about what to cover. Specifically, decisions about the content of a universal access benefit package should be specified through a fair, deliberative process that conforms to these general conditions. In Section 5 we shall return to consider in more detail what kinds of interventions are in general supported by this account.

Accountability for reasonableness can arguably be thought of as a form of pure procedural justice (Rawls 1971) because we lack prior consensus on the fine-grained principles needed to resolve disputes about these resource allocation issues, though we may arrive at mutually acceptable justifications through deliberation about specific cases. It differs from gambling, Rawls’s example of a case of pure procedural justice, in two ways. First, the appeal to process is constrained by some prior moral principles. For example, an outcome should not contradict what fair equality of opportunity requires by discriminating against some subgroup by race or gender. A local decision-making body could not engage in gender or race bias and consider that a fair outcome. One might claim that the same constraint applies to the gambling case: if only whites and no blacks were allowed to gamble, then the outcome of a spin of a fair roulette wheel would also not be fair—though some might reply this is a constraint on who plays the game, not on whether we view the outcome of the spin of a fairly balanced wheel as fair outcome. Second, we can imagine philosophical reasoning persuading us to adopt a principle that renders the appeal to a fair process unnecessary, but we cannot imagine such a philosophical “proof” of the fairness of a gambling outcome that would lead us to think the spin of a fair roulette wheel or a throw of a properly balanced die can be rendered unnecessary in the same way. Though fair equality or opportunity, including non-discrimination, constrains acceptable outcomes of fair process, it is too general an idea to settle what counts as an acceptable outcome. That requires agreement, in general by a range of stakeholders, on reasons for thinking an allocation is an acceptable way to meet needs fairly and so protect opportunity for those involved. The point behind insisting on what we call the “relevance” condition is to search for mutually justifiable reasons for thinking that a particular resource allocation is an acceptable way to aim at fair equality of opportunity. The condition takes us beyond mere consistency with fair equality of opportunity since that principle does not determine what to do in the face of disagreements about priorities, aggregation, and other problems.

The argument for universal access sketched earlier specifically embraces Rawls’s fair equality of opportunity principle. It is worth remarking that the variations on this argument might retain steps 1–3 but modify the principle that is appealed to in 4, provided there is a reasonable connection between any substituted principle and the central observation in 3, that health affects the opportunity range open to people. For example, Sen has argued that the appropriate target of concerns about equality is a space of capabilities, thought of as functionings we can choose to exercise. A principle requiring us to protect the range of capabilities for people (either equally or to some sufficient level) would also provide a basis for keeping people functioning normally through universal access to interventions that reduce the health risks to them or that treat them for departures from normal functioning. Though Sen has not developed this account into a theory of justice that articulates a set of principles of justice, the central point here is that a concern to protect a space of functionings we can choose to exercise is equivalent to the focus of the earlier argument on protecting opportunities that it is reasonable for people to exercise (Daniels 2010).

A third alternative version of the earlier argument might (in 4) invoke a principle assuring equal opportunity for welfare or advantage (Arneson 1988; Cohen 1989), a view that later came to be called “luck egalitarianism.” Arguably, such a principle would also support a universal access system that included a broad range of preventive and treatment services. This particular principle, however, will differ in terms of what is covered from the opportunity-based account described earlier for it more explicitly leaves room to exclude coverage for conditions for which an individual is substantively responsible. It says we do not owe each other assistance or compensation for bad “option” luck in the way we do for bad “brute” luck. At the same time, it might include access to services that correct for some disadvantages (e.g. lower manual dexterity or lower intelligence) that might be considered normal functioning by the account sketched earlier. Still, this is a universal access system, even if it excludes coverage for conditions for which society holds individuals responsible (see Daniels 2011). Nevertheless, some luck egalitarians reject the appeal to opportunity proposed in the account sketched here (Segall 2010).

A second general line of argument in favor of universal access to some forms of health care builds on the idea that prudent individuals would insure themselves against the prospect of needing certain kinds of health care. We shall consider two versions of this argument, Dworkin’s (1981, 1994, 2000) effort to spell out the implications of treating people with equal respect, and Gibbard’s (1982) appeal to an ex ante pareto optimality principle combined with an assumed right to a decent basic minimum of income. As we shall see, though both arguments use different assumptions to support universal access to different health care benefit packages, their main point is to counter certain implausible views about what benefits should be included in a universal access system.

Dworkin’s argument can be sketched as follows:

• We have an obligation to treat people as equals.
• Treating people as equals is best achieved by giving people equality of resources (and this idea can in theory be shown to be coherent by devising an appropriate initial auction, combined with appropriate post-auction trades and insurance schemes against disadvantaging outcomes).
• Suppose we had equality of resources in the U.S., for example, that income and wealth were equally distributed, and that all people had information about health care interventions and their effects as good as what the best doctors have, and that no one has prior information about the specific risks faced by specific individuals.
• Then each person could act prudently to buy insurance protection against various health needs without government subsidies or otherwise distorted markets.
• What most people would prudently insure themselves against ought to be included in a universal access health system. (Some kinds of protection would thus be imprudent to include and we should abandon a rule of rescue that included them.)
• Where there is disagreement about what people count as prudent insurance (some would buy it, others not), then we need to consult with representative people of different views and make decisions about universal coverage that reflect that consultation.

Some comments will clarify key aspects of this argument. First, the first two premises involve both a strong egalitarian assumption, though one that is widely held (treating people as equals) and a very strong (specific and detailed) way of achieving it (equality of resources). Discussion of the details of these claims would take us well beyond the scope of this essay. Suffice it to say that this argument cannot proceed to an account of universal access to health care without some more general assumptions for a view of justice. In that regard, it shares with the fair equality of opportunity account the need to borrow justification for universal access from more general concerns of justice.

Second, the specific assumptions in (3) are very strong and arguably cannot be realized. The argument that presupposes them should thus be seen as an analytic tool and not an attempt to say anything very specific about how real institutions could be designed. (We note that this strong requirement is not needed by the model of universal and equal access that emphasizes real choice. Instead, the choice model allows for income inequalities and only needs subsidies to equalize the affordability of buying insurance equal in scope to what the ACA requires of insurance purchased on the exchanges it authorizes.) Without, for example, knowing what level of resources would result from equalizing resources, we can say little about what levels of insurance coverage for specific conditions are welfare enhancing for individuals. Since there is no feasible way to meet the assumptions about the distribution of medical knowledge or the exclusion of knowledge of individual risks, these assumptions make Dworkin’s argument completely hypothetical and theoretical rather than practical. Third, the assumption that there is an ideally competitive insurance market postulated in the fourth step of the argument adds to the hypothetical nature of the argument as a whole.

Fourth, the argument focuses primarily on personal medical services and not broader public health measures that reduce overall risk or distribute that risk more fairly. There is no mention of interventions beyond individual treatment or prevention measures, and the thrust of 4 and 5 make it clear the argument is about an insurance market only for those measures. The thrust of steps 5 and 6 make it clearer that the point of the argument is to clarify what a defensible content of a universal access benefit package would include. Specifically, the argument aims to establish that we need a more plausible view of what we owe each other by way of providing health care than the indefensible view that what rescues someone from death or disability must be provided regardless of costs or opportunity costs.

The other version of a prudential insurance argument for universal coverage rests on a weaker assumption that we have a right to a decent minimum of income. In Gibbard’s (1982) discussion, the assumption is invoked but not argued for. Like the other argument, the main thrust of Gibbard’s argument lies in its implications for the content of a universal access benefit package.

• Assume the Ex Ante Pareto Principle which says: If both a) the prospects of someone are better under policy P than Q , and b) no ones’ prospects are worse under Q than P , then P is better than Q . (There are no opposed interests in the cases where this principle applies.)
• Assume there is a right to a decent minimum of economic welfare. (Gibbard does not argue for this right, only that this precept plus the Ex Ante Pareto Principle are sufficient to establish there ought to be equal access to a decent minimum of care.)
• Health insurance that it is prudent for all to buy from their decent minimum defines essential health care, i.e., the decent minimum of health care.
• There should be universal access to a decent minimum of health care, for everyone is better off with such access and no one is worse off.
• There should not, however, be equal access to all health care, assuming the Ex Ante Pareto Principle, for the overall package of health care it is prudent to buy will differ above the decent minimum. Further, the Ex Ante Pareto Principle implies that some health care may not be worth purchasing insurance for by anyone.

Some comments will help clarify this argument sketch. First, Gibbard is concerned to show that this weak ethical principle has health policy implications that are significant (and are noted in steps 4 and 5). He defends the principle against anti-utilitarian arguments and against some intuitions that run counter to it but that may be irrational (on his view). Second, to arrive at the main conclusion in 4—supporting universal access to a decent minimum of care—Gibbard adopts an ethical precept that is sufficient to support provide a basis for a universal level of insurance purchasing. He does not, as noted, argue for the specific right articulated here. He might, however, try to derive some support for it from utilitarian arguments about decreasing marginal utility of income and wealth, for it is weaker than the more egalitarian view that Brandt (1979) defends on utility maximizing grounds and for which Gibbard expresses some sympathy.

Third, the crux of the argument for the conclusion in step 4 is the idea that if everyone acts prudently at the decent minimum economic threshold of welfare to buy some kinds of health care, what they buy, assuming they bear the inclusive social cost of the insurance (including any losses of efficiency), will constitute the decent minimum of care. To say it is prudent for a person to buy the insurance (while bearing those costs) is (using the Ex Ante Pareto Principle) to say the person has better prospects with the insurance than without and that no one is worse off as a result. Presumably, however, this requires that there be a competitive market for such insurance (an assumption Dworkin had to make in his argument), and it is not obvious how to achieve that in light of the pervasive uncertainties that exist in medical markets (cf. Arrow 1963), a point Gibbard notes.

Fourth, above the decent welfare minimum, it is unlikely that access to the some broader insurance package is prudent for all people to buy. That is the reason Gibbard says it is not equitable to require equal access to all health care. Here equity is equated with ethically acceptable, and what counts as ethically acceptable is (among other things) what is endorsed by the Ex Ante Pareto Principle. The same principle shows that some kinds of care are not prudent for anyone to buy—prospects are better for all people if they do not buy insurance for that care—and so a defense is made for some implications of cost effectiveness analysis.

Fifth, unlike Dworkin, who admits there may be disagreements about what it is prudent to do, Gibbard does not make that concession. Consequently, he is not concerned, as is Dworkin (or the proponent of accountability for reasonableness, in the earlier argument), with developing a way of resolving disputes about what counts as prudent.

A different kind of argument in favor of universal access to a decent minimum of health care does not turn on support of general principles of justice (fair equality of opportunity, treating peoples as equals, or a right to a decent minimum of economic welfare), but rather on a pluralism of moral considerations plus an argument for state coordinated (coerced) beneficence (Buchanan 1984). In his discussion, Buchanan first dismisses various accounts that try to ground a universal right to a decent minimum of care, but here we shall concentrate on the positive argument supporting the idea of universal access through a legal entitlement to such care despite the absence of any moral right to it.

The argument can be sketched as follows:

• There are a set of special rights to a decent minimum of care that are held by these groups: members of groups, such as African Americans and Native Americans, that are owed compensation for long-standing injustice done to them; individuals harmed in their health by private or corporate actions, such as polluting public spaces or exposing workers to toxins; members of groups that have made exceptional sacrifices for the good of society as a whole, such as wounded veterans.
• Access to some forms of preventive services derive from a Harm Prevention Principle that justifies the use of public funds for certain public health measures plus a constitutional argument that requires equal protection from harms that the public acts to prevent.
• Access to some forms of beneficial services is justified by such prudential considerations as the importance of some forms of health care to producing a productive work force and a citizenry fit for national defense.
• Together these considerations would justify a legal entitlement to some forms of health care.
• Enforcing contributions can lead to producing the public good of a decent minimum of health care for all whereas not enforcing contributions would lead many to choose alternative ways of maximizing the good they can produce through individual actions, undermining the production of the public good;
• Enforcing contributions produces an assurance that others will contribute to the decent basic minimum and that ones own contribution to it therefore is worth making since others will do the same.

Some points of clarification are in order. First, it remains unclear just how the special rights argued for combine to produce a decent minimum for all. Only some people hold them, and it is not fully clear what these rights entitle their bearers to. Second, it is unclear that when we add the entitlements of these special rights bearers to the content of what follows from the Harm Prevention Principle or the prudential considerations, we end up with what people would call a decent minimum of care. How the broader entitlements of the special rights bearers (if they are broad) get combined with the care that ought to universally be provided according the Harm Prevention Principle and the prudential considerations? No clear account is offered. Put another way, these pluralist considerations might suffice to establish some legal entitlements by some people to some forms of care, but it is not obvious that what emerges is a universal legal entitlement to a decent minimum of care.

Third, the arguments for enforcing beneficence seems to imply that there is a collective duty to engage in beneficent actions, whereas the duty the argument explicitly mentions is an individual duty of beneficence. The fact that individuals might fail to produce certain public goods through individual (unenforced) beneficence is a limitation that enforced coordination overcomes, but it is not a failure that results from their not discharging their duty. To treat it as if it is seems to presuppose a collective responsibility to do as much good as possible.

Several lessons can be learned from this review of lines of justification for universal access to care. One such lesson is that rationales for universal access derive from more general considerations of justice. As such, they borrow their justificatory force from the arguments for those general considerations. They also bring with them from those general theories specific considerations that may affect the content of the claim to universal access. Thus, a family of egalitarian theories that talk about equality of opportunity in different ways might thus all support universal access to health care because of its impact on opportunity, but they justify different kinds of access because they view the obligation to promote opportunity in somewhat different ways.

A second lesson is that some rationales depend on highly idealized assumptions and might provide less clarity about the design of benefit packages than might be hoped. For example, the arguments from prudential insurance—despite their different ethical presuppositions—give less guidance to institutional design and design of a benefit package than might have been hoped since they presuppose extrapolating from consumer behavior in a truly competitive and ideally informed insurance market. Similarly, both lines of argument make it impossible to be specific about what prudent insurance would include because we do not know what level of purchasing is possible at either the “equal resources” or “decent economic minimum” that the two views posit. In contrast, the deliberative fair process that supplements the fair equality of opportunity account does not require such a hypothetical context to yield results.

A third lesson is that avoiding a unifying theoretical account of universal access to care may cost more than it gains. Specifically, eschewing appeal to a background theory that justifies health care because it contributes to something else of importance to social justice (fair equality of opportunity, treating people as equals), and appealing instead to a pluralism of considerations, risks losing clarity about what care is part of the “decent minimum” it purports to provide legal entitlements to.

In the next two sections, we shall focus in more detail on what the fair equality of opportunity account says we owe each other and its implications for a right to health care. We adopt this focus because in contrast to the other views surveyed, it is more explicit about the content of the health care we owe to each other. We shall note the implications of other views where feasible.

On the fair equality of opportunity view, meeting the health needs of all persons, viewed as free and equal citizens, is of comparable and special moral importance. (If “citizens” is taken broadly to include all members of a community, then arguably long-term unauthorized immigrants should be included (Daniels and Ladin forthcoming). Specifically, since meeting health needs protects the range of opportunities people can exercise, then any social obligations we have to protect opportunity imply obligations to protect and promote health (normal functioning) for all people. Various recent theories of justice, despite their differences, affirm that we have such social obligations to protect opportunity, and so they converge on the importance of protecting health.

On the opportunity-based view, justice requires that we protect people’s shares of the normal opportunity range by treating illness when it occurs, by reducing the risk of disease and disability before they occur, and by distributing those risks equitably. Within the medical system, this means we must give all people access to a reasonable array of services that promote and restore normal functioning and we must not neglect preventive measures in favor of curative ones. It means we must look beyond the medical system to traditional public health measures that profoundly affect risk levels and their distribution. We must also look beyond the health sector to the broader social determinants of health and their distribution. Since we cannot meet all the health needs that arise inside or outside the health sector, we must be accountable for the reasonableness of the resource allocation decisions we make.

The alternative views noted in the previous section arguably have narrower scope, though some may be more expandable than others. Dworkin’s prudential insurance approach might have the same scope as the opportunity-based view if the insurance policy that (most?) prudent buyers purchase includes protections against health risks that go beyond treatments for illness. Dworkin is not explicit about how that broader policy might be designed. What can be purchased in any case is constrained by the level of resources available in the equality of resources approach, and Dworkin is sensitive to the fact that some purchasers may disagree about what prudence requires. Gibbard’s prudent insurance buyers presumably work with a smaller premium unless a decent economic minimum is equal to what we get on the equal resources view. Gibbard is more explicitly talking only about insurance for medical services, and it might be harder to expand his account to one that meets health needs more broadly. Buchanan’s decent minimum quite deliberately meets fewer health needs than the opportunity-based view.

Consider more specifically what the opportunity-based account of justice and health care requires by way of preventive services. It requires (1) reducing the risk of disease and (2) seeking an equitable distribution of those risks. The first requirement is obvious. It is often more effective to prevent disease and disability than it is to cure them when they occur (or to compensate individuals for loss of function, where cure is not possible). Cost-effectiveness arguments will have some bearing on claims about the appropriate distribution of acute vs. preventive measures (Russell 1986). Since it is better in general to avoid the burdens of disease than to reduce them once they occur, many types of preventive measures will be given prominence in a system governed by the opportunity-based account.

The second requirement should also seem obvious, especially in light of what we know about the importance of the social determinants of health. Consider the point from the perspective of occupational health. Suppose a health-care system is heavily weighted toward acute care and that it provides equal access to its services. Thus anyone with severe respiratory ailments—black lung, brown lung, asbestosis, emphysema, and so on—is given adequate comprehensive medical services as needed, but little is done to reduce exposures to risk in the workplace. Does the system meet the demands of justice?

Such a system is incomplete and unjust, according to the fair equality of opportunity view. If some groups in the population are differentially at risk of getting ill, it is not sufficient merely to attend to their illnesses. Where risk of illness differs systematically in ways that are avoidable, guaranteeing equal opportunity requires that we try to eliminate the differential risks and to prevent the excess illness experienced by those at avoidable, greater risk (of course subject to resource limits and fair process in setting limits). Otherwise the burdens and risks of illness will fall differently on different groups, and the risk of impaired opportunity for those groups will remain, despite the efforts to provide acute care. Care is not equivalent to prevention. Some disease will not be detected in time for it to be cured. Some is not curable, even if it is preventable, and treatments will vary in efficacy. We protect equal opportunity best by reducing and equalizing the risk of these conditions arising. The fact that we get an equal chance of being cured once ill because of equitable access to care does not compensate us for our unequal chances of becoming ill.

For these reasons, the fair equality of opportunity account places special importance on measures aimed at the equitable distribution of the risks of disease. Reduction in carbon emissions aimed at keeping the global temperature increases within a reasonable limit could reduce the chances of climate change increasing the risk of disease for all; even if the risk of disease to individuals is unequal from climate change, health inequities makes reducing carbon emissions like other public health measures. For example, some public-health measures, such as water and waste treatment, have the general effect of reducing risk. But historically, they have also had the effect of equalizing risk between socioeconomic classes and between groups living in different geographical areas. Similarly, many other environmental measures, such as recent clean air laws and pesticide regulations, have both general effects on risk reduction and specific effects on the distribution of risks. For example, pollutants emitted from smokestacks have a different effect on people who live downwind from those who live upwind. Gasoline lead emissions have greater effect on urban than rural populations. But other health-protection measures primarily have an effect on the distribution of risks: the regulation of workplace health hazards is perhaps the clearest example. Only some groups of workers are at risk from workplace hazards, though many workers face some risk or other, especially in manufacturing settings. Just health requires that stringent regulation in all of these ways must be part of the health-care system.

