Volume 2, Issue 9 -- November 1999

Extending the Scope of Health Ethics: Social Determinants of Health

Ms. K needs an operation. She is a chronic alcoholic and functionally illiterate. Discussion of factors such as environment, job stress, education, and income levels are rarely seen in health ethics literature. However, when research reveals that these factors have a significant and lasting impact upon the health of the population, a case may be made for expanding the area of concern of health ethics to encompass not only whether Ms. K can give truly informed consent for the operation, but also to why she is an alcoholic and illiterate.

The federal government recently released Toward a Healthy Future: Second Report on the Health of Canadians, which documents the myriad of ways in which a variety of factors, including socioeconomic status, the physical environment, and having a sense of control over one's future, interact to determine whether one will be healthy or unhealthy. The report indicates that these factors, which are often referred to as the social determinants of health, "operate independently of the amount of money we spend upon health care."¹ The report also states that "low-income Canadians are more likely to die earlier and to suffer more illnesses than Canadians with higher incomes."²

Limits of the Biomedical Approach

A strictly biomedical approach, which views the body in isolation as a machine-like entity governed by cause-and-effect relations of disease pathogen to illness, cannot satisfactorily explain why some people live longer and are less prone to disease and accident than others. Instead, a population health approach must be used, which focuses on the interrelated and interdependent conditions that determine health. Research conducted using this approach indicates that one's position in any sort of hierarchy has an impact on one's health. The lower one is in the hierarchy, the less healthy one tends to be, as measured by incidence of diseases and average longevity.³ One study of British civil servants⁴ , revealed that those lower in the organizational hierarchy were, overall, less healthy than their superiors, despite socioeconomic standing well above the "poverty line". For people with low incomes, who often find themselves at the bottom of educational, economic, social, and vocational hierarchies, the detrimental health effects of ranking lower in the hierarchy are amplified. These individuals experience health effects of low socioeconomic status, such as inadequate nutrition, unhealthy living conditions, poor self-esteem, and job insecurity. Therefore, income levels tend to be indicators for other determinants of health.

It is not merely a question of increasing income levels, because health is determined not simply by the average wealth of the members of that population, but by the equity of the distribution of wealth among the members of the group. It is possible to have high population health without extremely high per capita wealth, if the existing wealth is distributed equitably, as is the case with Sweden. Conversely, there can be high per capita wealth without corresponding gains in population health status, as in the United States, for example.

Limits of "Medical" Ethics

Health ethics has become synonymous with medical ethics. But just as medical models of disease epidemiology are insufficient to explain why some people get sick while others do not, a health ethics that focuses exclusively on micro and meso level ethical issues in identifiably medical contexts is also insufficient to deal with all the ethical issues that involve health. Including discussion of the social determinants of health as macro level issues in health ethics debates forces us to recognize the ethical implications of policies in areas seemingly disparate from health ethics, including city planning, job creation, social services, transportation, and education.

Using the population health model, disease and injuries are viewed as "symptoms" of a broader social "disease", a disease which is caused by economic and social inequalities. Health ethics ought to focus debate on these social inequities by looking at systemic causes of health and disease and the social principles and policies that have brought these systemic causes into being.

Health status impacts educational and job opportunities, which in turn play a significant role in determining socioeconomic status, and vice versa. Socioeconomic factors often create vicious circles, wherein poverty begets poor health, which brings with it increased poverty. Likewise, social determinants can create virtuous circles, wherein economic prosperity brings with it improved health which in turn increases wealth.

Health Ethics & Social Determinants

The social determinants of health ought to be considered health ethics issues for reasons both principled and practical. We believe, in Canada, that citizens are entitled to equality of opportunity, as is embodied in the Charter of Rights and Freedoms. When an identifiable group of people are being systematically denied this equality of opportunity because of their health status, an ethical issue arises. Ethics is a set of guidelines for how we interact with each other, both directly and indirectly. Population health research indicates that the way we interact on social, political and economic levels is apparently detrimental to the health of certain groups of people. Since we don't believe, as a group, that the well-off have a right to be healthier than other people, health ethics must work to identify and rectify the conditions that cause some groups of people to be considerably more healthy than others.

