In the field of public health it is common knowledge that the determinants of people’s health include many factors other than medical care. In the same vein, the contemporary literature on social inequalities in health has stressed the importance of social factors other than access to health care. It is thus surprising that bioethics has, until recently, focused exclusively on medical care and neglected the ethical implications of broader social factors that impact on people’s health. The good news is that this is changing, and there is now significant ongoing work on the topic of health equity. The essay by Daniels, Kennedy, and Kawachi is an example. We agree with the authors that social inequalities in health raise important questions about justice, but have some comments on the details of their argument.

Daniels, Kennedy, and Kawachi define social inequalities in health as differences in average health between socioeconomic groups. If we are concerned about social justice, however, this definition does not go far enough. The empirical literature shows significant health differentials with respect to other social groups too–for instance, those defined by gender, race and ethnicity, or geographical location. The problem is compounded if these factors interact with socioeconomic status and, as a result, health differentials exist within socioeconomic groups–for example, black men with low incomes have worse health than white men with similar incomes.

The authors use the framework developed by Margaret Whitehead and Goran Dahlgren to link empirical research on social inequalities in health with philosophical work on justice. According to Whitehead and Dahlgren, inequalities in health are inequitable (unjust) if they are "avoidable, unnecessary, and unfair." Yet, fairness surely subsumes what is unavoidable and what is "necessary." Problems of justice and fairness only arise if a certain outcome could have been otherwise; and if what is necessary is interpreted to mean something other than what is unavoidable, then a judgment on what is necessary must ultimately be made with reference to justice and fairness. The framework thus reduces to the question: when are health inequalities unfair or unjust, and why?

The authors base their response on Rawls’s theory of justice as fairness. The issue is whether the existing framework of Rawlsian justice can take care of the problem of social inequalities in health, or whether we need to rethink what justice requires in addressing health inequalities. The authors do not settle this issue, and two different views of the relationship between Rawlsian justice and social inequalities in health are identifiable in their paper.

The first view is that although Rawls did not have the problem of social inequalities in health in mind when he formulated justice as fairness, implementing his principles will go a long way toward reducing such inequalities. This argument suggests that we do not need to pay special attention to the problem of health inequalities. By ensuring greater justice in Rawls’s original sense, we will–as a side-effect–also solve the problem of health inequalities. This view relies on the premise–not made explicit by the authors–that inequalities in health are unjust if, and only if, they are the result of unjust social arrangements.

The second view is based on the premise that a conception of justice should explicitly tackle problems of inequalities in health. This view relies on an extension of the Rawlsian principle of "fair equality of opportunity." Daniels originally developed this view in his book Just Health Care to deal with fair access to health care. According to this account, health is defined as normal functioning and fair equality of opportunity requires the maintenance of normal functioning. But if broader social factors affect people’s health, there is no reason why the extension of the principle of fair equality of opportunity should apply only to health care and neglect the other determinants of health.

We thus discern two views as to how Rawlsian justice might apply in dealing with the problem of social inequalities in health. Their simultaneous presence in the essay creates a tension, since they each might yield a different assessment of what should be done and for what reason. Whereas the extended fair equality of opportunity principle seems to require efforts to correct health inequalities as such, the first account only addresses the problem indirectly. Moreover, the first account is contingent on the empirical relationships that Kawachi, Kennedy, and others have observed. Had the empirical relationships observed been the reverse–for example, had higher income inequality been associated with smaller health inequalities–then implementing Rawlsian justice according to the first view could actually worsen inequalities in health. On the other hand, the extended fair equality of opportunity view is not contingent on any such empirical relationships, and appears to provide a stand-alone case for redressing social inequalities in health.

The tension becomes even more apparent when the authors consider whether we should correct those social inequalities in health that remain after we have implemented Rawlsian justice according to the first view. Specifically, they ask whether it would ever be "reasonable to allow some health inequality in order to produce some non-health benefits for those with the worst health prospects." If trade-offs between health and non-health goods are admissible, these health inequalities may be justifiable–provided the non-health gains under just social arrangements compensate for the health losses. The authors suggest that decisions about trade-offs and compensation are matters for the democratic process, and not for justice itself to settle. But what if pervasive inequalities in health remain–or are even exacerbated–with or without compensation through other goods? What is needed, it seems to us, is an account that explicitly evaluates the distribution of health outcomes and recognizes that health inequalities raise independent problems of social justice. The extended fair equality of opportunity principle would appear to provide the basis for such an account. Were the authors to develop this account, though, the first view of what Rawlsian justice requires would seem to be redundant.

Recent research on social inequalities in health does raise important questions about justice and, in principle, we have no problem with the use of a Rawlsian approach. To us, however, the account provided by Daniels, Kennedy, and Kawachi remains ambiguous about the precise conception of justice that is invoked to address the problem of social inequalities in health.