What other sorts of social policies should governments pursue in order to reduce inequalities in health risks, especially in light of what we now know about the social determinants of health? The menu of options should include policies aimed at equalizing individual life opportunities, such as investment in basic education and other early childhood interventions, affordable housing, income security, and other forms of antipoverty policy. We know, for example, that early interventions aimed at child development, like the Perry High/Scope Project (Schweinhardt et al. 1993), have lasting effects on educational achievement, employment, marriage, and the reduction of mental illness. The War on Poverty Program Head Start produced lasting effects on educational achievement; educational achievement, in turn, has a direct influence on health behavior in adulthood, including diet, smoking, and physical activity (Acheson et al. 1998). Other policies that might reduce differential risk could explore changes in the degree of control and authority workers have in the workplace (Marmot et al. 1997). Even broader interventions, including addressing inequalities in the distribution of wealth, power, and resources, are recommended by the WHO Commission on the Social Determinants of Health (2010). Though the connection between these broad, intersectoral social policies and health may seem somewhat remote, and they are rarely linked to issues of health in our public policy discussions, growing evidence suggests that they should be so linked.

One central implication of this view about health for all is that there should be universal access, based on health needs, to whatever array of public health and personal medical services provides support for fair equality of opportunity under reasonable resource constraints. This implication must be unpacked since health needs are met in various ways, through public health as well as personal medical services.

Public health services promote the conditions that reduce certain risks of disease or disability. They reduce risks by assuring a clean and safe living and working environment and by providing protection against infectious diseases. These services should attend to the risks faced by the entire population and aim to reduce risks in an equitable fashion.

However much we can reduce risks to population health and do so in an equitable fashion, some people will still become ill or disabled and require personal medical services or other forms of social support that compensate for the effects of loss of function. Even if the proper arrangement of the social determinants of health and adequate attention to public health greatly reduce the burden of disease and disability in a society, most people will still need medical care at various points in their lives, especially as they age. To protect the range of opportunities for those whose loss of normal functioning we cannot prevent, we will have to devote some significant resources to such medical and social support services. Obviously, careful deliberation in a fair process will be needed to determine the proper allocation of resources to prevention vs. cure and social support.

Personal medical services that are deemed essential to promoting fair opportunity for all must be accessible to all. Specifically, this will generally mean “universal coverage” through some form of public or private insurance for services deemed to be a “decent” or “adequate” array, as required by the appeal to the underlying concept of protecting fair equality of opportunity. There should be no obstacles—financial, racial, geographical, and so on—to access to the basic tier of the system. Determining what is in that basic tier must be clarified in light of arguments about how to protect fair equality of opportunity under reasonable resource constraints, and these arguments require a fair process (accountability for reasonableness) in which appropriate democratic deliberation can take place. The theory rules out arbitrary exclusions of whole categories of kinds of services that meet needs of the sort that should be met in the basic tier. Historically, for example, preventive services, mental health care, rehabilitative, and long-term care services have been excluded from both public and private insurance schemes, for various cultural and economic reasons. Most of these “categorical” exclusions are unjustifiable from the perspective of protecting normal functioning, but specific limit-setting choices can only be made through a fair, deliberative process.

Just what forms of organization—public or private administration and financing—are implied is not a question to which the opportunity-based account of justice and health provides a unique answer. There is probably an array of “just-enough” institutional structures that can provide the needed protection of opportunity. Similarly, just what kinds of “tiering” or inequalities in services above the basic tier are compatible with protecting opportunity for all may not get specific answers from the general theory, though it will clearly supply constraints. Reasonable disagreements about these questions should be addressed in a fair deliberative process.

If health care were the only or most important determinant of population health, then an opportunity-based account of justice and health would be right to focus solely on a right to health care and to ignore the more contentious and possibly misleading right claim to health. A right to health care would then be a special case of a right to fair equality of opportunity. Such a right to health care is properly understood as system-relative. The entitlements it involves are contingent claims to an array of health care services that protect fair shares of the opportunity range under reasonable resource constraints.

This simple picture of a right to health care must be modified in two ways to accommodate points already made in our discussion. First, since the category of socially controllable factors determining population health and its distribution is clearly broader than health care alone (even if we include traditional public health measures within the domain of health care), the point of claiming a right to health cannot simply be to claim that others owe us certain kinds of health care. Does this give us more reason to talk about a right to health? Second, whatever sense we can make out of a right to health (or health care), the specific entitlements it involves cannot be determined except through a fair deliberative process. Consider these modifications in turn.

If health needs are broader than needs for health care, should we try to make sense of a right to health? We face an immediate and serious objection. The expression “right to health” appears to embody confusion about the kind of thing that can be the object of a right claim. Health is an inappropriate object, whereas health care is. If our poor health is not the result of anyone’s doing, or failing to do, something for us or to us that might have prevented, or might cure, our condition, then it is hard to see how any right of ours is violated.

People who claim a right to health may mean something less troubling. They should be understood to be claiming that certain individuals or groups or society as a whole are obliged to perform various actions, such as designing certain institutions and distributing important goods in certain ways that promote or maintain or restore their health, and they are obliged to refrain from actions that interfere with it. The reference to health should be construed as a handy way to characterize functionally the relevant, socially-controllable actions, namely those that affect population health and its distribution. This gloss on the meaning of a right to health broadens the range of actions from the provision of health care to the meeting of the broader set of health needs that arises when we grasp the broader determinants of health. This gloss allows us to see why some advocates, for example of a human right to health, have insisted on a “right to health ” and not just on a “right to (certain) health care services.” They want, and reasonably so, the right to imply that there are obligations to perform a broad range of actions that affect health, even if these actions are not normally construed as health care services and even if they involve factors outside the health sector, however broadly construed. The gloss makes it clear, however, that a right to health, so understood, is not violated when there has been a just distribution of the socially controllable factors affecting health, yet health fails anyway. Consequently, we do not have to denounce as confused those who claim a right to have the full range of their health needs met.

Just what entitlements follow from a right to have a broad set of health needs met is system relative and depends on resource allocation decisions that are made in a fair deliberative process. To see the point, consider an objection sometimes made to the narrower claim to a right to health care, namely Fried’s (1978) objection that an individual right to health care invites falling into a “bottomless pit.” Fried is worried that if we posit a fundamental individual right to have needs satisfied, no other social goals will be able to override the right claims to all health-care needs.

No such fundamental right to have specific needs met is directly posited on the view sketched here. Rather, the particular rights and entitlements of individuals to have certain needs met are specified only as a result of a fair deliberative process aimed at meeting population health needs fairly. Typically, not all health needs can be met under reasonable resource constraints. Deciding which needs should actually be met and what resources are to be devoted to doing so—both within and outside the health sector—requires careful moral judgment and a wealth of empirical knowledge about the effects of alternative allocations. The right to health can yield entitlements only to those needs that it is reasonable to try to meet.

This restriction on how we specify the content of the right to health means, for example, that we cannot directly infer from (a) the moral fact that Jack has a right to health care and (b) the empirical fact that an experimental pancreas transplant offers him his only chance at survival that (c) Jack is entitled to that intervention. Jack’s medical entitlements—given his right—depend both on his condition and on the array of interventions it is reasonable to provide the population of which he is a member. That reasonable array in turn depends on what we know is effective, what resources we have, and what priority should be given to meeting his need compared to that of others. If pancreas transplants are of unproven efficacy, or if their cost or cost-effectiveness makes including them in a benefit package unreasonable, given what else it would be better to include, then coverage for such transplants may be denied for Jack and others. Although a moral right to health is grounded in the general idea that we have obligations to protect opportunity by promoting normal functioning, its specific content is in this fundamental way system-relative.

We noted earlier some dimensions of the limit setting that must go on. The various institutions that affect opportunity must be weighed against each other. Similarly, the resources required to provide for fair equality of opportunity must be weighed against what is needed to provide for other important social institutions. This is true even though guaranteeing fair equality of opportunity has (lexical or strict) priority over principles of justice promoting wellbeing in other ways, at least within Rawls’s theory of justice as fairness. The point is that institutions, including health care institutions, capable of protecting opportunity can be maintained only in societies whose productive capacities they do not undermine. The bugaboo of the bottomless pit is less threatening in the context of such a theory. The price paid is that we are less clear, in general and abstracting from the application of the theory to a particular society, just what the individual claim comes to.

The right to health must be system relative for another reason that is implied by a deeper feature of the opportunity-based account. What is special about meeting health needs, for purposes of justice, is that it contributes to protecting individuals’ fair shares of the normal opportunity range for their society. That range, to emphasize the point, is society relative. This relativity, however, then also infects claims about what we are entitled to when a health system is designed for a specific society. The relativization of the normal range to a society captures an important requirement for a theory of just health care. It is not a feature we should lightly abandon. The importance of meeting specific health needs will vary depending on facts about a society, and a distributive principle must leave room for such variation. Curing dyslexia might well be more important in some societies than others, though it is an instance of pathology in all of them. (Suppose a disease is widespread, even universal, in a society. Say it is a form of anemia that affects all and is debilitating across the board. One might think that impact on the normal opportunity range will not tell us how important it is to treat this disease, since it hurts all individuals equally. But the opportunity account still helps us here, for it is not only a principle governing competitive advantage. The anemia in this case is a disease which keeps each individual from adequately carrying out any life plan that otherwise would be reasonable in his society. Remember, the reference point is normal species-functioning, not simply functioning in a certain society.)

Consider the claim that it is a matter for the courts to decide what should be included in a right to health or health care. In some countries, such a right is embodied in the constitution of the country. In Colombia, for example, the public has been encouraged to file law suits, called tutelas, some of which are aimed at compelling insurance schemes to cover services that should be covered (by law) in the benefit package and some of which aim to expand coverage for the plaintiff to include a service not part of the defined benefit package. Further, all signatories to international treaties that recognize a human right to health are legally bound to recognize that right, and arguably, their courts should play a role in doing so. We might distinguish two roles of the courts. One uncontroversial role would be to insist that the delegated authorities (the ministry of health) specify the criteria and the process used to define the benefit package, and then exercise judicial review of whether specific decisions are made through that process that use those criteria. A more controversial role would be for the courts to try to determine more directly what should be included in a right to health. To perform the latter task, the courts would need to know many things about the capability of the health system to sustainably deliver a particular service in light of competing claims on services, that is on resources. If the courts are not in a position to play that role, then they should restrict their task to making sure that the ministry of health performs that task according to an acceptable process.

We shall conclude by considering how equal must our rights to health or health care be? Specifically, must everyone receive exactly the same kinds of health-care services and coverage, or is fairness in health care compatible with a ‘tiered’ system? Around the world, even countries that offer universal health insurance differ in their answers to this question. In Canada, for example, no supplementary insurance is permitted. Everyone is served solely by the national health-insurance schemes, though people who seek additional services or more rapid service may go elsewhere, as some Canadians do by crossing the border. In Britain, supplementary private insurance allows about 10 per cent of the population to gain quicker access to services for which there is extensive queuing in the public system. Basing a right to health care on an obligation to protect equality of opportunity is compatible with the sort of tiering the British have, but it does not require it, and it imposes some constraints on the kind of tiering allowed.

The primary social obligation is to assure everyone access to a tier of services that effectively promotes normal functioning and thus protects equality of opportunity. Since health care is not the only important good, resources to be invested in the basic tier are appropriately and reasonably limited, for example, by democratic decisions about how much to invest in education or job training as opposed to health care. Because of their very high “opportunity costs,” there will be some beneficial medical services that it will be reasonable not to provide in the basic tier, or to provide only on a limited basis, for example, with queuing. To say that these services have “high opportunity costs” means that providing them consumes resources that would produce greater health benefits and protect opportunity more if used in other ways.

In a society that permits significant income and wealth inequalities, some people will want to buy coverage for these additional services. Why not let them? After all, we allow people to use their after-tax income and wealth as they see fit to pursue the quality of life and opportunities they prefer. The rich can buy special security systems for their homes. They can buy safer cars. They can buy private schooling for their children. Why not allow them to buy supplementary health care for their families?

One objection to allowing a supplementary tier is that its existence might undermine the basic tier either economically or politically. It might attract better-quality providers away from the basic tier, or raise costs in the basic tier, reducing the ability of society to meet its social obligations. The supplementary tier might undermine political support for the basic tier, for example, by undercutting the social solidarity needed if people are to remain committed to protecting opportunity for all. These objections are serious, and where a supplementary tier undermines the basic tier in either way, economically or politically, priority must be given to protecting the basic tier. In principle, however, it seems possible to design a system in which the supplementary tier does not undermine the basic one. If that can be done, then a system that permits tiering avoids restricting liberty in ways that some find seriously objectionable.

A second objection is not to tiering itself but to the structure of inequality that results. Compare two scenarios. In one, most people are adequately served by the basic tier and only the best-off groups in society have the means and see the need to purchase supplementary insurance. That is the case in Great Britain. In the other, the basic tier serves only the poorest groups in society and most other people buy supplementary insurance. The Oregon plan to expand Medicaid eligibility partly through rationing the services it covers has aspects of this structure of inequality, since most people are covered by plans that avoid these restrictions (Daniels, 1991). The first scenario seems preferable to the second on grounds of fairness. In the second, the poorest groups can complain that they are left behind by others in society even in the protection of their health. In the first, the majority has fewer grounds for reasonable resentment or regret.

If the basic tier is not undermined by higher tiers, and if the structure of the inequality that results is not objectionable, then it is difficult to see why some tiering should not be allowed. There is a basic conflict here between concerns about equality and concerns about liberty, between wanting to make sure everyone is treated properly with regard to health care and wanting to give people the liberty to use their resources (after tax) to improve their lives as they see fit. In practice, the crucial constraint on the liberty we allow people seems to depend on the magnitude of the benefit available in the supplementary tier and unavailable in the basic tier. Highly visible forms of saving lives and improving function would be difficult to exclude from the basic tier while we make them available in a supplementary tier. In principle, however, some forms of tiering will not be unfair even when they involve medical benefits not available to everyone.

• Acheson, D., 1998, Report of the Independent Inquiry into Inequalities in Health , London: The Stationery Office.
• Aday, L. A., 1975, “Economic and non-economic barriers to the use of needed medical Services”, Medical Care , 13(6): 447–56.
• –––, 2001, At Risk in America: The Health and Health Care Needs of Vulnerable Populations in the United States , San Francisco, CA: Jossey-Bass Publishers, 2 nd edition.
• Aday, L.A., and Anderson, R., 1974, “A framework for the study of access to medical care”, Health Service Research , 9: 208–20.
• –––, 1975, Development of Indices of Access to Medical Care , Ann Arbor, MI: Health Administration Press.
• Aday, L. A., Anderson, R., and Fleming, G. V., 1980, Health Care in the U.S.: Equitable for Whom? , Beverly Hills, CA: Sage.
• Aday, L. A., Begley, C. E., Lairson, D. R., and Balkrishnan, R., 2004, Evaluating the Healthcare System: Effectiveness, Efficiency, and Equity , Chicago, IL: Health Administration Press, 3 rd edition.
• Arneson, R., 1988, “Equality and equal opportunity for welfare”, Philosophical Studies , 93: 77–112.
• Arrow. K., 1963, “Uncertainty and the welfare economics of medical care”, American Economic Review , 53: 941–73.
• –––, 1973, “Some ordinalist-utilitarian notes on Rawls’s theory of justice”, Journal of Philosophy , 70(9): 251.
• Brandt, R., 1979, Theory of the Good and the Right , New York: Oxford University Press.
• Buchanan, A., 1984, “The right to a decent minimum of health care”, Philosophy and Public Affairs , 13(1): 55–78.
• Bump, P., 2017, “Millions might lose health coverage? Not to hear Republican leaders tell it,” Washington Post , March 12, 2017, available online .
• CSDH, 2008, Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health , Geneva: World Health Organization. [ Available online ]
• Cohen, G. A., 1989, “On the currency of egalitarian justice”, Ethics , 99: 906–44.
• Daniels, N., 1981, “Health care needs and distributive justice”, Philosophy and Public Affairs , 10(2): 146–79.
• –––, 1985, Just Health Care , New York: Cambridge University Press.
• –––, 1991, “Is the Oregon rationing plan fair?”, Journal of the American Medical Association , 265(17): 2232–5.
• –––, 1993, “Rationing fairly: Programmatic considerations”, Bioethics , 79(2/3): 36–46.
• –––, 2008, Just Health: Meeting Health Needs Fairly , New York: Cambridge University Press.
• –––, 2009a, “Social and Individual Responsibility for Health”, in Distributive Justice and Responsibility , C. Knight and Z. Stemplowska (eds.), Oxford and New York: Oxford University Press.
• –––, 2010, “Capabilities, Opportunity, and Health”, in Measuring Justice: Primary Goods and Capabilities , I. Robeyns and H. Brighouse (eds.), Cambridge: Cambridge University Press, pp. 131–149.
• Daniels, N. and Ladin, K., forthcoming, Immigration and Access to Health Care, in Routledge Companion to Bioethics , K. Arras, R. Kukla, and E. Fenton (eds.), New York: Routledge.
• Daniels, N. and Sabin, J. E., 1997, “Limits to health care: Fair procedures, democratic deliberation, and the legitimacy problem for insurers”, Philosophy and Public Affairs , 26: 303–50.
• –––, 2008, Setting Limits Fairly: Learning to Share Resource for Health , New York: Oxford University Press.
• Dworkin, R., 1981, “What is Equality? Part 2: Equality of resources”, Philosophy and Public Affairs , 10: 185–246.
• –––, 1994, “Will Clinton’s Plan Be Fair?”, New York Times Review of Books , 41(1–2).
• –––, 2000, Sovereign Virtue: The Theory and Practice of Equality , Cambridge, MA: Harvard University Press.
• Emergency Medical Treatment and Active Labor Act (EMTALA), 1986, Stat. 42 USC 1395dd. [ Available online ].
• Fadiman, A., 1997, The Spirit Catches You and You Fall Down: a Hmong child, her American doctors, and the collision of two cultures , New York: Farrar, Straus, and Giroux.
• Fried, D., 1976, “Equality and rights in medical care”, Hastings Center Report , 6: 29–34.
• –––, 1978, Right and Wrong , Cambridge, MA: Harvard University Press.
• Gibbard, A., 1982, “The prospective pareto principle and its application to questions of equity of access to health care: a philosophical examination”, Milbank Memorial Fund Quarterly/Health and Society , 60: 3.
• Institute of Medicine (IOM), 2002, Care Without Coverage: Too Little, Too Late , Washington, DC: National Academies Press.
• Institute of Medicine (IOM), 2002, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care , Washington, DC: National Academies Press.
• Johnson, T. D., 2007, ‘Census Bureau: Number of U.S. Uninsured Rises to 47 Million Americans are Uninsured: Almost 5 Percent Increase Since 2005’, Nation’s Health , 37(8): 1–10.
• Jost, T., 2017, Health Affairs Blog, Health Affairs , January 20, 2017, available online .
• Marmot, M., 2004, The Status Syndrome: How Social Standing Affects Our Health and Longevity , New York: Henry Hold, Times Books.
• Marmot, M. G., Hemingway, B.H., Brunner, E., and Stansfield, S., 1997, “Contribution of job control and other risk factors to social variations in coronary heart disease incidence”, The Lancet , 350: 235–9.
• Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. No. 108–173, 117 Stat 2066 (2003). [Available online]
• U.S. Supreme Court, 2012, National Federation of Independent Business et al. v. Sebelius, Secretary of Health and Human Services, et al. , 567 U.S. 519 (2012), 132 S.Ct. 2566, 183 L. Ed. 2d 450, available online .
• Newhouse, J. P., 2004, “Consumer-Directed Health Plans and the RAND Health Insurance Experiment”, Health Affairs 23: 107–113.
• Ottersen, T., Norheim, O.F., et al., 2014, Making fair choices on the path to universal health coverage , Geneva: World Health Organization, available online .
• Rawls, J., 1971, A Theory of Justice , Cambridge, MA: Harvard University Press.
• –––, 1995, Political Liberalism , New York: Columbia University Press.
• –––, 2001, Justice as Fairness: A Restatement , E. Kelly (ed.), Cambridge, MA: Harvard University Press.
• Russell, L., 1986, Is Prevention Better Than Cure? , Washington, DC: Brookings Institution.
• Schweinhardt, L. J., Barnes, H.V., and Weikart, D. P., 1993, Significant Benefits: High/Scope Project Perry Preschool Study Through Age 27 , Ypsilanti, MI: High/Scope Press.
• Segall, S., 2010, Health Luck and Justice , Princeton, N.J.: Princeton University Press.
• Selden, T.M., and Sing, M., 2008, “The Distribution of Public Spending for Health Care in the United States, 2002”, Health Affairs , 27: w349–w359.
• Sen, A. K., 1980, “Equality of what?”, in The Tanner Lectures on Human Values , S. McMurrin (ed.), Salt Lake City: University of Utah Press, pp. 197–220.
• –––, 1992, Inequality Reexamined , Cambridge: MA: Harvard University Press.
• Sloan, F. and Bentkover, J. D., 1979, Access to Ambulatory Care and the US Economy , Lexington, MA: Lexington Books.
• Sreenivasan, G., 2007, “Health care and equality of opportunity”, Hastings Center Report , 37(2): 21–31.
• Williams, B., 1971, “The idea of equality [1962]”, in Justice and Equality , H. A. Bedau (ed.), Englewood Cliffs, NJ: Prentice-Hall, pp. 116–37
• World Health Organization (WHO), 1948, “WHO definition of Health” in Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. [ Available online ]
• –––, 2010, Health Systems Financing: The Path to Universal Coverage , Geneva: World Health Organization. [ Available online ]

How to cite this entry . Preview the PDF version of this entry at the Friends of the SEP Society . Look up topics and thinkers related to this entry at the Internet Philosophy Ontology Project (InPhO). Enhanced bibliography for this entry at PhilPapers , with links to its database.

