social justice in healthcare essay

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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.

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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.

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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.

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Medicine and Social Justice: Essays on the Distribution of Health Care (2nd edn)

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Because medicine can preserve life, restore health and maintain the body’s functions, it is widely acknowledged as a basic good that just societies should provide for their members. Yet, there is wide disagreement over the scope and content of what to provide, to whom, how, when, and why. In this book, some of the best-known philosophers, physicians, legal scholars, political scientists, and economists writing on the subject discuss what social justice in medicine should be. The forty-two chapters in this second edition update and expand upon the thirty-four chapters of the first edition. Eighteen chapters from the original volume are revised to address policy changes and challenging issues that have emerged in the intervening decade. Twenty-two chapters are entirely new. The treatment of foundational theory and conceptual issues related to access to health care and rationing medical resources have been expanded to provide a more comprehensive and nuanced discussion of the background concepts that underlie distributive justice debates, with global perspectives on health and well-being added. New additions to the section on health care justice for specific populations include chapters on health care for the chronically ill, soldiers, prisoners, the severely cognitively disabled, and the LGBT population. New chapters address questions of justice related to genetics, medical malpractice, research on human subjects, pandemic and disaster planning, newborn screening, and justice for the brain dead and those with profound neurological injury.

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• 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

37k Accesses

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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

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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.

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

Hosein Habibzadeh, Madineh Jasemi & Fariba Hosseinzadegan

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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.

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Not applicable.

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The authors declare that they have no competing interests.

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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

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

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Guest Essay

What Martin Luther King Jr. Knew About Crime and Mental Illness

By Alvin L. Bragg Jr.

Mr. Bragg Jr. is the Manhattan district attorney.

In September 1958, the Rev. Dr. Martin Luther King Jr. was stabbed with a seven-inch steel letter opener. He had been autographing copies of his first book in Blumstein’s department store in Harlem. The woman who stabbed him was named Izola Ware Curry .

When Dr. King found out she was schizophrenic, he harbored no ill will toward her , saying instead, “I know that we want her to receive the necessary treatment so that she may become a constructive citizen in an integrated society where a disorganized personality need not become a menace to any man.”

Dated description aside, King recognized that people in crisis need mental health care to be healthy and safe. The many Izola Ware Currys in New York today are far more likely to find themselves in jail, or relegated to street corners and subway stations, than they are to receive comprehensive treatment. This disconnect can set the stage for people with mental illness to be both victims and perpetrators of real violence.

Mental illness isn’t a crime, and jail isn’t the answer for those experiencing it. We must meet the needs of people in crisis with treatment and support. In order to do so, we need more funding.

Lawmakers in Albany right now are in the final stages of negotiating our state budget. Gov. Kathy Hochul and the leaders of the Senate and Assembly must make good on their earlier support for significant investments in mental health care — especially for New Yorkers who have been struggling, posing potential dangers to themselves and others. Doing so now can reduce assaults in our city by people experiencing mental health crises. They can also ensure that when those people do commit crimes, they are held accountable in a manner that reduces recidivism.

Around half of people in New York City jails — some 3,000 men and women — have been diagnosed with some degree of mental illness. On any given day, hundreds await evaluations or beds at dwindling and overwhelmed state psychiatric hospitals . On a typical day at Manhattan Criminal Court, you’ll witness the churn of people struggling with mental illness, caught up in a cycle of recidivism and incarceration instead of receiving the therapy, medication and other services that would help them lead healthy, productive lives.

And it’s not only New York. According to the Vera Institute of Justice, in the United States, people with serious mental illness are more likely to encounter law enforcement than they are to receive treatment . Since the 1950s, around the time King barely dodged death, the number of state hospital psychiatric beds has decreased by around 94 percent. In many cases, jails and prisons filled the void. While large-scale psychiatric institutionalization was far from perfect — to say the very least — meaningful community-based alternatives never materialized.

Today, corrections facilities double as de facto mental health hospitals across the nation — and about 63 percent of those with a history of mental illness do not receive treatment while incarcerated in state and federal prison.