On the practical side, working to improve general health of the population reduces acute health care costs, and therefore some of the problems that are created by scarce health care resources will be lessened (although there may be an additional set of problems created by a healthier population that lives longer). In addition, Towards A Healthy Future indicates that there are economic benefits for a society when its population is healthier, as productivity rises and health care costs decrease.

We cannot remedy deficiencies in population health in the health care setting alone. Health ethics can play a role in calling attention to the health impacts of policies made in a variety of other settings. This doesn't mean that health issues alone should determine the agenda for other areas of social policy-making, but it does mean that we need to recognize that health issues are not dealt with exclusively by hospitals or even health ministries and that health ethics issues aren't confined to identifiably "medical" settings.

References

• ¹ Canada, Federal Provincial and Territorial Advisory Committee on Population Health, Toward a Healthy Future: Second Report on the Health of Canadians. (Ottawa: Government of Canada, 1999.) viii. 

• ² ibid. ix.

• ³ Robert G. Evans, Morris L. Barer, and Theodore R. Marmor, eds., Why Are Some People Healthy and Others Not?: The Determinants of Health of Populations (New York: Aldine de Gruyter, 1994)

• ⁴ Evans, Robert G., "Introduction", Why Are Some People Healthy and Others Not?: The Determinants of Health of Populations, eds. Robert G. Evans, Morris L. Barer, and Theodore R. Marmor (New York: Aldine de Gruyter, 1994) 5.

PHEN Internet Discussion Forum

In effort to continue facilitating discussion and dialogue amongst PHEN members about health ethics in the Alberta context, as well as fostering networking between members and providing a forum for the sharing of knowledge, experience, and expertise, PHEN has set up an internet mailing list.

This list is effectively a cyber-forum where Network members can discuss topical and relevant issues in health ethics. The discussion on the list will be guided by the thoughts and interests of PHEN members: members can raise questions or introduce topics of interest at their discretion. One may participate in the discussion by sending an email to the list or simply watch as others share their thoughts. From time to time, Marika Warren, a Senior Research Assistant with PHEN, will share a case study, article, or other such tool with the the group to catalyze discussion.

If you are interested in subscribing, please send an e-mail to majordomo@www3.incentre.net with "subscribe phen" (without quotations) in the subject line and the body of the message. The volume of messages is expected to be light, for those concerned about in-box flooding, and, of course, one can unsubscribe from the list at any time.

We are hoping that interested members of the Network will sign up over the next few weeks. Marika will begin the discussion in earnest in the first week of January. The discussion list will run for a trial period of six to nine months. For more information or if you encounter technical problems, please e-mail Marika Warren at warren@phen.ab.ca.  

PHEN Membership Renewal

A reminder to all that PHEN memberships expire on December 31, 1999. In order to avoid missing out on the benefits of your membership, including your subscription to In Touch, please be sure to send in your membership renewal form (enclosed with this month's In Touch). Membership dues remain at the low rate of $10 for individuals and $25 for institutions. Payment can either be made by cheque (mail in your renewal form to the address indicated) or credit card (fax the form with your credit card number to the number indicated).

Thank you for your continued support of the Network and of the discussion of health ethics issues in Alberta!  

Announcements

• Legislation and Policy: Bill 40 (Health Information Act) received second reading in the Alberta Legislature on Nov 18, 1999. The legislation has significant implications for research ethics boards, particularly regarding the review of protocols which involve identifiable health information. 

• On Nov 15, 1999, Alberta Health and Wellness released the final report of the Long Term Care Review, submitted to the Minister by Policy Advisory Committee Chair Dave Broda. The Ministry is requesting input (by January 7, 2000) on the report's 50 recommendations to government relating to seniors' health and continuing care services. To view the final report, call (780) 427-7164 for hard copies. When viewing the report, see especially Recommendation #46: Take Steps To Explore Ethical Issues (in Continuing Care).

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.