• The Henry J. Kaiser Family Foundation , health policy, media resources, public health education, etc.
• The Commonwealth Fund , health policy, health reform, and performance improvement.
• National Center for Health Statistics , Department of Health and Human Services/Center for Disease Control.
• Families USA: The Voice for Health Care Consumers .

beneficence, principle of | egalitarianism | equality | equality: of opportunity | ethics, biomedical: justice, inequality, and health | -->ethics, biomedical: justice and allocation of scarce resources --> | health | justice | justice: distributive | social minimum [basic income]

Copyright © 2017 by Norman Daniels

• Accessibility

Support SEP

Mirror sites.

View this site from another server:

• Info about mirror sites

The Stanford Encyclopedia of Philosophy is copyright © 2023 by The Metaphysics Research Lab , Department of Philosophy, Stanford University

Library of Congress Catalog Data: ISSN 1095-5054

Social Justice in Healthcare

Three personal values vital to you and why you value them.

Three personal values vital to me are courage, adaptability, and self-respect. Courage is essential as it helps me take risks to tackle different situations and make principled decisions. Adaptability enables me to embrace new experiences, be flexible to diverse aspects of life, and adjust to different circumstances. Self-respect is crucial as it enables me to engage in healthy relationships, keeping in mind my values and standards even in the face of external pressures.

I value courage, adaptability, and self-respect over other values because they help me navigate effectively in personal and professional environments. They also help me navigate challenges and embrace growth from diverse perspectives. Additionally, the values enlighten me in fostering connections with others and maintaining healthy relationships. Moreover, I value them more since they encourage me to embrace change, learn from experience, and live within my boundaries.

Greatest social justice need in the community you live in

The greatest social justice need in the Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) community is equality. The LGBTQ needs equal employment opportunities with inclusivity and addressing issues of harassment. They also need equal access to social services such as healthcare services and public accommodation. Additionally, they need equal legal protection and access to equal rights like other citizens.

I know that equality among the LGBTQ is essential because, in most instances, they are denied access to social services and employment opportunities due to the identification of their gender. Equality is important because it assures fairness and justice to all people despite their gender identity. It also supports crucial physical and mental health aspects due to equal access to health care services. Moreover, it addresses the issues of discrimination and fosters a discrimination-free environment.

A critical social justice need related to your future career

Diversity and inclusion are a critical social justice need for my future nursing career. Diversity and inclusion in the profession involve working with staff from diverse backgrounds regardless of gender or background differences. Also, it includes serving patients equally and maintaining effective communication to meet patients’ needs. Diversity and inclusion allow the decision-making process to involve all the staff in developing the best strategies to improve work services.

Social justice issues might impact nursing by establishing trust and effective communication to meet patients’ needs. Also, it might address factors influencing health and wellness, creating effective care plans. Issues such as inclusivity create a collaborative work environment and improve teamwork. Inclusive decision-making contributes to a more inclusive organizational and professional culture.

Non-profit sites that relate to equality among the LGBTQ community

Stonewall Columbus is a non-profit site that fights for the equality of the LGBTQ community in central Ohio and across states. It serves a population of about 45,000 people to resource every year. The mission of Stonewall Columbus is to ensure the inclusion of the LGBTTQ community in political and social aspects. It serves the community through programs and listing local products and services from LGBTQ platforms.

TransOhio organization also fights for the equality of the LGBTQ community in Ohio. It serves up to 1.4 million people, especially young people. The mission of the TransOhio organization is to ensure equality in health, education, and support services among the transgender and ally communities. It serves the community through social networking to build friendships and youth and support programs to discuss challenges and support young individuals navigating gender identity.

How nursing code of ethics intersect with nursing ethical standards

The nursing code of ethics intersects with ethical standards as it outlines the nursing profession’s values and principles. It offers guidance on how to handle different situations within the profession. It further elaborates on the principles that need to be applied in different contexts. It also guides nurses on decision-making procedures requiring patients’ consent before carrying out activities such as medication options.

The nursing code also highlights professional values like transparency, confidentiality, and integrity. It encourages collaboration and inclusion with patients and other staff members to ensure the delivery of quality services. It encourages nurses to be competent in their work and include diversity in the work areas despite cultural, background, race, or ethical differences. The nursing code of ethics encourages accountability of actions, as mistakes due to carelessness have consequences.

Daum, C. W. (2020). Social equity, homonormativity, and equality: An intersectional critique of the administration of marriage equality and opportunities for LGBTQ social justice.  Administrative Theory & Praxis ,  42 (2), 115-132.https://www.tandfonline.com/doi/abs/10.1080/10841806.2019.1659044

Santisi, G., Lodi, E., Magnano, P., Zarbo, R., & Zammitti, A. (2020). Relationship between psychological capital and quality of life: The role of courage.  Sustainability ,  12 (13), 5238. https://www.mdpi.com/2071-1050/12/13/5238

Stanford, F. C. (2020). The importance of diversity and inclusion in the healthcare workforce.  Journal of the National Medical Association ,  112 (3), 247-249. https://doi.org/10.1016/j.jnma.2020.03.014

Stonewall Columbus. (2021). Stonewall Columbus is [Review of  Stonewall Columbus is ]. In  YouTube . https://stonewallcolumbus.org/

TransOhio. Ohio’s only statewide Trans-led organization. https://www.transohio.org/

Cite This Work

To export a reference to this article please select a referencing style below:

Related Essays

In what ways are the theories of freud and nietzsche similar, applying the impact model, ways used by trade unions to fight against gender, ethnic, or age discrimination in the workplace, interview with a school leader and smart goal, effects of depression on mental health, annotated bibliography on school shootings in the united states, popular essay topics.

• American Dream
• Artificial Intelligence
• Black Lives Matter
• Bullying Essay
• Career Goals Essay
• Causes of the Civil War
• Child Abusing
• Civil Rights Movement
• Community Service
• Cultural Identity
• Cyber Bullying
• Death Penalty
• Depression Essay
• Domestic Violence
• Freedom of Speech
• Global Warming
• Gun Control
• Human Trafficking
• I Believe Essay
• Immigration
• Importance of Education
• Israel and Palestine Conflict
• Leadership Essay
• Legalizing Marijuanas
• Mental Health
• National Honor Society
• Police Brutality
• Pollution Essay
• Racism Essay
• Romeo and Juliet
• Same Sex Marriages
• Social Media
• The Great Gatsby
• The Yellow Wallpaper
• Time Management
• To Kill a Mockingbird
• Violent Video Games
• What Makes You Unique
• Why I Want to Be a Nurse
• Send us an e-mail

• Search Menu

Sign in through your institution

• Browse content in Arts and Humanities
• Browse content in Archaeology
• Anglo-Saxon and Medieval Archaeology
• Archaeological Methodology and Techniques
• Archaeology by Region
• Archaeology of Religion
• Archaeology of Trade and Exchange
• Biblical Archaeology
• Contemporary and Public Archaeology
• Environmental Archaeology
• Historical Archaeology
• History and Theory of Archaeology
• Industrial Archaeology
• Landscape Archaeology
• Mortuary Archaeology
• Prehistoric Archaeology
• Underwater Archaeology
• Zooarchaeology
• Browse content in Architecture
• Architectural Structure and Design
• History of Architecture
• Residential and Domestic Buildings
• Theory of Architecture
• Browse content in Art
• Art Subjects and Themes
• History of Art
• Industrial and Commercial Art
• Theory of Art
• Biographical Studies
• Byzantine Studies
• Browse content in Classical Studies
• Classical Literature
• Classical Reception
• Classical History
• Classical Philosophy
• Classical Mythology
• Classical Art and Architecture
• Classical Oratory and Rhetoric
• Greek and Roman Archaeology
• Greek and Roman Epigraphy
• Greek and Roman Law
• Greek and Roman Papyrology
• Late Antiquity
• Religion in the Ancient World
• Digital Humanities
• Browse content in History
• Colonialism and Imperialism
• Diplomatic History
• Environmental History
• Genealogy, Heraldry, Names, and Honours
• Genocide and Ethnic Cleansing
• Historical Geography
• History by Period
• History of Agriculture
• History of Education
• History of Emotions
• History of Gender and Sexuality
• Industrial History
• Intellectual History
• International History
• Labour History
• Legal and Constitutional History
• Local and Family History
• Maritime History
• Military History
• National Liberation and Post-Colonialism
• Oral History
• Political History
• Public History
• Regional and National History
• Revolutions and Rebellions
• Slavery and Abolition of Slavery
• Social and Cultural History
• Theory, Methods, and Historiography
• Urban History
• World History
• Browse content in Language Teaching and Learning
• Language Learning (Specific Skills)
• Language Teaching Theory and Methods
• Browse content in Linguistics
• Applied Linguistics
• Cognitive Linguistics
• Computational Linguistics
• Forensic Linguistics
• Grammar, Syntax and Morphology
• Historical and Diachronic Linguistics
• History of English
• Language Variation
• Language Families
• Language Acquisition
• Language Evolution
• Language Reference
• Lexicography
• Linguistic Theories
• Linguistic Typology
• Linguistic Anthropology
• Phonetics and Phonology
• Psycholinguistics
• Sociolinguistics
• Translation and Interpretation
• Writing Systems
• Browse content in Literature
• Bibliography
• Children's Literature Studies
• Literary Studies (Modernism)
• Literary Studies (Asian)
• Literary Studies (European)
• Literary Studies (Eco-criticism)
• Literary Studies (Romanticism)
• Literary Studies (American)
• Literary Studies - World
• Literary Studies (1500 to 1800)
• Literary Studies (19th Century)
• Literary Studies (20th Century onwards)
• Literary Studies (African American Literature)
• Literary Studies (British and Irish)
• Literary Studies (Early and Medieval)
• Literary Studies (Fiction, Novelists, and Prose Writers)
• Literary Studies (Gender Studies)
• Literary Studies (Graphic Novels)
• Literary Studies (History of the Book)
• Literary Studies (Plays and Playwrights)
• Literary Studies (Poetry and Poets)
• Literary Studies (Postcolonial Literature)
• Literary Studies (Queer Studies)
• Literary Studies (Science Fiction)
• Literary Studies (Travel Literature)
• Literary Studies (War Literature)
• Literary Studies (Women's Writing)
• Literary Theory and Cultural Studies
• Mythology and Folklore
• Shakespeare Studies and Criticism
• Browse content in Media Studies
• Browse content in Music
• Applied Music
• Dance and Music
• Ethics in Music
• Ethnomusicology
• Gender and Sexuality in Music
• Medicine and Music
• Music Cultures
• Music and Culture
• Music and Religion
• Music and Media
• Music Education and Pedagogy
• Music Theory and Analysis
• Musical Scores, Lyrics, and Libretti
• Musical Structures, Styles, and Techniques
• Musicology and Music History
• Performance Practice and Studies
• Race and Ethnicity in Music
• Sound Studies
• Browse content in Performing Arts
• Browse content in Philosophy
• Aesthetics and Philosophy of Art
• Epistemology
• Feminist Philosophy
• History of Western Philosophy
• Metaphysics
• Moral Philosophy
• Non-Western Philosophy
• Philosophy of Action
• Philosophy of Law
• Philosophy of Religion
• Philosophy of Science
• Philosophy of Language
• Philosophy of Mind
• Philosophy of Perception
• Philosophy of Mathematics and Logic
• Practical Ethics
• Social and Political Philosophy
• Browse content in Religion
• Biblical Studies
• Christianity
• East Asian Religions
• History of Religion
• Judaism and Jewish Studies
• Qumran Studies
• Religion and Education
• Religion and Health
• Religion and Politics
• Religion and Science
• Religion and Law
• Religion and Art, Literature, and Music
• Religious Studies
• Browse content in Society and Culture
• Cookery, Food, and Drink
• Cultural Studies
• Customs and Traditions
• Ethical Issues and Debates
• Hobbies, Games, Arts and Crafts
• Natural world, Country Life, and Pets
• Popular Beliefs and Controversial Knowledge
• Sports and Outdoor Recreation
• Technology and Society
• Travel and Holiday
• Visual Culture
• Browse content in Law
• Arbitration
• Browse content in Company and Commercial Law
• Commercial Law
• Company Law
• Browse content in Comparative Law
• Systems of Law
• Competition Law
• Browse content in Constitutional and Administrative Law
• Government Powers
• Judicial Review
• Local Government Law
• Military and Defence Law
• Parliamentary and Legislative Practice
• Construction Law
• Contract Law
• Browse content in Criminal Law
• Criminal Procedure
• Criminal Evidence Law
• Sentencing and Punishment
• Employment and Labour Law
• Environment and Energy Law
• Browse content in Financial Law
• Banking Law
• Insolvency Law
• History of Law
• Human Rights and Immigration
• Intellectual Property Law
• Browse content in International Law
• Private International Law and Conflict of Laws
• Public International Law
• IT and Communications Law
• Jurisprudence and Philosophy of Law
• Law and Society
• Law and Politics
• Browse content in Legal System and Practice
• Courts and Procedure
• Legal Skills and Practice
• Primary Sources of Law
• Regulation of Legal Profession
• Medical and Healthcare Law
• Browse content in Policing
• Criminal Investigation and Detection
• Police and Security Services
• Police Procedure and Law
• Police Regional Planning
• Browse content in Property Law
• Personal Property Law
• Study and Revision
• Terrorism and National Security Law
• Browse content in Trusts Law
• Wills and Probate or Succession
• Browse content in Medicine and Health
• Browse content in Allied Health Professions
• Arts Therapies
• Clinical Science
• Dietetics and Nutrition
• Occupational Therapy
• Operating Department Practice
• Physiotherapy
• Radiography
• Speech and Language Therapy
• Browse content in Anaesthetics
• General Anaesthesia
• Neuroanaesthesia
• Browse content in Clinical Medicine
• Acute Medicine
• Cardiovascular Medicine
• Clinical Genetics
• Clinical Pharmacology and Therapeutics
• Dermatology
• Endocrinology and Diabetes
• Gastroenterology
• Genito-urinary Medicine
• Geriatric Medicine
• Infectious Diseases
• Medical Oncology
• Medical Toxicology
• Pain Medicine
• Palliative Medicine
• Rehabilitation Medicine
• Respiratory Medicine and Pulmonology
• Rheumatology
• Sleep Medicine
• Sports and Exercise Medicine
• Clinical Neuroscience
• Community Medical Services
• Critical Care
• Emergency Medicine
• Forensic Medicine
• Haematology
• History of Medicine
• Medical Ethics
• Browse content in Medical Dentistry
• Oral and Maxillofacial Surgery
• Paediatric Dentistry
• Restorative Dentistry and Orthodontics
• Surgical Dentistry
• Browse content in Medical Skills
• Clinical Skills
• Communication Skills
• Nursing Skills
• Surgical Skills
• Medical Statistics and Methodology
• Browse content in Neurology
• Clinical Neurophysiology
• Neuropathology
• Nursing Studies
• Browse content in Obstetrics and Gynaecology
• Gynaecology
• Occupational Medicine
• Ophthalmology
• Otolaryngology (ENT)
• Browse content in Paediatrics
• Neonatology
• Browse content in Pathology
• Chemical Pathology
• Clinical Cytogenetics and Molecular Genetics
• Histopathology
• Medical Microbiology and Virology
• Patient Education and Information
• Browse content in Pharmacology
• Psychopharmacology
• Browse content in Popular Health
• Caring for Others
• Complementary and Alternative Medicine
• Self-help and Personal Development
• Browse content in Preclinical Medicine
• Cell Biology
• Molecular Biology and Genetics
• Reproduction, Growth and Development
• Primary Care
• Professional Development in Medicine
• Browse content in Psychiatry
• Addiction Medicine
• Child and Adolescent Psychiatry
• Forensic Psychiatry
• Learning Disabilities
• Old Age Psychiatry
• Psychotherapy
• Browse content in Public Health and Epidemiology
• Epidemiology
• Public Health
• Browse content in Radiology
• Clinical Radiology
• Interventional Radiology
• Nuclear Medicine
• Radiation Oncology
• Reproductive Medicine
• Browse content in Surgery
• Cardiothoracic Surgery
• Gastro-intestinal and Colorectal Surgery
• General Surgery
• Neurosurgery
• Paediatric Surgery
• Peri-operative Care
• Plastic and Reconstructive Surgery
• Surgical Oncology
• Transplant Surgery
• Trauma and Orthopaedic Surgery
• Vascular Surgery
• Browse content in Science and Mathematics
• Browse content in Biological Sciences
• Aquatic Biology
• Biochemistry
• Bioinformatics and Computational Biology
• Developmental Biology
• Ecology and Conservation
• Evolutionary Biology
• Genetics and Genomics
• Microbiology
• Molecular and Cell Biology
• Natural History
• Plant Sciences and Forestry
• Research Methods in Life Sciences
• Structural Biology
• Systems Biology
• Zoology and Animal Sciences
• Browse content in Chemistry
• Analytical Chemistry
• Computational Chemistry
• Crystallography
• Environmental Chemistry
• Industrial Chemistry
• Inorganic Chemistry
• Materials Chemistry
• Medicinal Chemistry
• Mineralogy and Gems
• Organic Chemistry
• Physical Chemistry
• Polymer Chemistry
• Study and Communication Skills in Chemistry
• Theoretical Chemistry
• Browse content in Computer Science
• Artificial Intelligence
• Computer Architecture and Logic Design
• Game Studies
• Human-Computer Interaction
• Mathematical Theory of Computation
• Programming Languages
• Software Engineering
• Systems Analysis and Design
• Virtual Reality
• Browse content in Computing
• Business Applications
• Computer Games
• Computer Security
• Computer Networking and Communications
• Digital Lifestyle
• Graphical and Digital Media Applications
• Operating Systems
• Browse content in Earth Sciences and Geography
• Atmospheric Sciences
• Environmental Geography
• Geology and the Lithosphere
• Maps and Map-making
• Meteorology and Climatology
• Oceanography and Hydrology
• Palaeontology
• Physical Geography and Topography
• Regional Geography
• Soil Science
• Urban Geography
• Browse content in Engineering and Technology
• Agriculture and Farming
• Biological Engineering
• Civil Engineering, Surveying, and Building
• Electronics and Communications Engineering
• Energy Technology
• Engineering (General)
• Environmental Science, Engineering, and Technology
• History of Engineering and Technology
• Mechanical Engineering and Materials
• Technology of Industrial Chemistry
• Transport Technology and Trades
• Browse content in Environmental Science
• Applied Ecology (Environmental Science)
• Conservation of the Environment (Environmental Science)
• Environmental Sustainability
• Environmentalist Thought and Ideology (Environmental Science)
• Management of Land and Natural Resources (Environmental Science)
• Natural Disasters (Environmental Science)
• Nuclear Issues (Environmental Science)
• Pollution and Threats to the Environment (Environmental Science)
• Social Impact of Environmental Issues (Environmental Science)
• History of Science and Technology
• Browse content in Materials Science
• Ceramics and Glasses
• Composite Materials
• Metals, Alloying, and Corrosion
• Nanotechnology
• Browse content in Mathematics
• Applied Mathematics
• Biomathematics and Statistics
• History of Mathematics
• Mathematical Education
• Mathematical Finance
• Mathematical Analysis
• Numerical and Computational Mathematics
• Probability and Statistics
• Pure Mathematics
• Browse content in Neuroscience
• Cognition and Behavioural Neuroscience
• Development of the Nervous System
• Disorders of the Nervous System
• History of Neuroscience
• Invertebrate Neurobiology
• Molecular and Cellular Systems
• Neuroendocrinology and Autonomic Nervous System
• Neuroscientific Techniques
• Sensory and Motor Systems
• Browse content in Physics
• Astronomy and Astrophysics
• Atomic, Molecular, and Optical Physics
• Biological and Medical Physics
• Classical Mechanics
• Computational Physics
• Condensed Matter Physics
• Electromagnetism, Optics, and Acoustics
• History of Physics
• Mathematical and Statistical Physics
• Measurement Science
• Nuclear Physics
• Particles and Fields
• Plasma Physics
• Quantum Physics
• Relativity and Gravitation
• Semiconductor and Mesoscopic Physics
• Browse content in Psychology
• Affective Sciences
• Clinical Psychology
• Cognitive Neuroscience
• Cognitive Psychology
• Criminal and Forensic Psychology
• Developmental Psychology
• Educational Psychology
• Evolutionary Psychology
• Health Psychology
• History and Systems in Psychology
• Music Psychology
• Neuropsychology
• Organizational Psychology
• Psychological Assessment and Testing
• Psychology of Human-Technology Interaction
• Psychology Professional Development and Training
• Research Methods in Psychology
• Social Psychology
• Browse content in Social Sciences
• Browse content in Anthropology
• Anthropology of Religion
• Human Evolution
• Medical Anthropology
• Physical Anthropology
• Regional Anthropology
• Social and Cultural Anthropology
• Theory and Practice of Anthropology
• Browse content in Business and Management
• Business History
• Business Strategy
• Business Ethics
• Business and Government
• Business and Technology
• Business and the Environment
• Comparative Management
• Corporate Governance
• Corporate Social Responsibility
• Entrepreneurship
• Health Management
• Human Resource Management
• Industrial and Employment Relations
• Industry Studies
• Information and Communication Technologies
• International Business
• Knowledge Management
• Management and Management Techniques
• Operations Management
• Organizational Theory and Behaviour
• Pensions and Pension Management
• Public and Nonprofit Management
• Strategic Management
• Supply Chain Management
• Browse content in Criminology and Criminal Justice
• Criminal Justice
• Criminology
• Forms of Crime
• International and Comparative Criminology
• Youth Violence and Juvenile Justice
• Development Studies
• Browse content in Economics
• Agricultural, Environmental, and Natural Resource Economics
• Asian Economics
• Behavioural Finance
• Behavioural Economics and Neuroeconomics
• Econometrics and Mathematical Economics
• Economic Methodology
• Economic Systems
• Economic History
• Economic Development and Growth
• Financial Markets
• Financial Institutions and Services
• General Economics and Teaching
• Health, Education, and Welfare
• History of Economic Thought
• International Economics
• Labour and Demographic Economics
• Law and Economics
• Macroeconomics and Monetary Economics
• Microeconomics
• Public Economics
• Urban, Rural, and Regional Economics
• Welfare Economics
• Browse content in Education
• Adult Education and Continuous Learning
• Care and Counselling of Students
• Early Childhood and Elementary Education
• Educational Equipment and Technology
• Educational Strategies and Policy
• Higher and Further Education
• Organization and Management of Education
• Philosophy and Theory of Education
• Schools Studies
• Secondary Education
• Teaching of a Specific Subject
• Teaching of Specific Groups and Special Educational Needs
• Teaching Skills and Techniques
• Browse content in Environment
• Applied Ecology (Social Science)
• Climate Change
• Conservation of the Environment (Social Science)
• Environmentalist Thought and Ideology (Social Science)
• Natural Disasters (Environment)
• Social Impact of Environmental Issues (Social Science)
• Browse content in Human Geography
• Cultural Geography
• Economic Geography
• Political Geography
• Browse content in Interdisciplinary Studies
• Communication Studies
• Museums, Libraries, and Information Sciences
• Browse content in Politics
• African Politics
• Asian Politics
• Chinese Politics
• Comparative Politics
• Conflict Politics
• Elections and Electoral Studies
• Environmental Politics
• European Union
• Foreign Policy
• Gender and Politics
• Human Rights and Politics
• Indian Politics
• International Relations
• International Organization (Politics)
• International Political Economy
• Irish Politics
• Latin American Politics
• Middle Eastern Politics
• Political Theory
• Political Methodology
• Political Communication
• Political Philosophy
• Political Sociology
• Political Behaviour
• Political Economy
• Political Institutions
• Politics and Law
• Politics of Development
• Public Administration
• Public Policy
• Quantitative Political Methodology
• Regional Political Studies
• Russian Politics
• Security Studies
• State and Local Government
• UK Politics
• US Politics
• Browse content in Regional and Area Studies
• African Studies
• Asian Studies
• East Asian Studies
• Japanese Studies
• Latin American Studies
• Middle Eastern Studies
• Native American Studies
• Scottish Studies
• Browse content in Research and Information
• Research Methods
• Browse content in Social Work
• Addictions and Substance Misuse
• Adoption and Fostering
• Care of the Elderly
• Child and Adolescent Social Work
• Couple and Family Social Work
• Direct Practice and Clinical Social Work
• Emergency Services
• Human Behaviour and the Social Environment
• International and Global Issues in Social Work
• Mental and Behavioural Health
• Social Justice and Human Rights
• Social Policy and Advocacy
• Social Work and Crime and Justice
• Social Work Macro Practice
• Social Work Practice Settings
• Social Work Research and Evidence-based Practice
• Welfare and Benefit Systems
• Browse content in Sociology
• Childhood Studies
• Community Development
• Comparative and Historical Sociology
• Economic Sociology
• Gender and Sexuality
• Gerontology and Ageing
• Health, Illness, and Medicine
• Marriage and the Family
• Migration Studies
• Occupations, Professions, and Work
• Organizations
• Population and Demography
• Race and Ethnicity
• Social Theory
• Social Movements and Social Change
• Social Research and Statistics
• Social Stratification, Inequality, and Mobility
• Sociology of Religion
• Sociology of Education
• Sport and Leisure
• Urban and Rural Studies
• Browse content in Warfare and Defence
• Defence Strategy, Planning, and Research
• Land Forces and Warfare
• Military Administration
• Military Life and Institutions
• Naval Forces and Warfare
• Other Warfare and Defence Issues
• Peace Studies and Conflict Resolution
• Weapons and Equipment

