Elsevier

The Lancet

Volume 364, Issue 9439, 18–24 September 2004, Pages 1092-1097
The Lancet

Public Health
Ethics of the social determinants of health

https://doi.org/10.1016/S0140-6736(04)17067-0Get rights and content

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Justice as fairness

An important starting point for a philosophical discussion of the social determinants of health is the application of John Rawls' theory of justice to such determinants.18, 21 In A theory of justice, Rawls24 argued that justice requires the fair distribution of primary goods and that rational people behind a “veil of ignorance” about their personal circumstances would choose principles of justice that maximise the minimum level of primary goods. Primary goods are allocated to individuals on the

A capability perspective

By contrast with Rawls' theory and other well-known philosophies, Amartya Sen developed the capability approach.32, 33, 34 This philosophical framework, with roots in Aristotle's political theory,39, 40, 41, 42, 43 applies to the social determinants of health,37, 38 but it is more “people centred” and “agency-oriented” in its philosophical basis and more nuanced in its practical application. This view sees the expansion of human capabilities—the real freedoms that people have—as the ultimate

A broad and multifaceted approach

A capability approach to the social determinants of health thus recognises the importance of addressing health needs on multiple fronts, in multiple domains of policy that affect all determinants of health (not just socioeconomic inequalities). It emphasises the integration of public policies into a comprehensive set of health improvement strategies delivered through a plurality of institutions. Information about the factors and processes that can improve health (and reduce health inequalities)

Conclusion

It is important to reflect on the richness of the Rawlsian approach to social justice generally and to the social determinants of health more specifically. Such efforts have advanced our thinking about health equity and its determinants. Despite its many strengths, however, the Rawlsian approach has limitations; an alternative approach to health and its determinants (within and outside the health sector) is found in Sen's capability approach. This approach takes human capabilities and freedoms

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