But it is in New York City where the failed mental health system seems to be on starkest display.

Desperate scenes of people in clear distress on subway platforms, in city parks and on bustling street corners, are commonplace. And although overall crime is down , the city has witnessed terrifying acts of violence and alarming incidents of disorder. Innocent people shoved in front of oncoming trains is a citywide nightmare. Women fear being randomly punched while walking down the street. This is a humanitarian disaster, and a public health and safety crisis.

We must do better — for those with real and complex mental health needs, and for all New Yorkers who currently fear for their safety. But attaining a comprehensive mental health system won’t happen overnight.

In the past few years, I’ve committed $9 million to two programs, Neighborhood Navigators and Court Navigators . In both programs, individuals with lived experience — designated “navigators”— help guide our struggling neighbors through the complex landscape of social services. It’s a start, but so much more is needed.

This year’s state budget is another opportunity to continue to build New York’s mental health infrastructure. My office submitted a detailed proposal to Albany leaders outlining mental health investments that are urgently needed this year. If we fail to take systemic action, New Yorkers will continue to confront daily scenes of desperation, and risk falling victim to shocking — but not surprising — acts of arbitrary violence.

Most directly related to the work of the Manhattan district attorney’s office, I’ve asked Albany to invest at least $25 million to expand and strengthen New York’s problem-solving courts. Such courts provide precisely the kind of treatment options that King may have wanted for his attacker, but that did not exist then. In exchange for pleading guilty, participants are offered court-supervised treatment instead of incarceration.

If they comply with their treatment plan and avoid rearrest (typically for 18 to 24 months), their felony plea can be reduced to a misdemeanor or dismissed. One mental health court found that it reduced the likelihood of rearrest by 46 percent.

I also urged Albany leaders to fund community-based mental health treatment, investing $16.3 million to fund 20 new teams to provide support to justice-involved individuals with serious mental illness. Similar initiatives have been shown to reduce overall recidivism .

For those who cannot be safely diverted from incarceration to treatment in the community, Hope House , which recently broke ground in the Bronx, will soon offer a safe and humane alternative to the Rikers Island jail complex, with 24-hour security and therapeutic treatment. The state should commit $30 million in capital funding to scale up the Hope House model.

Supportive housing provides essential stability to those with mental illness who have been justice-involved. Thousands of individuals returning to New York City from state prison go straight to shelters. Homelessness increases the risk of incarceration, which in turn increases the risk of homelessness. To break this vicious cycle, Albany should invest in building 500 new re-entry apartments over the next three years, and should expand an existing housing program for people leaving city jails.

Since I took office, we have made substantial progress in driving down murders and shootings in Manhattan, but the rise in felony assaults remains a persistent challenge. To reverse the post-Covid rise in random assaults of and by people with untreated mental illness, prevention-oriented investments are critical; enforcement has little deterrence value for crimes committed by those experiencing a mental health crisis.

Following his brush with death at the hands of Izola Ware Curry, King recognized treatment as the best path to keep those with mental illness, and those around them, safe. With assaults like the one King suffered becoming more common, our leaders in Albany must heed his call today and invest in a comprehensive mental health network.

Now is the time for action to address our mental health emergency.

Alvin L. Bragg Jr. is the Manhattan district attorney.

The Times is committed to publishing a diversity of letters to the editor. We’d like to hear what you think about this or any of our articles. Here are some tips . And here’s our email: [email protected] .

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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: 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.
• 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.
• 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.
• 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.
• 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.
• 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.
• 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 […]
• Journal Editors’ Role Regarding Social Justice Issues Journal editors can involve professionals from social justice forums such as civil rights lawyers in their journals as well as reduce the complexity of the presentation of social justice article contents.
• 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.
• 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 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.
• 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”.
• 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.
• Community Engagement and Social Justice Promotion Furthermore, as social justice is integrated into the curriculum, I would like to participate in practice-oriented assignments and class discussions to make a meaningful change.
• 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.
• 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.
• 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.
• 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 […]
• 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.
• 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?
• Chicago (A-D)
• Chicago (N-B)

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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.