• < Previous chapter
• Next chapter >

26 Researching Critical Questions on Social Justice and Public Health: An Ecosocial Perspective

• Published: August 2013
• Cite Icon Cite
• Permissions Icon Permissions

Critical and creative work can and must be done to determine why injustice exists, including who gains and who loses and how it wreaks its woe, thereby generating knowledge for both rectifying harm and creating just and sustainable solutions. Critical research questions focus on: What is the evidence that social injustice harms health? What can be done to prevent this harm? There are four key reasons to develop a research agenda for social justice in public health: Ignorance forestalls action. The “facts” never “speak for themselves.” Specificity matters. Research can exacerbate and even generate, rather than help rectify social inequalities in health. This chapter discusses a proposal for a public health research agenda that advances issues of social justice and includes four components: theory, monitoring, etiology, and prevention. For each component, the author delineates broad principles and provides specific examples.

Signed in as

Institutional accounts.

• GoogleCrawler [DO NOT DELETE]
• Google Scholar Indexing

Personal account

• Sign in with email/username & password
• Get email alerts
• Save searches
• Purchase content
• Activate your purchase/trial code
• Add your ORCID iD

Institutional access

Sign in with a library card.

• Sign in with username/password
• Recommend to your librarian
• Institutional account management
• Get help with access

Access to content on Oxford Academic is often provided through institutional subscriptions and purchases. If you are a member of an institution with an active account, you may be able to access content in one of the following ways:

IP based access

Typically, access is provided across an institutional network to a range of IP addresses. This authentication occurs automatically, and it is not possible to sign out of an IP authenticated account.

Choose this option to get remote access when outside your institution. Shibboleth/Open Athens technology is used to provide single sign-on between your institution’s website and Oxford Academic.

• Click Sign in through your institution.
• Select your institution from the list provided, which will take you to your institution's website to sign in.
• When on the institution site, please use the credentials provided by your institution. Do not use an Oxford Academic personal account.
• Following successful sign in, you will be returned to Oxford Academic.

If your institution is not listed or you cannot sign in to your institution’s website, please contact your librarian or administrator.

Enter your library card number to sign in. If you cannot sign in, please contact your librarian.

Society Members

Society member access to a journal is achieved in one of the following ways:

Sign in through society site

Many societies offer single sign-on between the society website and Oxford Academic. If you see ‘Sign in through society site’ in the sign in pane within a journal:

• Click Sign in through society site.
• When on the society site, please use the credentials provided by that society. Do not use an Oxford Academic personal account.

If you do not have a society account or have forgotten your username or password, please contact your society.

Sign in using a personal account

Some societies use Oxford Academic personal accounts to provide access to their members. See below.

A personal account can be used to get email alerts, save searches, purchase content, and activate subscriptions.

Some societies use Oxford Academic personal accounts to provide access to their members.

Viewing your signed in accounts

Click the account icon in the top right to:

• View your signed in personal account and access account management features.
• View the institutional accounts that are providing access.

Signed in but can't access content

Oxford Academic is home to a wide variety of products. The institutional subscription may not cover the content that you are trying to access. If you believe you should have access to that content, please contact your librarian.

For librarians and administrators, your personal account also provides access to institutional account management. Here you will find options to view and activate subscriptions, manage institutional settings and access options, access usage statistics, and more.

Our books are available by subscription or purchase to libraries and institutions.

• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Rights and permissions
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

• Mission and Vision
• Scientific Advancement Plan
• Science Visioning
• Research Framework
• Minority Health and Health Disparities Definitions
• Organizational Structure
• Staff Directory
• About the Director
• Director’s Messages
• News Mentions
• Presentations
• Selected Publications
• Director's Laboratory
• Congressional Justification
• Congressional Testimony
• Legislative History
• NIH Minority Health and Health Disparities Strategic Plan 2021-2025
• Minority Health and Health Disparities: Definitions and Parameters
• NIH and HHS Commitment
• Foundation for Planning
• Structure of This Plan
• Strategic Plan Categories
• Summary of Categories and Goals
• Scientific Goals, Research Strategies, and Priority Areas
• Research-Sustaining Activities: Goals, Strategies, and Priority Areas
• Outreach, Collaboration, and Dissemination: Goals and Strategies
• Leap Forward Research Challenge
• Future Plans
• Research Interest Areas
• Research Centers
• Research Endowment
• Community Based Participatory Research Program (CBPR)
• SBIR/STTR: Small Business Innovation/Tech Transfer
• Solicited and Investigator-Initiated Research Project Grants
• Scientific Conferences
• Training and Career Development
• Loan Repayment Program (LRP)
• Data Management and Sharing
• Social and Behavioral Sciences
• Population and Community Health Sciences
• Epidemiology and Genetics
• Medical Research Scholars Program (MRSP)
• Coleman Research Innovation Award
• Health Disparities Interest Group
• Art Challenge
• Breathe Better Network
• Healthy Hearts Network
• DEBUT Challenge
• Healthy Mind Initiative
• Mental Health Essay Contest
• Science Day for Students at NIH
• Fuel Up to Play 60 en Español
• Brother, You're on My Mind
• Celebrating National Minority Health Month
• Reaching People in Multiple Languages
• Funding Strategy
• Active Funding Opportunities
• Expired Funding Opportunities
• Technical Assistance Webinars

• Community Health and Population Sciences
• Clinical and Health Services Research
• Integrative Biological and Behavioral Sciences
• Intramural Research Program
• Training and Diverse Workforce Development
• Inside NIMHD
• ScHARe HDPulse PhenX SDOH Toolkit Understanding Health Disparities For Research Applicants For Research Grantees Research and Training Programs Reports and Data Resources Health Information for the Public Science Education

• NIMHD Programs
• Education and Outreach
• 2024 Awardees
• Michaela: 2024 Mental Health Essay
• Extramural Research
• Intramural Research
• NIMHD Collaborations
• Fuel Up to Play 60 en Espanol
• COVID-19 Information and Resources

2024 Mental Health Essay Contest Awardee: Gold

Exposing the Impact of Social Media on Teenage Mental Health: A Journey of Self-Discovery

Michaela, maryland.

High school began for me amid the pandemic. Like so many others, my mental health was affected. Virtual land became my reality. I turned to screens for connection. As a 14-year-old with a still-developing brain, my thoughts and feelings were ripe for programming. I experienced many ups and downs, like riding a roller coaster; only at every turn the pervasive influence of social media infected my psyche. Social media is a significant part of teenage experiences; scary to say, it became my life. Instagram, TikTok, and Snapchat, the triad of our digital age, wished me good morning and bid me goodnight. I became infected with the “holy trinity” of body dysmorphia: obsessive mirror usage, unreal concern about a body part, and constant comparison syndrome. The digital forms of others and the carefully curated versions of myself, programmed me, leaving indelible marks on my mind.

It began innocently enough. A kid having a phone was not in my mom’s repertoire. She felt that kids didn’t need a phone. Mom set a “when you start high school” bar for the phone. As fate would have it, I had an overnight camp during middle school. Worried about me being alone, Mom caved. I got my phone. Everyone at camp had Snapchat, and asked for my “Snap.” Mom let me download it because she trusted me. I never gave her any reason not to trust me. I was a good girl.

Fast forward four years, and I’m still a good girl, but that person became buried under lies. Lies that were virtual aspects of me, through disappearing conversations, photos on the “for your eyes only” section, and perfectly angled poses. I needed those perfection posts as constant reinforcement of this idealized image I crafted. Sadly, even with these “perfect” photos, I obsessed about what I wasn’t. I felt less than because I didn’t have the “hourglass” shape. In reality, strangers would come up to me and ask me if I was a model. I have that body. Tall, lean, athletically fit. A model’s body that everyone wants. Ironic, isn’t it?

Consequently, the last four years of school, were heavily influenced by the digital demons to the point that I forgot who I was. My friends had to approve my posts. I couldn’t make a decision without them. I had to time posts so a friend could be “first” to comment. I compulsively bought fake “likes” to make me appear more popular.

In the throes of this virtual maelstrom, my family challenges reached a crescendo with the death of my dogs and my father’s life-threatening illness. Seeking solace, I unwittingly dove deeper into socials for escape, inadvertently exacerbating my mental health struggles.

Then a significant senior year victory occurred. I was offered a scholarship to play collegiate Division 1 soccer. The pressure may have been off for college, but my commitment post opened a wormhole for jealousy to take its aim. I expected friends to be excited. That was my first mistake, followed by more, including me taking almost every word they said personally. I accept responsibility. I took everything to heart and it hurt. In a seemingly innocuous incident where friends mocked a filter that was used on my photos, I hit my limit.

I spontaneously decided to deactivate my Instagram. I decided to pull away from toxicity. I decided to find myself. I felt liberated. No, I do not regret it.

However, the aftermath was unexpected. Friends, dropped me. I was forwarded anonymous posts on an “extreme confessions” Instagram account. Those posts about me were degrading, offensive, and vile. I was shocked and confused, especially since the initial response about me deactivating social media was “good for you” and “I’ll do it with you.”

No one ever joined me. To the contrary, they stood against me.

Have you ever heard of “Crab Mentality” or the crab-bucket effect? It basically means, “If I can’t have it, you can’t either.” Crabs that try to climb out of the bucket are pulled back down by the others.

I felt like a crab.

But I decided to be THE crab that makes it out of the bucket before I was completely cooked like the rest.

How do we fix this? Or better yet, how do we prevent social media addiction? I have nieces who are nine and seven. I don’t want them or any children lured into the chaos.

Obviously, a supportive community is paramount. Implementing educational programs that promote media literacy, and coping mechanisms for teenage girls focusing on building self-esteem and embracing individuality. Additionally, requiring mental health classes incorporating mindfulness and breathwork techniques can help immensely.

To prevent addiction and brainwashing, social media should be treated like any dangerous substance. Longitudinal studies are needed to determine the ramifications social media use has on developing brains. Laws against underage (U18) usage should be enforced; if violated, parents are fined, or repeat offenders jailed. It could be the wake-up call needed. Typically, when presented with what “could happen,” parents don’t usually get the message until it’s too late. That being the case, let’s be smart about using technology, instead of it using us through brain hacking and notification dopamine hits. Everyone can stay connected through texting or a call, an app is not needed.

In conclusion, the journey to reclaiming mental health amidst the pressures of social media requires a collective effort. In the spirit of truth, however, it takes desire from the inflicted person to choose self-love and individuality. By fostering compassion, promoting confidence, and cultivating a support system, we can empower teenagers to break free from the shackles of unrealistic standards and embrace their inimitability.

NIH recognizes these talented essay winners for their thoughtfulness and creativity in addressing youth mental health. These essays are written in the students' own words, are unedited, and do not necessarily represent the views of NIH, HHS, or the federal government.

Page published May 31, 2024

May 2024: NIH Announces Winners of High School Mental Health Essay Contest

Dec. 2023: High School Students Invited to Reflect on Mental Health Stigma in National Essay Contest

National Institute of Mental Health

National Institute on Minority Health and Health Disparities

Eunice Kennedy Shriver National Institute of Child Health and Human Development

Staying Connected

• Funding Opportunities  
• News & Events  
• HHS Vulnerability Disclosure  
• Privacy/Disclaimer/Accessibility Policy  
• Viewers & Players  

Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice

This essay about Martin Luther King Jr. highlights his role as a leader in the civil rights movement, emphasizing his advocacy for nonviolent resistance and social justice. Born into segregation, King rose to prominence through his leadership in events like the Montgomery Bus Boycott and his famous “I Have a Dream” speech. His work extended beyond racial equality, addressing poverty and militarism. Although he was assassinated in 1968, King’s legacy endures, inspiring global movements for equality and justice, and reminding us of the ongoing struggle for a truly equitable society.

How it works

In the chronicles of American history, few figures stand out as prominently as Martin Luther King Jr., a symbol of hope, courage, and unwavering determination in the quest for civil rights and social justice. Born into a deeply segregated society, King emerged as a leader who championed nonviolent resistance to injustice, inspiring countless individuals worldwide with his compelling speeches, strategic activism, and steadfast dedication to equality. His groundbreaking efforts not only reshaped the American social landscape but also left a lasting impact on the global struggle for human rights.

From an early age, King’s life was marked by a profound sense of purpose. Born on January 15, 1929, in Atlanta, Georgia, he was raised in a nation where segregation and discrimination were rampant. Despite the pervasive systemic obstacles, King thrived academically, graduating from Morehouse College at the age of 19. He continued his academic journey, earning a doctorate in systematic theology from Boston University. It was during his time in Boston that King encountered the teachings of Mahatma Gandhi, whose philosophy of nonviolent resistance significantly influenced his own approach to activism.

King’s rise as a civil rights leader began in the mid-1950s when he became involved in the Montgomery Bus Boycott, a crucial event in the fight against segregation. The boycott, initiated by Rosa Parks’ arrest for refusing to surrender her seat to a white passenger, lasted over a year and resulted in the desegregation of Montgomery’s public transportation. King’s leadership in orchestrating the boycott propelled him into the national spotlight and established the foundation for his role in the civil rights movement.

Throughout the late 1950s and early 1960s, King led numerous nonviolent protests and demonstrations aimed at dismantling racial segregation and discrimination. His philosophy of nonviolent resistance, rooted in the principles of love, truth, and justice, became the bedrock of the civil rights movement. In 1963, King delivered his renowned “I Have a Dream” speech during the March on Washington for Jobs and Freedom, captivating the nation with his vision of a future where individuals would be judged by their character rather than the color of their skin.

King’s advocacy extended beyond racial equality to include broader issues of social and economic justice. He spoke out against poverty and militarism, viewing the interrelated threats of racism, poverty, and militarism as dangers to society’s moral integrity. In 1967, King delivered a poignant speech condemning the Vietnam War, drawing connections between the domestic struggle for civil rights and the global fight for liberation.

Tragically, King’s life was abruptly ended on April 4, 1968, when he was assassinated in Memphis, Tennessee, at the age of 39. His assassination shocked the nation and the world, causing widespread outrage and grief among millions who were moved by his message of hope and unity. Despite his untimely death, King’s legacy persisted as a powerful call for justice and equality.

In the years following his death, King’s impact on American society has only deepened. His birthday is now observed as a national holiday, and his speeches and writings continue to inspire new generations of activists and advocates for social change. The Civil Rights Act of 1964 and the Voting Rights Act of 1965, landmark legislations that ended segregation and guaranteed voting rights for African Americans, stand as enduring testaments to King’s vision and leadership.

King’s influence extends far beyond the United States, inspiring liberation and equality movements worldwide. From South Africa to India, Latin America to the Middle East, King’s doctrine of nonviolent resistance has resonated with people fighting for their rights and dignity.

However, despite the significant strides made, King’s dream of a genuinely just and equitable society remains unfulfilled. The ongoing presence of racial inequality, economic injustice, and systemic discrimination highlights the persistent challenges we face. In confronting these issues, King’s legacy urges us to recommit to the quest for justice and equality for all.

Reflecting on Martin Luther King Jr.’s pioneering contributions to civil rights and social justice, we are reminded of the profound impact that ordinary individuals can have in driving extraordinary change. King’s life exemplifies the transformative power of love, courage, and solidarity in overcoming adversity. His legacy continues to serve as a beacon for those striving to create a more just and compassionate world, reminding us that while the moral universe’s arc may be long, it ultimately bends towards justice.

Cite this page

Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice. (2024, May 28). Retrieved from https://papersowl.com/examples/martin-luther-king-jr-pioneering-achievements-in-civil-rights-and-social-justice/

"Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice." PapersOwl.com , 28 May 2024, https://papersowl.com/examples/martin-luther-king-jr-pioneering-achievements-in-civil-rights-and-social-justice/

PapersOwl.com. (2024). Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice . [Online]. Available at: https://papersowl.com/examples/martin-luther-king-jr-pioneering-achievements-in-civil-rights-and-social-justice/ [Accessed: 31 May. 2024]

"Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice." PapersOwl.com, May 28, 2024. Accessed May 31, 2024. https://papersowl.com/examples/martin-luther-king-jr-pioneering-achievements-in-civil-rights-and-social-justice/

"Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice," PapersOwl.com , 28-May-2024. [Online]. Available: https://papersowl.com/examples/martin-luther-king-jr-pioneering-achievements-in-civil-rights-and-social-justice/. [Accessed: 31-May-2024]

PapersOwl.com. (2024). Martin Luther King Jr.: Pioneering Achievements in Civil Rights and Social Justice . [Online]. Available at: https://papersowl.com/examples/martin-luther-king-jr-pioneering-achievements-in-civil-rights-and-social-justice/ [Accessed: 31-May-2024]

Don't let plagiarism ruin your grade

Hire a writer to get a unique paper crafted to your needs.

Our writers will help you fix any mistakes and get an A+!

Please check your inbox.

You can order an original essay written according to your instructions.

Trusted by over 1 million students worldwide

1. Tell Us Your Requirements

2. Pick your perfect writer

3. Get Your Paper and Pay

Hi! I'm Amy, your personal assistant!

Don't know where to start? Give me your paper requirements and I connect you to an academic expert.

short deadlines

100% Plagiarism-Free

Certified writers

150 Social Justice Essay Topics & Examples

⭐ top 10 social justice issues to write about, 🏆 best social justice topic ideas & essay examples, ⭐ simple & easy social justice essay titles, 📌 most interesting social justice topics to write about, 👍 good social justice research topics, ❓ research questions about social justice.

Social justice essays are an excellent tool for demonstrating your awareness of the current issues in society.

Inequality in society should be addressed, and social justice advocates are at the forefront of such initiatives. Everyone should be able to achieve their goals and dreams if they put in the effort, assuming of course that reaching that target is at all possible.

To that end, you should ask various social justice essay questions and investigate different situations, particularly those that surround marginalized communities.

While the civil rights movement has succeeded in eliminating discriminatory policies and gender segregation, people should remain vigilant so that inequality again.

There are many topics you can discuss in your essay, but is better to focus on something specific and conduct a detailed investigation. It is easy to take some examples of data that shows a situation that seems unequal and declare that the system is flawed.

However, the data may be inaccurate, and the causes may be different from what you initially perceive them to be. Many fields will be too small for statistic laws to apply, and so there will be a temporary prevalence of people with a specific trait.

Declarations of premature conclusions and calls to action based on these conjectures are not productive and will generally lead to harm.

Be sure to consider evidence from both sides when discussing the topic of injustice, especially in its sensitive applications.

The case of police officers and the racial disparity in arrests is a prominent example, as there is significant disagreement, and neither side can be considered entirely correct.

At other times, unequal treatments may be explained by racial and gender differences without the application of discriminatory practices, particularly with regards to cultural practices.

The importance of justice is above debate, but it is not always about declaring one side correct while the other is wrong and at fault. Humanity operates best when it is unified and follows the same purpose of fairness.

Lastly, try to avoid confusing equality with equity, as the two social justice essay topics are significantly different. The former involves similar starting conditions and opportunities for all people, though they will likely achieve varying successes in life.

The latter means equality of outcomes, meaning that the unsuccessful receive support, which logically has to come at the expense of those who succeed.

You may support either position, with equality being a more traditional concept that seems logical to many people and equity being considered effective at improving the conditions of marginalized communities. However, make your position clear, as the difference is critical and informs your personal concept of social justice.

Here are some additional tips for your paper:

• Separate the points you make in your essay with social justice essay titles. These titles will help the reader navigate the paper and understand your main claims.
• Try to introduce original ideas instead of contributing to ongoing debates. An essay does not allow enough space to let you add something that will change the situation to such discussions.
• The topic of social justice is inherently political, as most suggestions will involve policy-level changes. However, you should try to distance yourself from politics and work with factual information.

Visit IvyPanda to find more social justice essay examples and other useful paper samples to boost your creative process!

• Unemployment.
• Global Warming.
• School Shooting.
• Income Inequality.
• Global Pandemic.
• Social Security.
• Racial & LGBTQ Discrimination.
• Mental Health Stigma.
• Famine and Starvation.
• Discrimination in Voting.
• Social Justice in Education With a clear distinction between justice taught in class and justice allowed to thrive in the school environments, teachers can be able to observe how their students perceive and response to social injustices in the […]
• Advocating for Social Justice in Healthcare However, health care is also often related to the idea of social justice a term that describes the allocation of resources and benefits to people according to their needs and abilities.
• Social Justice From the Biblical Point of View Furthermore, all oppressed and poor people are considered to be “righteous” in the Bible because it “is a reflection of God’s faithful love in action and his desire for justice and righteousness in this world”.
• Social Justice: The Catholic’s Social Teachings on Justice The church also seeks to instill value in the prisoners’ lives through teachings and practices that accept prisoners as people who deserve to be treated with dignity.
• Promoting Social Justice Through Serving God Therefore, serving God in action correlates with the promotion of social justice and reflects the importance of Christian teachings about kindness towards others.
• Social Justice and Mental Health However, it is difficult to imagine the U.S.taking nationwide action on mental health due to the absence of healthcare for physical health, which is widely accepted as a serious issue.
• Jay-Z’s Contribution to Hip-Hop and Fight for Social Justice One should admit that the crime rate among black people in some poor areas is really quite high, and that is another problem Jay-Z covers in his music.
• Prosperity and Social Justice The short story was also the subject of debate when it was first written because it failed to fit in any particular genre at the time.”The Yellow Wallpaper” was mostly considered a horror story when […]
• Freedom and Social Justice Through Technology These two remarkable minds have made significant contributions to the debates on technology and how it relates to liberty and social justice.
• Factors of Strategic Management of Social Justice Starting to talk about economic and technological changes that affect the sector of social justice, it is possible to observe tendencies of the level of development of the country from social policy.
• Social Justice from a Philosophical Perspective Although their theories of justice were significant, they would not have existed without Plato’s influence and the contribution that their ideas of justice have made to political philosophy.
• Social Justice in the Modern World The main link in social relations is a measure of social justice, a derivative of the equality of people’s opportunities to realize their potential.
• Social Justice Quotes from “The Wife’s Lament” by Beck “never worse than now ever I suffer the torment of my exile”.”that man’s kinsmen began to think in secret that they would separate us” “so we would live far apart in the world” “My lord […]
• Social Justice in Counseling Psychology The other barrier which is likely to arise in the process of integrating social justice in the workplace is legal and ethical issues.
• Social Justice and Vulnerability Theories When the country’s economic analyzers assess the status of the economy, the older people are regarded as the first group of the population that is pulling the economy backward because they are entirely dependent.
• Social Justice in Social Work Practice The moral approach of social work is fundamentally based on the idea of social justice. Despite the numerous risks associated with advocating for social justice, criticizing injustice is one of the few courageous ways to […]
• Researching the Concept of Social Justice A special kind of justice is social justice, the subjects of which are large social groups, society as a whole, and humanity.
• The Role of Quilting in the African American Striving for Social Justice Perhaps quilting has become not only one of the symbols of African American national culture but also a way in which many black women have become visible and significant.
• Social Justice and Importing Foreign Nurses Evaluation Given the lag between the submission of the article and its publication, it means that these sources most likely reflect the situation with the recruitment of foreign-educated nurses by the end of the 2000s.
• Promoting Social Justice With Head Start Program This essay will discuss the role of the Head Start program in the promotion of social justice in the US, focusing on the values taught to the children and the activities that constitute the program.
• Religion, Politics, and Social Justice Organized religions want to change and implement rebranding to fit the new trend, concentrating on social justice in general rather than the individual spiritual aspirations of a person or a family.
• Social Justice and Its Relevance in This Century To put the issue in perspective, he references the civil rights movement of the 1960s and juxtaposes it against the fact that the US had a black president.
• Social Justice Arts as a Remedy for People The work led to the formation of the movement called Black Lives Matter which calls for an end to oppressing black people through law enforcement.
• Social Justice, Diversity and Workplace Discrimination It also includes the fair distribution of the national wealth and resources among all citizens and the unbiased treatment of all individuals.
• Social Justice: Why Do Violations Happen? If there is social inequality in a society, it must be corrected to serve the interests of the most oppressed groups of the population.
• Definition of Social Justice and Social Justice in Leadership They should evaluate the situation, identify areas that need improvement and develop a plan to support the achievement of social justice.
• Social Justice Leadership and Supervision While the concepts of leadership and supervision tend to be referenced within the clinical contend and primarily apply to the responsibilities of the professionals in mental institutions, the issues articulated in the article and chapters […]
• Uganda’s Economic Planning and Social Justice On the eastern, it borders Kenya, North is Southern Sudan, to the west is DRC and to the southwest is Rwanda, while to the South is Tanzania.
• Rise of Mental Social Justice It relates to the social justice leadership in clinical and supervisory practice in mental health settings by challenging the modern tenets of managerialism and neoliberalism.
• Social Justice in the US Healthcare System Social justice is a relatively broad concept, the interpretation of which often depends on the political and economic views of an individual.
• Conceptualizing Supervision in Search of Social Justice Based on these findings, it could be concluded that Social justice leadership is meant to become the remedy and the ideological, political, and medical opponent of the dominant positivist biomedical paradigm.
• Researching HIV, AIDS and Social Justice Disney claims that poverty and social injustice lead to the spread of HIV/AIDS among underprivileged people in all countries. The disease was a kind of stigma and infected people were subjected to discrimination and alienation.
• Equal Pay Convention Ratified by New Zealand and Ensuring Social Justice This paper seeks to identify whether the ratification of the International Labour Organisation equal pay for an equal value of work Convention by New Zealand delivered social justice to the women in the New Zealand […]
• Influence of Socioeconomic Status and Social Justice on Health in the US In the video, Richard David and James Collins have determined that racism, inappropriate social policies, and chronic stress are major social factors that lead to the delivery of low-weight babies among African American women.
• Social Justice Perspective Thus public health deals not only with the guarantee of a long healthy life but also regulate and control the death rate, try to expand the life interval, and other things that the policy of […]
• Deaf Youth: Social Justice Through Media and Activism The Deaf Youth USA for instance strives to educate, inspire, and empower the deaf youth to make difference in the communities.
• Re-Examining Criminal and Social Justice Systems: Reducing Incarceration Rates in the US The changes in criminal justice policy over the past decades and the alteration of the same from one of rehabilitative and social justice to one of retributive justice and increasing reliance on imprisonment as a […]
• Social Justice and Ethics: Beneficiaries of U.S. Welfare Programs In United States the beneficiaries include the poor, the old, the disabled, survivors, farmers, corporations and any other individual who may be eligible.
• Social Justice and Feminism in America So as to make a change in this situation, the feminists in America took efforts to improve the condition of women.
• Equality of Opportunity and Social Justice: Affirmative Action If this is the situation in advanced nations of the world, the plight in the newly emerging states in Africa, Asia, and Latin America can easily be imagined as to how difficult would it be […]
• Christianity Religion and Asian World: Social Justice It was also said that the greatest botched opportunity in all church history was in the 1260s the court of the great Kublai Khan asked the Polos when they returned to Italy in 1269 to […]
• Social Justice for Indigenous Women in Canada However, the problem of social justice or, to be more accurate, the lack thereof becomes especially poignant when considering criminal issues and their management, as well as the factors that contribute to reducing the rates […]
• Social Justice and Educational Reform in the US People are free to develop their individual attitudes to the importance of social justice in education and leadership. Social justice may be used in the creation of job announcements, proposals, and statements to attract attention […]
• Social Justice in Quality Health Care The provision of accessible health services is necessary to minimize the health risks of the low-income households and improve their quality of life.
• What Is Social Justice? To my mind, the two most important principles of justice that should be used to govern within a just society are the selection of highly virtuous state leaders and government representatives to put in charge […]
• Social Justice: Philosophy of Employment The philosophy of empowerment supports dignity and self-worth; as such, value to all people, regardless of their status or race is an important rule of empowerment.
• American Women’s Movements for Social Justice Like Alice Walker, Deborah Gray, and Collins, Tyra Banks continues the legacy of black women since she is ready to campaign against racism, sexism, and discrimination.
• Social Justice Group Work for Homeless Young Mothers The group discussed in the article was started for the purpose of assisting residents address the problem of homelessness especially in aspects of parenting and during pregnancy periods.
• Readings for Diversity and Social Justice: An Anthology In that way, the authors noted that racial and ethnic differences tend to produce impact on lives of communities in the entirety of their aspects, and thus can aggravate other social justice issues.
• Health Care Services: Social Justice Analysis For instance, the level of poverty in the USA is on the rise, and many people simply have no funds to purchase their health insurance. In conclusion, it is possible to note that social justice […]
• Social Justice Issues: Elderly Minority Groups Students should know the peculiarities of the populations in question and should be aware of practices and services available to those patients.
• Black Lives Matter and Social Justice Social media is a new public platform that has proved to be extremely effective in fighting against the normalization of violence against African-Americans.
• Ethics and Social Justice in Education Policies The real-life problem that contributes to those controversies is the multicultural genuineness of the community that was exposed to the federal and state standard reforms that transpired throughout the last ten years.
• Administrative Constitutionalism and Social Justice The current point of view at the crimes and violence is predestined by the commercial pressure applied to the mass media sources. In the majority of the cases, popular media becomes the viral source of […]
• Counselors as Social Justice Advocates The compelling vision of social justice is to achieve “free, full, and equal participation” of all groups in society to realize their aspirations and mutual needs.
• U.S. Postal Service’s Ethics and Social Justice In spite of the fact that the current agency was organized in 1971, the background of the organization is related to the development of the first postal service in the country based on the U.S.
• David Miller’s Theory of Desert in Social Justice The dependence of rewards on the variety of external and conditional factors makes the public and scholars question the idea of the desert and its use for justice.
• Ethics Issues: Social Justice In other words, it is observed that an individual has a duty of ensuring that the law is followed while the government is expected to provide the basic rights and freedoms.
• Education and Social Justice The society should also reduce the gap between the poor and the rich. The current level of inequality explains why “every school should reinvent itself in order to deal with social injustice”.
• Social justice and the black – white achievement gap From a national perspective, the achievement gap between the Black and White is reported to have narrowed down in 2007 as compared to the same gap in 1990.
• Setting an Agenda for Social Justice According to Wilkinson, Brundrett is a professor of Educational Research in the Faculty of Education, Community, and Leisure and the head of the Centre for Research and Evaluation, in the Liverpool John Moores University.
• Social Justice: Wray’s Essential Aspects of Biblical Law and Justice Wray has conducted an extensive study on the subject of social justice and suggests that students taking any course on law or social justice must go back to the origins of these laws and justice, […]
• Social and Criminal Justice Responses to Sex Work The negative attitude of the community and the criminalization of sex works made workers of his industry vulnerable and susceptible for the physical assaults of men in the street, their customers and even policemen.
• Social Justice and the Australian Indigenous People The main idea behind the formation of the social justice commission was to give the indigenous Australian people choice by empowering them to stand up for their rights.
• Is Social Justice the Same Thing as Political Egalitarianism? An Analysis from a Theory of Justice Perspective This is the question that is likely to arise when one is analyzing social justice in the context of political developments in the society.
• Social Justice and Gay Rights This perception of gays was radically reformed thanks to the efforts of gay rights movements which trace their roots to the 1960s and the Stonewall Riots of 1969 which marked the birth of the gay […]
• The People Demand Social Justice: The Social Protest in Israel as an Agoral Gathering
• The Woman Who Spoke of Love and Social Justice
• Peace and Eco-Social Justice: Failed Distributive Justice, Violence and Militancy in India
• Spirituality, Women ‘s Issues, Sustainability, and Social Justice
• Multicultural Counseling Social Justice and Advocacy Reaction
• The Paradox of Dominate Ideologies in The Fight of Social Justice
• Letter from Birmingham Jail’ by Martin Luther King Jr. and Social Justice
• Richard Spencer and the Issues of Social Justice and White Nationalism
• The Moving Beyond Pity and Inspiration: Disability as a social Justice Issue by Eli Clare
• The Importance of Human Rights and Social Justice
• Social Justice: The Role of Higher Education, Criminality and Race
• Turning Points in the Lives of Chinese and Indian Women Leaders Working Toward Social Justice
• Paulo Freire’s Social Justice Idea
• Producing and Practicing Social Justice in Education
• Urban Social Justice: The Gentrification Debate
• The Role of Education in Society as Explained in Conell’s Social Justice in Education
• The Issues of the Canadian Social Services and Social Justice Domain
• Wellbeing, Freedom, and Social Justice: The Capability Approach
• The Principle of Social Justice and Advocacy Support
• The Biblical Prophets’ Teachings on the Love of God in Social Justice
• The Relationship Between Free Market and Social Justice
• Uneasy Bedfellows: Social Justice and Neo-Liberal Practice in the Housing Market
• The Ethics of Pricing and Access to Health Care: A Social Justice Issue
• Measuring Attitudes Toward Distributive Justice: The Basic Social Justice Orientations Scale
• The Importance of the Covenant House as a Symbol of Christian Social Justice
• Social Justice Orientation and Multicultural Environment
• The New Political Economy of J. S. Mill: The Means to Social Justice
• The ‘s Coat of Arms Are Trust, Empathy, and Social Justice
• The Vietnam War and Its Impact on The Creation of Social Justice
• Race Relations and Social Justice Problems
• Poverty, Inequality and Social Justice in Nonmetropolitan America
• Rape Culture, Rapth, and the Cycles of Social Justice
• The Three Social Justice Issues That Fires Me Up as a Citizen in the United States
• Reading Baldwin After Harvey: Why Climate Change Is a Social Justice Issue
• The Importance of Social Justice Is Universal Across
• Effective Practice During The Social Justice System
• The Issue of Social Justice Activism in Various Social Media Networks
• Sustainable Development and Social Justice: Expanding the Rawlsian Framework of Global Justice
• Once Upon Today: Teaching for Social Justice with Postmodern Picturebook
• The Congressional Black Caucus Use of Social Media for Social Justice Issues
• The Effective Teaching Techniques of Lisa Espinosa in Providing Information on the Topic of Cultural Relevance and Social Justice
• Reading Baldwin After Harvey: Why Climate Change Is a Social Justice Issue?
• How Does Social Justice Highlight the Relationship Between Social Welfare and Crime Control?
• Social Justice and Academic Success: Is Individual Effort Enough?
• Rawls’s Theory of Social Justice: How Decisions Are Made?
• Are Consultation and Social Justice Advocacy Similar Exploring the Perceptions?
• How Arc Advances Social Justice?
• What Are the Different Factors Affect Social Justice?
• What Does the Information Society Mean for Social Justice and Civil Society?
• What Is the Connection Between Curricular Practices, Social Justice and Democratic Purpose in the United States Education System?
• How the United States Has Both Market and Social Justice?
• What Is the Impact of Social Justice on The United States?
• What Is the Impact of Social Justice on Human Development?
• How Does Social Justice Actions Project?
• When High Pressure, System Constraints, and a Social Justice Mission Collide?
• What Is the Concept of Social Justice Social Work?
• What Is the Connection Between Free Market and Social Justice?
• What Is the Goal of Social Justice Education?
• What Social Justice Issues Are You Most Passionate About?
• What Is Consist Social Justice Western Perspectives?
• How Social Justice Course Changed My Outlook?
• What Are the Three Social Justice Issues That Fires Up as a Citizen in the United States?
• What Has Limited the Impact of UK Disability Equality Law on Social Justice?
• What Is Rawls’ Expanding Framework for Global Justice?
• How Does the Film “Lord of Flies” Relate to Social Justice?
• Does the Legal System Promote Social Justice?
• Are the People Demand Social Justice?
• Social Justice and the University Community: Does Campus?
• What Does “Social Justice” Mean?
• What Does Teaching for Social Justice Mean for Teachers?
• Why Is Education a Social Justice and Right for Each Child?
• Children’s Rights Research Ideas
• Women’s Rights Titles
• Socioeconomic Status Paper Topics
• Human Rights Essay Ideas
• Sociological Perspectives Titles
• Idealism Paper Topics
• Respect Essay Topics
• Libertarianism Research Topics
• Chicago (A-D)
• Chicago (N-B)

IvyPanda. (2024, February 29). 150 Social Justice Essay Topics & Examples. https://ivypanda.com/essays/topic/social-justice-essay-examples/

"150 Social Justice Essay Topics & Examples." IvyPanda , 29 Feb. 2024, ivypanda.com/essays/topic/social-justice-essay-examples/.

IvyPanda . (2024) '150 Social Justice Essay Topics & Examples'. 29 February.

IvyPanda . 2024. "150 Social Justice Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/social-justice-essay-examples/.

1. IvyPanda . "150 Social Justice Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/social-justice-essay-examples/.

Bibliography

IvyPanda . "150 Social Justice Essay Topics & Examples." February 29, 2024. https://ivypanda.com/essays/topic/social-justice-essay-examples/.

• Research article
• Open access
• Published: 12 January 2021

Social justice in health system; a neglected component of academic nursing education: a qualitative study

• Hosein Habibzadeh 1 ,
• Madineh Jasemi 1 &
• Fariba Hosseinzadegan   ORCID: orcid.org/0000-0002-3464-7385 1  

BMC Nursing volume  20 , Article number:  16 ( 2021 ) Cite this article

38k Accesses

12 Citations

Metrics details

In recent decades, increasing social and health inequalities all over the world has highlighted the importance of social justice as a core nursing value. Therefore, proper education of nursing students is necessary for preparing them to comply with social justice in health systems. This study is aimed to identify the main factors for teaching the concept of social justice in the nursing curriculum.

This is a qualitative study, in which the conventional content analysis approach was employed to analyze a sample of 13 participants selected using purposive sampling method. Semi-structured interviews were conducted to collect and analyze the data.

Analysis of the interviews indicated that insufficient education content, incompetency of educators, and inappropriate education approaches made social justice a neglected component in the academic nursing education. These factors were the main sub-categories of the study and showed the negligence of social justice in academic nursing education.

Research findings revealed the weaknesses in teaching the concept of social justice in the nursing education. Accordingly, it is necessary to modify the content of nursing curriculum and education approaches in order to convey this core value. Since nursing educators act as role models for students, especially in practical and ethical areas, more attention should be paid to competency of nursing educators, specially training in the area of ethical ideology and social justice.

Peer Review reports

Professional values include action standards that are accepted by group members and provide a framework for evaluating beliefs and notions affecting behavior [ 1 ]. Acquisition of professional nursing values is a prerequisite for resolving conflicts; it improves service quality and increases job satisfaction of nurses [ 2 ]. The core values accepted and presented by American Association of Colleges of Nursing (AACN) (1998) include human dignity, integrity, autonomy, altruism, and social justice [ 3 ], out of which social justice has attracted more attention in recent years. Disproportionate burden of diseases and deaths in parts of the society associated with environmental and socioeconomic factors has been recognized for decades; however, the number of documents on these issues has increased dramatically over the past 15 years [ 4 ]. The WHO Commission on Social Determinants of Health attributes these differences to social inequalities in the distribution of power, income, shelter, education, and healthcare as well as climate change, vulnerability, and other life conditions. It also prioritizes social justice as a mechanism for correcting and eliminating inequalities [ 5 ]. Social justice in the health system refers to providing equal healthcare services for all individuals, regardless of their personal characteristics [ 6 ]. The AACN defines social justice as fair treatment, regardless of one’s economic status, race, ethnicity, age, citizenship, disability, or sexual orientation [ 7 ].

Although social justice has been identified as a professional value in documents issued by reputable nursing associations such as International Council of Nurses (ICN), Canadian Nurses Association (CNA), American Nurses Association (ANA), and AACN [ 8 ], the discussion of social justice in nursing profession has always been accompanied by serious doubts and concerns [ 9 ]. In addition, nurses’ responses to social injustice have not always been admirable, and nursing profession’s poor performance originates from various factors such as unawareness [ 10 ].

Development of a professional value such as social justice is a continuous and long-term process that begins with professional nursing education and continues throughout years of nursing practice. Education plays a key role in acquiring professional values [ 11 ]. Students, educators, faculties, clinical and educational experiences, and individual values are among the most important components of learning and development of professional values [ 12 ]. It is very important to train highly skilled and qualified nurses to provide necessary care for heterogeneous populations in today’s ever-changing demographic prospect. Nursing students must understand their responsibility for poplulation health issues and social factors affecting health (eg, world hunger, environmental pollution, lack of access to health care, violation of human rights, and inequitable distribution of health care resources, including nursing services) and in this regard acquire the necessary knowledge and skills [ 13 ].

To institutionalize the concept of social justice in nursing students, especially in developed countries, measures have been taken in the area of education, which include modifications made to nursing curriculum and education approaches [ 14 ]. For instance, simulation is a one of new methods utilized for teaching this concept [ 15 ]. Since the mid-2000s, there has been an increase in tendency towards online learning [ 16 ], co-curricular experiences [ 17 ], and digital storytelling [ 18 ] in order to promote students’ understanding of social justice issues. Nevertheless, some studies have addressed the weaknesses of nursing curriculum in teaching social justice [ 19 , 20 ] and have attributed nurses’ inability in pursuing social justice to their poor scientific and practical competencies [ 21 ]. Although several quantitative and qualitative studies have been conducted in recent decades to institutionalize the concept of social justice among nursing graduates [ 22 , 23 , 24 , 25 ], academic nursing education has unfortunately failed to train competent nurses who seek information and training on social justice. Considering the importance of this subject, a qualitative approach [ 26 ] was adopted to provide an in-depth understanding of social justice based on the realistic results derived from the participants’ real experiences. Therefore, in this study, the experiences of nursing educators and students in identifying the main factors for teaching the concept of social justice in nursing education program were analyzed.

Study design and setting

This qualitative study was conducted using a conventional content analysis method. The participants were recruited from three nursing faculties (Urmia, Tabriz, and Tehran) and two teaching hospitals of Tehran (Motahari Hospital) and Urmia (Talegani Hospital) in Iran. These cities were selected due to their large size and forerun in educational, clinical, and social nursing activities.

Study participants

In view of the objective of the study - identify the main factors for teaching the concept of social justice in the nursing curriculum - we initially selected nursing educators by purposive sampling method. Nursing educators who had more than 5 years of service experience and among the prominent educators with activity in nursing institutions that involved in developing social justice were selected. The data from the study then led us to students and clinical nurses. Among the students, the final year undergraduate students, exemplary and active in social fields, and among the nurses, those with more than 2 years of service experience, accepted by the system professionally and actively in the field of social justice, such as voluntary activities in public health promotion, were selected for the interview.

The participants included 6 men and 9 women with the mean age of 39.07 ± 12.92 years old and mean work experience of 20.00 ± 7.22 years. Out of all the participants, 5 individuals had PhD, whereas 2 had Master’s degrees; the rest had Bachelor’s degrees in nursing. In total, 7 individuals were nursing educators, 2 individuals were clinical nurses, and 4 individuals were nursing students (Table  1 ).

Data collection

The data were collected using in-depth, semi-structured individual interviews conducted at the times and in the places selected by the participants (mainly at nursing faculties). Each interview lasted for 30–90 min; they were audio recorded upon the participants’ permission and transcribed verbatim. All the 13 interviews were conducted by the research team (FH, MJ, and HH) between February and November 2019. The participants were asked questions about their experiences of (learning/teaching) social justice issues. Considering the abstract nature of the research subject, the researchers raised more objective questions. For instance, the educators were asked to “describe their experiences of modification to the curriculum to cover social justice issues”, whereas the students were asked to “describe their experiences of social justice-based practices during internships”. In addition, to better identify factors affecting social justice education in nursing, the educators and students were asked questions such as “Considering your experiences, what factors have affected your engagement in social justice in education?” and “How do you describe education approaches adopted by educators for teaching social justice?”, respectively. (See Additional file  1 for details). The researchers continued the interviews until the data were completely saturated, i.e. when no new idea, concept, or category was derived from the final interviews.

To better relate to the environments of the study and the participants and analyze the data realistically, the researchers also used field notes. Field notes are a brief summary of the observations made while collecting data. This is not limited to a particular type of activity or behavior and assesses the non-verbal behaviors of the participants and their interactions with others. It also depicts a picture of a social position. In this study, field notes also made a detailed presentation of the situation in the right place immediately after the interview and provided the opportunity to confirm the psychological and emotional reactions of the participants. For example, attending the emergency ward of one of the teaching hospitals in Urmia city and observing nursing education in the clinical environment led to a field note focusing the training on the clinical procedures that confirm the insufficient educational content and lack of attention to social justice in nursing education.

Data analysis

After the data were collected, they were analyzed using the conventional content analysis approach. For this purpose, Grundheim and Lundman’s (2004) method was adopted [ 27 ]. In this method, an entire interview is regarded as an analysis unit involving notes that must be analyzed and coded. The researchers listened to the interviews for several times and transcribed the recorded interviews verbatim. The paragraphs, sentences, and words were considered meaning units. A meaning unit is a set of words and sentences that are related to each other in content and are categorized based on their content and context. The texts were reviewed several times to highlight words containing key concepts or meaning units and extract the initial codes. The codes were then reviewed several times in a continuous process from code extraction to labeling. Similar codes were merged, categorized, and labeled and the subcategories were determined. The extracted subcategories were finally compared and merged (if possible) to form the main categories.

Assessing data accuracy and stability

Guba and Lincoln’s (1986) criteria were used to ensure the accuracy and stability of the research data. The credibility of the data was assessed using member-checking and prolonged engagement techniques. For member-checking technique, the participants reviewed the content of the interview and the resulting codes to ensure the accurate meaning and for really reflecting their experiences. The data were also assessed by an external researcher (peer debriefing). To ensure the dependability, data collection methods, interview, taking notes, coding, and data analysis were expressed in detail in order to make judging by the external auditor (external auditing). In order to achieve confirmability, the audit trail method was used, so that all stages of the research, especially the stages of data analysis and the results, were provided to checking of two expert colleagues in the field of qualitative research. The transferability of the findings was also established by providing a rich description of the research report and the content of the interviews was represented by the selected quotations from the participants [ 28 ].

Ethical considerations

The participants were selected after the approval of Ethics Committee of Urmia University of Medical Sciences and the necessary permissions (Code: IR.UMSU.REC.1397.223) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.

Classification of the interviews showed that three sub-categories of “insufficient educational content”, “limited competency of nursing educators”, and “inappropriate education approaches” led to the emergence of the main category called “social justice; a neglected component of academic education” (Table  2 ).

Social justice; a neglected component of academic education

Proper education plays a major role in training justice-seeking nurses. Social justice and its importance in healthcare are constituents of the nursing syllabus. Paying more attention to this issue in practical and objective areas of education by educators can influence students’ thoughts, attitudes, and behaviors to pursue justice in health systems. However, Iran’s education system has unfortunately failed to promote justice because of insufficient educational content, limited competency of nursing educators, and inappropriate education approaches.

Insufficient educational content

Development of a comprehensive nursing curriculum, especially on ethical issues such as social justice, could substantially contribute to the preparation of socially and morally conscious nurses who are able to make significant changes in the public health at local, national, and international levels. In this study, the participants highlighted some weaknesses in the content of the existing nursing curriculum such as lack of attention to social justice, discontinuity in presenting courses on ethical values, and allocating most of the nursing courses to medical issues and clinical care.

Lack of attention to social justice in nursing curriculum

Social justice is a core nursing value which plays a significant role in promoting justice by nursing students and nurses. However, according to the participants, it has unfortunately been neglected in the existing nursing curriculum. In this regard, one participant stated,

“In the fourth semester, we studied a course on nursing ethics. I think there was no discussion on social justice because I don’t remember anything about this topic” (Participant No. 7/Nursing Student).

Regarding the importance of teaching social determinants of health, another participant stated,

“I was not aware of the importance of social issues in health until I participated in a workshop called ‘Social Justice in Health’. It really changed my beliefs and broadened my perspective” (Participant No. 10/Clinical Nurse).

Discontinuity in presenting courses on ethical values

Values are major components of the nursing profession. The institutionalization and development of professional values such as social justice contribute significantly to the future of this profession. The few number of courses presented on ethical values and discontinuity in the presented courses (for instance, no course on ethical values is provided for post-graduate students) were major items mentioned by the participants. In this regard, one of the participants stated,

“When students are repeatedly reminded of the importance of a value, they will realize its importance and the value will be institutionalized in them. We partially studied professional values and social justice issues in the fourth semester of our undergraduate courses; however, no similar course was provided for us afterwards during the Master’s program” (Participant No. 5/ Faculty Member).

Or another participant stated:

“We cannot deny that the ethical issues have been institutionalized in our professional graduates to some extent. But, these issues are not worked on in a principled and scientific manner and that there is no constant focus on them. After all, the effect of the hidden curriculum has been more prominent.”(Participant No.1/Faculty Member).

Allocating most of nursing courses to medical issues and clinical care

Diseases and clinical care are among the most fundamental parts of theoretical and practical training provided for nursing students; however, due to the multi-dimensional nature of the nursing profession, special attention should be paid to other dimensions as well. According to the research results, the existing nursing curriculum focuses mainly on transferring knowledge and skills associated with physical and routine care. One participant expressed,

“Most of our courses were related to various diseases and nursing care, and educators rarely talked about ethical and legal issues during their lectures” (Participant No. 6/ Nursing Student).

Another participant stated the reasons for the focus of nursing education on the physical and caring dimensions:

“Well, when we see that our graduates have problems in providing quality clinical care, we also have to do more in the field of clinical care.”(Participant No.3/ Faculty Member).

Limited competency of nursing educators

Educators play an undeniable role in training competent nurses through institutionalizing beliefs and behaviors. Using proper teaching and behavioral approaches, educators can improve students’ critical thinking skills and prepare them to promote justice in health systems. According to the participants, insufficient competency of nursing educators in teaching social justice issues and inappropriate value perspectives of educators in developing social justice were the main properties of this category.

Insufficient capabilities of educators in teaching social justice issues

Educators must be equipped with sufficient scientific, practical, and ethical capacities in order to effectively institutionalize the concept of social justice in students. According to the participants, nursing educators’ insufficient knowledge and experience about social justice issues make it difficult for them to transfer such knowledge to their students. One participant said,

“When I was a student, I once informed my educator about the unjust patient admission procedure in the surgical department. Yet, my educator recommended me to do what the head nurses would say. I did not see the necessary authority in my educator to establish justice” (Participant No. 11/ Clinical Nurse).

Low presence of nursing educators in clinical and community settings is also one of the factors that, according to the participants, has contributed to this problem.

“Unfortunately, our professors are so involved in education and research, especially to promote themselves, that they do not have the opportunity to address social issues.” (Participant No.9/ Faculty Member).

Inappropriate value perspectives of educators in developing social justice

The participants highlighted the important role of nursing educators’ ethical perspectives in promoting the quality of education and training qualified nurses who would provide services tailored to the needs of the society. They also argued that ethical values could help educators establish and expand social justice in health systems. According to the results, most of the educators had undesirable value perspectives on establishing social justice in the area of health. In this respect, participant no. 5 stated,

“When a nurse has no right to make any decisions in a healthcare system, what can I say to the student about social justice?” (Participant No. 5/ Faculty Member).

“My main responsibility is to transfer knowledge in the field of nursing and I think ethics should be taught by educators in medical ethics.” (Participant No.2/ Faculty Member).

Inappropriate education approaches

Education approaches are considered an essential part of the educational structure and play a key role in transferring ethical values such as social justice to students. Given the abstract nature of social justice, choosing the best education approach could help educators resolve complicated problems during teaching in order to institutionalize professional values and beliefs. According to the findings, educators adopt poor education approaches to transfer ethical values such as social justice and self-awareness to students. In this regard, focusing on traditional education approaches and using insufficient affective learning approaches were cited by the participants.

Focusing on traditional education approaches

Undoubtedly, lecturing is one of the most widely used education approaches; however, this traditional method is very ineffective in teaching abstract concepts such as social justice. According to the participants, educators mostly use lecturing approach to teach social justice issues and students are rarely involved in the teaching process. One participant argued that educators mainly use teacher-centered approaches in ethical discussions, stating,

“We (the students) had no active role in the professional ethics class. The educator spoke on relevant topics based on the availed syllabus and provided some examples of clinical ethical issues. However, I think that educators must discuss social justice issues with students to help them visualize and understand cases of injustice and discuss appropriate reactions in such situations” (Participant No. 13/ Nursing Student).

Another participant stated this:

“The predominant teaching method in professional ethics classes has been lecturing. Every now and then, there was some discussions in between, but it was very rare. Other nursing educators were also using the lecture method when talking about ethics” (Participant No. 7/ Nursing Student).

Using insufficient affective learning approaches

The use of affective learning strategies such as reflective activities and simulations leading to emotional responses plays an important role in creating self-reflection and transferring professional knowledge and skills to nursing students. However, based on the participants’ experience, affective learning approaches are not used effectively and systematically in teaching ethical issues such as social justice. In this regard, one participant stated,

“Since there are too many topics on professional ethics, we (educators) can only convey basic issues to students and it is difficult for us to adopt other learning strategies such as the affective approach” (Participant No. 4/ Faculty Member).

The same participant further stated:

“Now, in the professional ethics class, I do my best to teach the content with a combination of methods. For example, we have formed a group for medical students in the cyberspace (WhatsApp) and asked students to express the issues and questions of clinical ethics. They should raise it there because there is no time in the classroom for these issues. However, we have not performed the same for nursing students yet” (Participant No. 4/ Faculty Member).

According to the research findings, social justice in a health system is a neglected component of academic nursing education due to factors including insufficient educational content, limited competency of nursing educators, and inappropriate education approaches. These factors were introduced as the main research subcategories in this study.

Some weaknesses were observed in the content of nursing curriculum, which is an main factor in promoting professional nursing values such as social justice in nursing students. Lack of attention to the issue of social justice in nursing curriculum has also been mentioned in other studies [ 13 , 20 ]. Based on the participants’ experience, most of the nursing courses are allocated to medical issues and clinical care. According to Thurman, clinical specialties have received the main focus of nursing curriculum, whereas little attention has been paid to social justice issues [ 21 ] . This problem can be attributed to the poor performance of nurses in clinical care. The participants also believed that there was discontinuity in presenting courses on ethical values because the professional ethics course was presented only to undergraduate students. This issue disrupts the proper institutionalization of ethical values such as social justice in nursing students. Frenk et al. believe that the preparation of healthcare professionals to address current healthcare inequalities and challenges has been slowed down by obsolete, fragmented, and static curriculum [ 29 ]. In addition, Rozendo et al. highlighted inconsistencies in terms of presenting social justice-related issues in nursing curricula and argued that there was little material on social justice in post-graduate nursing programs [ 14 ].

Nursing educators’ competencies also affect teaching social justice issues. In today’s rapidly-changing world facing numerous crises, experienced educators play a significant role in training qualified nurses equipped with various skills enabling them to create social development. Accordingly, Read et al. highlighted the critical role of nursing educators in institutionalizing fundamental principles of social justice and health equity in students [ 30 ]. According to Ellis, educators should shift nursing students’ learning and thinking attitudes from individualism to community-centered frameworks and from tertiary (reactionary) to primary (preventive) care approaches [ 31 ]. However, unfortunately, the research findings indicated that nursing educators are not sufficiently qualified to teach and institutionalize social justice in students. In this regard, educators’ insufficient knowledge and experience in teaching social justice issues were highlighted by the participants. Borhani et al. found that ethical knowledge of nursing educators determined their students’ professional ethics competencies [ 32 ]. Akbas et al also argued that nursing educators’ knowledge and skills were the first and most important factors affecting their success in teaching issues of professional ethics [ 33 ]. As mentioned by the participants, inappropriate value perspectives of educators in developing social justice was another weakness of nursing educators. The significant impact of educators’ perspectives on teaching ethical values such as social justice has also been emphasized by Parandeh et al. [ 12 ].

Education approaches adopted to present and convey ethical values to students are of high importance. In this regard, Einhellig discussed the ineffectiveness of traditional approaches such as lecturing in institutionalizing social justice in nursing graduates and outlined the benefits of affective learning approaches [ 19 ]. According to the findings, lecturing is the dominant approach used to teach social justice in Iran’s nursing faculties, which is an inefficient teaching approach, as suggested by the research literature. This is probably due to the large number of students and limited time allocated to each academic course. While cognitive learning approaches rely on principles and concepts, affective learning approaches support the integration of knowledge with emotions, attitudes, and personal beliefs [ 34 ]. Neumann found that affective education approaches could enhance students’ understanding and use of ethical values [ 35 ]. Einhellig highlighted that nursing faculties need to use various strategies with a focus on behavior changes in order to successfully institutionalize the concept of social justice in nursing graduates [ 24 ].

Limitations

The findings of the present study were limited to factors affecting education of social justice in the nursing curriculum in the health system in the culture of Iran. Other limitations of this study was the consideration of the three nursing faculties and two teaching hospitals in Iran. As such, it may not be a representative of the experiences of all the nursing profession members in Iran. Limitations of our study proposed the need for conducting further studies with larger and mixed groups and in different cultures.

The research findings provided researchers with an insight into the weaknesses of nursing curricula, educators, and education approaches in social justice development in Iran. It seems that more attention must be paid to professional values and social determinant of health in nursing curricula in order to train justice-seeking nurses with a sense of responsibility. Educators play a prominent role in training competent individuals who are aware of and sensitive to social issues and inequalities. It is necessary to change the education approaches adopted by nursing educators in order to institutionalize the concept of social justice in students. After changing the content of nursing curriculum and applying different education approaches, future studies can focus on the impact of such changes on social development and social justice promotion.

Availability of data and materials

The interview dataset generated and analysed during the current study are not publicly available due to promises of participant anonymity and confidentiality. However, on reasonable request the data could be available from the corresponding author. All applications should be sent to [email protected] . All requests will be answered within a maximum of 1 month by email.

Abbreviations

World Health Organization

American Association of Colleges of Nursing

International Council of Nurses

American Nurses Association

Canadian Nurses Association

Kaya H, et al. Personal and professional values held by baccalaureate nursing students. Nurs Ethics. 2017;24(6):716–31.

Article   PubMed   Google Scholar  

Tehranineshat, B., C. Torabizadeh, and M. Bijani, A study of the relationship between professional values and ethical climate and nurses' professional quality of life. Int J Nurs Sciences. 2020;7(3):313-19.

American Association of Colleges of Nursing, The essentials of baccalaureate education for professional nursing practice. Washington, DC: American Association of Colleges of Nursing; 1998.

Perry DJ, et al. Exercising nursing essential and effective freedom in behalf of social justice: a humanizing model. ANS Adv Nurs Sci. 2017;40(3):242–60.

Plamondon KM, et al. The integration of evidence from the commission on social determinants of health in the field of health equity: a scoping review. Crit Pub Health. 2020;30(4):415–28.

Institute of Medicine, The future of nursing: Leading change, advancing health. Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing. Washington, D.C.: National Academies Press; 2011.

Davis RK, et al. Social justice as an expression of caring through holistic admissions in a nursing program: a proposed conceptual model. Nurs Forum. 2020;55(4):723–9.

Matwick AL, Woodgate RL. Social justice: a concept analysis. Public Health Nurs. 2017;34(2):176–84.

Browne AJ, Reimer-Kirkham S. Problematizing social justice discourses in nursing. In: Philosophies and practices of emancipatory nursing: Social justice as praxis; 2014. p. 21–38.

Chapter   Google Scholar  

Walter RR. Emancipatory nursing praxis: a theory of social justice in nursing. Adv Nurs Sci. 2017;40(3):225–43.

Article   Google Scholar  

Parvan K, Hosseini F, Zamanzadeh V. Professional Values from Nursing Students' Perspective in Tabriz University of Medical Sciences: a pilot study. Iran J Nurs (2008-5923). 2012;25(76):69–82.

Parandeh A, et al. Factors influencing development of professional values among nursing students and instructors: a systematic review. Global J Health Sci. 2015;7(2):284.

Google Scholar  

Waite R, Brooks S. Cultivating social justice learning & leadership skills: a timely endeavor for undergraduate student nurses. Nurse Educ Today. 2014;34(6):890–3.

Rozendo CA, Santos Salas A, Cameron B. A critical review of social and health inequalities in the nursing curriculum. Nurse Educ Today. 2017;50:62–71.

Menzel N, Willson LH, Doolen J. Effectiveness of a poverty simulation in second life®: changing nursing student attitudes toward poor people. Int J Nurs Educ Scholarsh. 2014;11(1):39–45.

Breen H, Jones M. Experiential learning: using virtual simulation in an online RN-to-BSN program. J Contin Educ Nurs. 2015;46(1):27–33.

Davis JN, Sullivan K, Guzman A. Catalyst for growth: the implications of co-curricular experiences for nursing education. J Nurs Educ. 2018;57(2):110–4.

LeBlanc RG. Digital story telling in social justice nursing education. Public Health Nurs. 2017;34(4):395–400.

Einhellig K, Hummel F, Gryskiewicz C. The power of affective learning strategies on social justice development in nursing education. J Nurs Educ Pract. 2015;5(1):121.

Canales MK, Drevdahl DJ. Social justice: from educational mandate to transformative core value, in Philosophies and practices of emancipatory nursing: Social Justice as Praxis. New York, NY: Routledge; 2014. p. 155–74.

Thurman W, Pfitzinger-Lippe M. Returning to the profession's roots: social justice in nursing education for the 21st century response. Adv Nurs Sci. 2017;40(4):318.

Torres-Harding SR, Meyers SA. Teaching for social justice and social action. J Prev Interv Community. 2013;41(4):213–9.

Groh CJ, Stallwood LG, Daniels JJ. Service-learning in nursing education: its impact on leadership and social justice. Nurs Educ Perspect. 2011;32(6):400–5.

Einhellig K, Gryskiewicz C, Hummel F. Social justice in nursing education: leap into action. J Nurs Care. 2016;5(374):2167–1168.1000374.

Hellman AN, et al. Understanding poverty: teaching social justice in undergraduate nursing education. J Forensic Nurs. 2018;14(1):11–7.

Speziale HS, Streubert HJ, Carpenter DR. Qualitative research in nursing: advancing the humanistic imperative. 5 th edition. 2011: Wolters Kluer: Lippincott Williams & Wilkins; 2011.

Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12.

Article   CAS   Google Scholar  

Lincoln YS, Guba EG. But is it rigorous? Trustworthiness and authenticity in naturalistic evaluation. New Dir Prog Eval. 1986;1986(30):73–84.

Frenk J, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet. 2010;376(9756):1923–58.

Read CY, Betancourt DMP, Morrison C. Social change: a framework for inclusive leadership development in nursing education. J Nurs Educ. 2016;55(3):164–7.

Ellis S. The existing intersection of social justice and nursing; 2013.

Borhani F, et al. Professional Ethical Competence in nursing: the role of nursing instructors. J Med Ethics Hist Med. 2010;3(3):1-8.

Akbas M, Kadioglu S, Tuncer I. Ethics in nursing education from the viewpoints of Turkish nursing educators. Int J Educ Sci. 2017;19(2–3):104–12.

Holt KM. Affective domain learning in high-fidelity simulation: students’ perspectives; 2017.

Neumann JA, Forsyth D. Teaching in the affective domain for institutional values. J Contin Educ Nurs. 2008;39(6):248–52.

Download references

Acknowledgments

This study is a part of a PhD dissertation approved and funded by Vice Chancellor for Research, Urmia University of Medical Sciences. The researchers would like to thank the authorities of School of Nursing and Midwifery, Urmia University of Medical Sciences, as well as the participants for their kind cooperation.

This study was funded by Department of Research, Urmia University of Medical Sciences, which had no role in the design of the study, data collection, analysis, interpretation of data, or writing the manuscript.

Author information

Authors and affiliations.

Faculty of Nursing and Midwifery, Urmia University of Medical Sciences, Urmia, Iran

Hosein Habibzadeh, Madineh Jasemi & Fariba Hosseinzadegan

You can also search for this author in PubMed   Google Scholar

Contributions

The study was designed by HH,MJ and FH. FH participated as the main interviewer. The initial deductive data analysis was done by FH and used as validation of the analysis carried out by HH and MJ. The final data analysis of the interviews was discussed and consented to by all authors. A first draft of the article was developed by FH and MJ. All authors then contributed to this, and finalized it together. FH was responsible for the final draft of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Fariba Hosseinzadegan .

Ethics declarations

Ethics approval and consent to participate.

The participants were selected after the approval of Ethics Committee of Urmia University of Medical Sciences and necessary permissions (Code: IR.UMSU.REC.1397.223) were granted. Prior to the interviews, the participants were informed about their anonymity, confidentiality of their information, the research method and objectives, and their right to leave the study at will. The participants also signed informed consent forms.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1., rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Habibzadeh, H., Jasemi, M. & Hosseinzadegan, F. Social justice in health system; a neglected component of academic nursing education: a qualitative study. BMC Nurs 20 , 16 (2021). https://doi.org/10.1186/s12912-021-00534-1

Download citation

Received : 04 July 2020

Accepted : 02 January 2021

Published : 12 January 2021

DOI : https://doi.org/10.1186/s12912-021-00534-1

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Social justice
• Health equity
• Qualitative study

BMC Nursing

ISSN: 1472-6955

• General enquiries: [email protected]

An official website of the United States government, Department of Justice.

Here's how you know

Official websites use .gov A .gov website belongs to an official government organization in the United States.

Secure .gov websites use HTTPS A lock ( Lock A locked padlock ) or https:// means you’ve safely connected to the .gov website. Share sensitive information only on official, secure websites.

OJJDP FY24 Post-Secondary Education Opportunities for Child Protection Professionals

Download PDF, 419.26 KB

With this solicitation, OJJDP seeks to develop and promote post-secondary and professional continuing education for child protection professionals in the field, including law enforcement officers, social workers, mental and medical health professionals, and prosecutors.

Eligibility

• State governments
• City or township governments
• Public- and state-controlled institutions of higher education
• County governments
• Native American Tribal governments (federally recognized)
• Native American Tribal organizations (other than federally recognized Tribal governments)
• Nonprofits having a 501(c)(3) status with the IRS, other than institutions of higher education
• Nonprofits that do not have a 501(c)(3) status with the IRS, other than institutions of higher education
• Private institutions of higher education
• For-profit organizations other than small businesses

Similar Opportunities

• OJJDP FY24 Nonparticipating States: Texas and Wyoming
• OJJDP FY24 Expanding Youth Access to Community-Based Treatment – Training and Technical Assistance and Program Development
• OJJDP FY24 Supporting Effective Interventions for Youth With Problematic or Illegal Sexual Behavior Program

Jackson Walker Says Judge Tried to Mislead Court on Romance (2)

By James Nani

A Jackson Walker partner was asked by a former Texas bankruptcy judge to file a potentially false court disclosure about his relationship with his secret live-in girlfriend, the firm said in court papers.

The Texas law firm’s filing Wednesday in several bankruptcy cases adds a blockbuster new allegation to the still-unfolding scandal surrounding the resignation of David R. Jones, once the busiest corporate bankruptcy judge in the country, after he admitted to the romance with attorney Elizabeth Freeman last year.

Jones, Freeman, and Jackson Walker are all facing litigation accusing them of improperly keeping the relationship out of the public eye.

Jackson Walker said Jones indicated in late 2022 that he wanted the matter kept under wraps, just as the firm was negotiating with Freeman over whether it should disclose the romance — or if she should leave the firm.

The filings provide new details in the timeline of the scandal, which has rocked the tight-knit bankruptcy community.

Freeman had insisted in 2021 that her relationship with Jones was over. But Jackson Walker found out on Feb. 1, 2022, that Jones and Freeman were still in a romantic relationship: a non-bankruptcy law firm partner heard about it from an acquaintance of Freeman’s ex-husband.

Jackson Walker’s management confronted Freeman on March 29 that year. The next day, she admitted that the two had “rekindled their relationship,” the firm said.

Jackson Walker spokesman Jim Wilkinson and Freeman attorney Tom Kirkendall declined to comment. Jones didn’t immediately respond to a request for comment.

‘Unprecedented Circumstances’

To be retained as counsel, law firms must disclose any connections to with interested parties in a case as part of standard filings in a suit.

Jackson Walker’s latest filings lay out its defense of how it tried to address the Jones-Freeman situation, why it shouldn’t be held responsible for what it says it Jones’ misconduct, and why the US Trustee’s push to claw back its fees should be rejected.

The “unprecedented circumstances required a thoughtful approach” that led to months of talks between the firm and Freeman’s attorney, Tom Kirkendall, about how to disclose the relationship. The situation was especially sensitive because Jones “was convinced” that the rules didn’t require disclosure of the relationship, Jackson Walker said.

By Oct. 28, 2022, Freeman was given a draft agreement to withdraw from Jackson Walker. The draft included language that Freeman would “confer and cooperate” with the firm when it came to existing clients, and allowed Freeman and the firm to continue to work together after she left.

As negotiations continued, Jones sometime in October or November 2022 invited Freeman’s colleague and Jackson Walker bankruptcy partner Matthew Cavenaugh into his chambers after a hearing, the firm said.

Jones told Cavenaugh that as the judge, he “alone” was required to disclose the relationship with Freeman—not the firm—and “insinuated that he was displeased with JW’s desire for a full disclosure of his romantic relationship with Ms. Freeman,” according to the filing.

Jones at the end of the conversation gave Cavenaugh a proposed disclosure that described Freeman as Jones’ former law clerk, noted they were former law partners, and said they maintained a “close personal relationship.” Jones’ proposal didn’t fully address the romantic element of their relationship, according to the firm.

Jones instructed Jackson Walker to use the proposed disclosure in future cases the firm brought before him in court, saying the firm “needs to make this happen,” according to the filing. The proposed disclosure didn’t mention Jones’ and Freeman’s shared home, either, according to Jackson Walker.

“JW determined that the disclosure was potentially misleading or untruthful because it did not fully disclose the nature of Judge Jones’s relationship with Ms. Freeman,” the firm said. “As a result, JW declined to use Judge Jones’s proposed disclosure, and proceeded with its separation from Ms. Freeman.”

Says ‘Acted Reasonably’

Jackson Walker made the statements about Jones and the timeline of the situation in several bankruptcy cases on Wednesday, including in the Chapter 11 of JCPenney .

The Justice Department’s bankruptcy monitor, the US Trustee’s office, is seeking to claw back at least $13 million in fees Jackson Walker earned in cases in which the firm failed to disclose the romantic relationship, including in JCPenney’s.

In the JCPenney filing, Jackson Walker said it didn’t violate any ethical rules, disclosure obligations, or other duties as alleged by the US Trustee. Jackson Walker “could not disclose information it did not know” and “acted reasonably,” the firm said.

Jackson Walker complained that the US Trustee has been targeting the firm, but so far had failed to impose any consequences on Jones or Freeman.

“It is ironic that the U.S. Trustee alleges JW should have disclosed the nature of the relationship to the same judge who knew of the relationship, allegedly had a duty to disclose or recuse himself, and who knowingly declined to do so,” Jackson Walker said.

A Justice Department spokesman declined to comment on Thursday.

The case is J. C. Penney Direct Marketing Services LLC , Bankr. S.D. Tex., No. 20-20184, response 5/22/24.

To contact the reporter on this story: James Nani in New York at [email protected]

To contact the editor responsible for this story: Maria Chutchian at [email protected]

Learn more about Bloomberg Law or Log In to keep reading:

Learn about bloomberg law.

AI-powered legal analytics, workflow tools and premium legal & business news.

Already a subscriber?

Log in to keep reading or access research tools.

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Elsevier - PMC COVID-19 Collection

Health and social justice

Jennifer prah ruger.

a Department of Epidemiology and Public Health, School of Medicine, Yale University, New Haven, CT 06520, USA

4 years into the new millennium, the health of the world's citizens is remarkably uneven. A child born today in Japan, for example, can expect to live to age 82 years on average, whereas it is unlikely that a newborn infant in Zimbabwe will reach his or her 34th birthday. 1 Over several decades, scientific progress has expanded our ability to improve human health, and many regions of the world have achieved significant health gains. Yet extreme deprivation in health is still widespread. Resolving this predicament of major health improvement in the midst of deprivation is one of the greatest global challenges of the new millennium.

These health disparities exist in a world that is becoming more closely linked in all domains, including health. The rapid spread and quick containment of severe acute respiratory syndrome (SARS) demonstrates the interconnectedness of our world as well as any recent health phenomenon. The same trend can be seen with HIV/AIDS and the potential to link solutions and best practices studied in one part of the globe with persistent health problems in another.

In the midst of such rapid global change and persistent health disparities, we need to revisit and underscore the moral and philosophical foundations for health improvement activities—to give them more forceful grounding and solidity. In this essay, I briefly survey some traditional philosophies of justice and health care. I then offer an alternative view of justice and health that is rooted in Amartya Sen's capability approach and Aristotle's political theory, and discuss the implications of this approach for health improvement across the globe.

Philosophical foundations

Theories of social justice (eg, fair and equitable treatment of people) have typically focused on justifying health care (medicine and public health) as a special social good. Rationalising greater equality in health care is typically the point of departure for most approaches to medical ethics (bioethics), even for approaches that include health assessment. In general, less attention has been paid to universal concerns of social justice with respect to health itself. This essay focuses on the question of why health, as opposed to health care, has special moral importance for social justice in health improvement activities. I also analyse the implications of equity in health and health care.

Philosophical theories have been reluctant to give health (by contrast with health care) special moral importance for at least one primary reason: they share the assumption that health is not an appropriate focal variable for assessing social justice. Egalitarian theories, for example, “propose that persons be provided an equal distribution of certain goods such as health care, but all prominent egalitarian theories of justice are cautiously formulated to avoid making equal sharing of all possible social benefits a requirement of justice”. 2 Utilitarian theories, although consequentialist (eg, assessing states of affairs or actions in terms of their consequences), focus on the space of “utilities” (satisfaction, desire fulfilment, preference), 3 whereas communitarian approaches focus on community values, 4 rather than on health itself. Liberal theories of justice are disinclined to focus on health because, as John Rawls purports in his book, A theory of justice, natural goods like health are not included as social values or social primary goods (eg, “liberty and opportunity, income and wealth and the bases of self-respect”) that are “things that every rational man is presumed to want.” 5 He adds that “health and vigor, intelligence and imagination, are natural goods; although their possession is influenced by the basic structure, they are not so directly under its control.” 5 Thus, according to Rawls, health is not one of the social primary goods that should be “distributed equally unless an unequal distribution of any, or all, of these values is to everyone's advantage.” 5 Although he discusses basic health care later in his book, Law of Peoples, Rawls does not include health in the list of social primary goods subject to distributive principles.

Norman Daniels argues that, “health is an inappropriate object, but health care, action which promotes health, is appropriate.” 6 He and others emphasise that “… a right claim to equal health is best construed as a demand for equality of access or entitlement to health services …”, 6 and note that a “‘right to health’ embodies a confusion about the kind of thing which can be the object of a right claim”. 6 Such reasoning illustrates the strong bias against health as a focal variable in current ethical theory.

A capability view of health

A contrasting argument is that health has special moral importance because of its status as an end of political and societal activity. According to Aristotle, society's obligation to maintain and improve health rests on the ethical principle of “human flourishing” 7 , 8 , 9 , 10 , 11 —the ability to live a flourishing, and thus healthy, life. 7 , 8 , 9 , 10 , 11 Flourishing and health are inherent to the human condition. 7 , 8 , 9 , 10 , 11 Indeed, certain aspects of health sustain all other aspects of human flourishing because, without being alive, no other human functionings are possible, including agency, the ability to lead a life one has reason to value. 12 , 13 , 14 It can be argued, therefore, that public policy should focus on the ability to function, and that health policy should aim to maintain and improve this ability by meeting health needs. 15 , 16 This view values health intrinsically and more directly than solely “instrumental” social goods, such as income or health care. It gives special moral importance to health capability: an individual's opportunity to achieve good health and thus to be free from escapable morbidity and preventable mortality. 15 , 16

Cass Sunstein

This line of reasoning—focusing on human capability—contrasts with the idea that health care is special because of its impact on equality of opportunity. 6 It also differs from the utilitarian view that health care is important for maximising the sum total of utilities and from procedural views that focus on guaranteed due process. The distinction between these approaches is rooted in the different points of focus that these theories support. Capability describes what individuals are able to do and be, offering a realistic sense of their freedom to pursue the lives they have reason to value. Thus, society is morally obligated to attach importance to averting or ameliorating loss in physical functioning even if a person's subjective utility assessment is quite high and even if opportunity of employment is still possible. In short, a person's ability to function, rather than to be happy or to have employment opportunities, should be the gauge for assessing public policy.

A capability view of health also includes human agency (ie, people's ability to live a life they value). 17 , 18 Although health directly affects the ability to exercise agency, agency influences health as well. For example, the ability to lead the life one values can improve one's mental health or well-being. Conversely, the ability to make unhealthy choices can degrade one's health status. Enabling individuals to exercise their agency—both individually and collectively—enables them to prioritise and decide which health domains they value most (eg, to trade-off quality and quantity of life) and to choose what health services they would like to consume (eg, making choices among treatment options).

The exercise of human agency can occur at both the individual and collective levels. Individual agency is important in decisions about health habits and risks, lifestyle, individual priorities, and decisions about treatment options. Collective agency is more important at the policy level, where open discussion and collective decision-making influence policy and resource allocation. This relates to the “process” aspect of freedom in the capability approach. 14

Policy implications

There are several sets of policy implications related to a capability view of health. First, the distinction between a capability approach to health and other well-known ethical approaches has implications for assessing social inequalities and for evaluating the effects of social policy on broader health determinants. Health care is not the only health determinant, as Michael Marmot and his colleagues' work has shown, 19 and one must not assume that more and better health care is all that is needed to improve health. The main impact of health care may depend on the type of care and sometimes on other factors. This places both health and health policy in a larger policy context and requires a greater understanding of social justice. 15 , 16 Thus, health and its determinants must be valued against other social ends in a broader public exercise of policy priorities. This exercise should be inclusive and democratic and should represent a process of public reasoning about the ends and means of public policy more broadly and about health policy specifically.

Second, although health care is only one of many health determinants, its influence on health should not be denied. Thus, health care is important and therefore, special, due to its role in influencing health and it must be socially guaranteed. It must be socially guaranteed in a manner that is consistent with improving health overall and reducing health inequalities that are attributable to health care—not in terms of equality in health care delivery (equal amounts or types), irrespective of health consequences.

Third, a capability view of health does not specify which type of health care (eg, a list or basic benefits package) should be guaranteed and to what level. Rather, it recognises the need for further specification through a democratic process that combines both procedural and substantive principles. Substantively, Sen's notion of “basic capabilities” provides guidance since this formulation generally implies that societal efforts be made to bring each individual's health functioning as close as possible to (or above) a certain level of minimal normal functioning (in so far as an individual's circumstances permit). “Basic capabilities” include the ability to avoid escapable morbidity and premature and preventable mortality. Premature mortality implies placing special emphasis on efforts to avert deaths from preventable causes that do not allow individuals to live a life of normal length (eg, a child dying of AIDS). On the question of how much priority should be given to society's worst-off individuals, this view promotes the use of “public reasoning” to forge a compromise between strict maximisation and prioritisation.

Fourth, this “process aspect” of freedom in the capability approach has implications for how health-related policy is made. It emphasises an individual's ability to participate in broad public-policy decision-making (eg, in prioritising between environmental and health care programmes) and in health policy decision-making (eg, in prioritising domains of health and health care for resource allocation). A democratic process can help define a comprehensive package of health benefits to which all should have equal access, and it can help prioritise different types of health care in efforts to maintain and improve health with the fewest possible resources. Such a process is not merely instrumental, however, since its justification lies in the concept that individuals should have the capability to participate in decision-making that affects them, such as about the goods and services that society will guarantee to them.

Fifth, the equity implications of access to those goods and services cannot be separated from the equity implications of financing them, because the capability principle requires that resources be allocated on the basis of medical need, not ability to pay. The costs of health-related goods and services directly affect health by reducing the demand for necessary health care or by increasing consumption of unnecessary care. Leaving people vulnerable to economic barriers therefore would fail to reduce deprivations in health. Additionally, the uncertainty of health need, the catastrophic costs of medical care, and the risk-averse nature of individuals places risk pooling (eg, through insurance) at the centre of health-care financing. 20 An expensive medical event can prevent access to health care or be a primary cause of financial ruin. From a capability point of view, “protective security”, 14 through health insurance, is a necessary safety net. And the economic burden of health care should be justly shared by all through the redistribution of funds from the well to the ill and the rich to the poor, using progressive financing and community rating. 21

Sixth, one of the most difficult tasks in applying an ethical framework that values health intrinsically is the conceptualisation and measurement of health and inequalities in its many domains. There are many approaches to measuring health equity. As Sudhir Anand and colleagues have shown, 22 the choice depends on numerous considerations, ranging from health domains to the weights attached to those domains. 22 Another consideration is the choice of groups for stratification. 22 Even within the capability perspective, one would need to determine what set of inequality measures would be most appropriate for a given exercise, although certain types of inequality assessment—for example, a goal of complete “health equality” (levelling down to lowest common denominator)—have less appeal than others. And certain health equity evaluations—for example, deciding how much priority to give the “worst-off”—will undoubtedly require public reasoning about values imbedded in the health equity concept. Although the capability view of health does not come down on an exact formula for judging inequalities in health, Sen has noted the potential use of “partial ordering” (eg, ordering some alternatives as opposed to ordering them all) of health states for assessing relative inequalities. In a collective exercise, incomplete theorisation may facilitate evaluation in health policy. 15 , 16 , 23

Gro Harlem Brundtland at the Framework Convention on Tobacco Control,2002

Incompletely theorised agreements

Incomplete theorisation is useful to a theory of health and social justice because it provides a framework for understanding collective decision-making on human goods that are plural and indistinct (such as health and inequality), and allows individuals to take divergent paths to a common, though often partial, agreement. It describes how people with divergent, even opposing, views on health, equity, and health-policy issues might reach agreement in specific situations and thus generate health-policy decisions that are legitimate and stable and reflect mutual respect. 15 , 16 , 23 The method of reaching agreement described here is called incompletely theorised agreements, developed by Cass Sunstein, 24 and it holds promise for health-policy decision-making at several levels. 15 , 16 , 23

An incompletely theorised agreement is one that is not uniformly theorised at all levels, from high-level justifications to low-level particulars. It complements and extends the capability approach by providing a framework for operationalising the capability approach at three or more levels. The first level is the conceptual level, which specifies the valuable functionings that constitute human flourishing and health. The second level is the policy level, which specifies policies and laws. The third level is the intervention level, which specifies actions in particular cases and decisions about medical treatments, public-health interventions or social services. This framework constitutes three different types of incompletely theorised agreements: incompletely specified agreements, incompletely specified and generalised agreements, and incompletely theorised agreements on particular outcomes.

Models of incompletely theorised agreements

Incompletely specified agreements

The first type of incompletely theorised agreement occurs when there is agreement on a general principle but sharp disagreement about particular cases. People who accept a general principle, such as the illegality of murder, need not agree on the application of this principle to particular cases. For example, they could disagree about whether abortion should be classified as murder. 24 This first type of agreement is closely connected to Rawls' “overlapping consensus”. In the health-policy context, citizens might agree on cost-effectiveness as a general principle, but also agree that β interferon, a drug that helps some individuals with multiple sclerosis, should be provided to such patients even though its cost per quality-adjusted life year (QALY) ranges from US$35 000 to $20 million, or agree that kidney dialysis should be provided despite its exorbitant cost for relatively small improvements in health-related quality of life.

Incompletely specified and generalised agreements

The second type of incomplete theorisation occurs when people agree on a mid-level principle but disagree about both the more general theory that accounts for it and outcomes in particular controversies. Here, Sunstein argues that the connections between the general theory and mid-level principles and also between specific cases and mid-level principles are unclear. 24 In the health policy context, citizens might agree that all should have access to life saving interventions, but disagree on both the underlying theoretical doctrine for this view and on whether all life saving interventions at all stages of life should be provided.

Incompletely theorised agreements on particular outcomes

This third type of incompletely theorised agreement describes how people reach agreement on particular public policy options. In this model, agreement is reached on low-level principles that are not necessarily derived from a particular high-level theory of the right or the good. In fact, the same low-level principles may be compatible with more than one high-level theory because people may disagree on or not fully understand a relatively high-level abstraction while agreeing on “a point of less generality”.

In such contexts, people “can know that X is true without entirely knowing why X is true.” 24 The emphasis here is on not knowing something entirely—completely theorising it from high to low levels. People might agree, for instance, that governments should prevent famine, eradicate malaria or tuberculosis, and not condone genital mutilation, but they might not know exactly why they hold such beliefs. This reasoning might be both moral and reasonable, but the deliberators might not explicitly state that their decision is derived from an underlying theory, even though it certainly might be informed by a lower level conception of the good life they articulated. This aspect of the framework complements the capability approach's emphasis on partial agreements and on identifying workable solutions that make the most of consensus and that can be “based on the contingent acceptance of particular provisions, without demanding complete social unanimity”. 14

Thus, in matters of public decision-making about health and health policy, the incomplete theorisation framework is useful in furthering a capability approach to health. 15 , 16 First, health, and thus health capabilities, is a multidimensional concept about which different people might have different, and sometimes conflicting, views, especially at an epistemological level. This heterogeneity makes complete theorisation difficult to achieve. Second, there might be no view of health, and thus health capabilities, that is ideal for all evaluative purposes; therefore, the pragmatism of the incomplete ordering of the capability approach and the incompletely theorised agreement on that ordering of the incomplete theorisation approach allows for reasoned public-policy decision-making in the face of multiple, and even conflicting, views on health. Third, there could be no single quantitative scale for comparing health capabilities and the inequalities in them; deviations in individuals' capability for functioning may occur in different domains of health capability that may not be quantifiably comparable. For example, one cannot quantifiably compare one individual's inability to hear or see with another's inability to bear children or to walk. These reductions in individuals' capabilities for functioning are qualitatively different and different people will have widely diverging views on which functional capability reduction is better or worse than the other. Thus, a framework for articulating and agreeing upon a conception of health functioning for prioritising health goods and services is required. Given the demands of policy evaluation in particular contexts, the combined approaches also allow reasoned agreement on central aspects of health and their respective capabilities without requiring people to agree on non-central aspects or fully understand their beliefs.

Global health institutions

What do these philosophical arguments imply for global health institutions? Global health institutions have important roles in the implementation of a capability approach to health because they can help generate and disseminate the knowledge and information required to reduce health disparities. For example, they can help create new technologies (eg, an HIV/AIDS vaccine), transfer, adapt, and apply existing knowledge (eg, prevention of malaria transmission), manage knowledge and information (eg, statistics on inequality in infant/child mortality and best practices), and help countries develop information and research capacity 25 , 26 (eg, health surveillance and information systems).

Global health institutions can also empower individuals and groups in national and global forums. Indirectly, they can push for greater citizen participation in health-related decision-making in developing countries, both within (eg, in determining resource allocation) and outside the health sector. Since greater empowerment in the health sector is built on more democratic governance overall, reform of state and social institutions may be needed to achieve these goals. And encouraging the political will for public action to reduce health inequalities will be essential. Global health institutions, particularly WHO and World Bank, can help governments improve the public administration needed to deliver quality health care to all. They should also give individuals and groups a greater voice in national and international forums and programmes, such as a health-sector loan or an international tobacco-control agreement, and engage more with civil society and the private sector.

Global health institutions can also provide technical assistance, financial aid, and global advocacy to support the development of equitable and efficient health systems and public health programmes. This assistance can occur at the macro level (eg, standardising diagnostic categories) or the micro level (eg, providing antiretroviral medicines for AIDS patients). Some global health institutions (eg, WHO) have tended to organise around specific diseases (HIV/AIDS, malaria, tuberculosis, polio, and SARS), whereas others such as the World Bank have favoured sector-wide initiatives. Although both perspectives are valuable, greater coordination among policy actors is essential. Such efforts should build on existing work such as the Rockefeller Foundation's global health equity initiative. 27

Finally, global health institutions should be linked to other institutions in a coordinated and integrated way. The Framework Convention on Tobacco Control (FCTC), for example, recognises the importance of integrating public policies into a comprehensive set of health improvement strategies. Through the FCTC, ministries of health and health-related associations, such as physician groups, are united with ministries of finance, economic planning, taxation, labour, industry, and education as well as with citizen groups and the private sector, to create a multisectoral national and international tobacco-control effort. The FCTC represents a growing trend in development policy toward an alternative paradigm that is broad, integrated, and multifaceted. 14 , 17 , 28 , 29 , 30 , 31 Adopting a multifaceted and integrated approach to health improvement requires rejecting a narrow view of health and its determinants and the philosophical foundations that support such a view.

Acknowledgments

I thank Amartya Sen, Sudhir Anand, Michael Marmot, and participants in the workshop on Rights, Dignity, and Inequality at Trinity College, Cambridge, UK, for helpful comments. I also thank Washington University School of Medicine and Center for Health Policy for support. J P Ruger is supported in part by a Career Development Award (grant 1K01DA016358–01) from the US National Institutes of Health.