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PHILOSOPHICAL PERSPECTIVES ON SOCIAL JUSTICE: A FRAMEWORK FOR DISCUSSING A CHILDREN, YOUTH, AND FAMILIES HEALTH POLICY AND RESEARCH AGENDA

ROBERT SEIDEL, MLA, PATRICK H. TOLAN, PHD, ANGELA DIAZ, MD, PHD, MPH, AND VELMA MCBRIDE MURRY, PHD

Discussions of health policy often invoke sentiments of “social justice” and “equity” as primary principles or long-term goals. Implicit in such discussions is an underlying assumption that there is consensus on what a just society might look like and what achieving justice or equity would mean in regard to health opportunities and outcomes. An accompanying presumption, at least implied, is that a body of principles of social justice on which we agree also exists. Yet, outside of academic political philosophy lectures and journals, the articulation of such principles is rare. Even rarer is the explicit connection of these principles to policy, research, and practice decisions. We contend not only that Americans disagree about what is just and equitable on these issues but also that there is a need to engage in careful consideration of what we mean by health equity in research, practice, promotion, and policy. In this endeavor, greater consideration is needed to clarify how these terms and their components are defined and actuated across varying constructions of social equity and justice. Even without consensus on a definition of social justice, discussions of its role in health can only benefit from some common awareness of the major interpretations. This essay provides a brief overview of some major schools of philosophical thought about social justice and equity to emphasize that there is a wide range of perspectives. These perspectives hold different ideas regarding the implications of social justice for health policy, research, and practice. While each school of thought has different definitions of social justice, there are shared concerns about how we ought to live together and what is fair, and that the manner in which resources and responsibilities are distributed and accessed can differ substantially.

While we acknowledge that our framework is an oversimplification of very complex issues, we begin the dialogue on the role of political philosophies regarding social justice and equity by selecting perspectives across different eras and cultures that fall into two broad varieties: those (generally with fullest expression in the European Enlightenment) that emphasize the rights and well-being of the individual, which we term individual-centric, and those that emphasize the well-being of the community or society, which we term community-centric.

Not surprisingly, there have been many thoughtful and sophisticated efforts to identify the right balance of these two perspectives or to reconcile them. However, for the present consideration, we focus on the contrast of basic values as a framework for organizing our discussion. Our intent is to increase our understanding of ways multiple political philosophies implicitly or explicitly offer different definitions of health equity and thereby imply different strategies and approaches to address social justice in health. That we are providing a brief summary suggests that there are inevitably omissions of details and nuances. Notwithstanding, the intent is less to provide a comprehensive or authoritative rendering of fine distinctions than to bring out the range of political perspectives and values that lead to different connotations of “social justice.” These variations in assumptions and values are rarely considered in discussions of health equity research and related practice and policy. This void served as the impetus for our essay, and our goal is to bring that consideration back into overt deliberation.

INDIVIDUAL-CENTRIC PHILOSOPHIES

U.S. society is marked by what is termed in political philosophy as liberalism, or a central concern for the protection and enhancement of the freedom of its citizens as individuals. This is not “liberalism” as it is commonly connoted in the current political debates in our country. As a philosophical term, “liberalism” embraces what most Americans consider to be both conservative and liberal policies and values. Further, philosophical notions of liberalism can consider government as both a potential threat to and protector of individual freedoms. This broad category embraces a number of more-specific perspectives, including libertarianism, John Rawls’s idea of justice as fairness (Rawls, 1971), and the capabilities approach championed by Amartya Sen (Sen, 2009) and Martha Nussbaum (Nussbaum, 2007).

Traditional American Liberalism

Within the overall liberalism that encompasses and frames most policy debates in our country, there is the more commonly identified form of liberalism that

focuses on fully realizing the promises in the Constitution, Bill of Rights, and other documents for all members of society. This can be seen as the philosophy motivating movements such as the Civil Rights Movement; Women’s Rights Movement; and Lesbian, Gay, Bisexual, Transgender, and Queer Rights Movement, as well as those putting religious freedom in contention with other rights and freedoms. What binds these efforts is the view or recognition of the discrepancies between the principles, laws, and policies of the United States in regard to individual freedom (and therefore equal justice) and equal access to those freedoms. The modern rights movements recognize the conflict between individual freedom and the actual treatment of groups of people based on race, gender, sexuality, age, religion, and other natural or socially constructed characteristics.

In regard to health discrepancies, modern liberalism views inequities in opportunity for healthy development as impediments to freedoms of some segments of society enjoyed by others (Sen, 2009). Governmental actions to improve health opportunities and health care access for those who are disadvantaged would, from this perspective, be seen as a necessary action to ensure this freedom is equitably enjoyed by all (Braverman, 2006).

Libertarianism

The libertarian perspective is often contrasted with traditional liberalism. The various strands of modern libertarianism, including Ayn Rand’s objectivism (Rand, 1961), emphasize individual choice over equal opportunity or access as the hallmark of guaranteed freedom (Daniels, 1985). While there are variations within this branch of liberalism as to how absolute that emphasis is in regard to health, the emphasis is on individuals’ right to control their bodies as well as their resources/capital, as long as their actions do not interfere with other individuals’ same rights. Within a broader opposition to government involvement, taxation-based financing, compulsory activities, and regulations that curtail choice, the libertarian approach to health care equity as a social-justice issue is to promote choice and focus any governmental or legal involvement to ensuring fair rules for commerce (Buchanan, 1984). This approach values the freedom of choice over potential inequities that may be sustained due to differences in status or capability but also argues that individual choice in a free-commerce market will lead to greater equity and justice.

Because libertarianism casts health influences, health care access, and health opportunities over the life span as understandable as commerce between individuals and that maximal individual freedom is the most essential value (and best solution), health equity solutions from this perspective tend to be in the

form of allowing many choices, minimizing requirements for health care, insurance, features of such insurance, or provision of health care to all. While there is recognition of historical and political bases for inequities of health opportunities, access, and outcomes, this general framework is still offered as the most appropriate and promising approach to health equity and social justice (Daniels, 1985).

Modern Liberalism

Justice as Fairness

Late-20th-century academic political philosophy, particularly in the United States, has been significantly influenced by John Rawls. Rawls sought to temper liberalism’s focus on individual rights with a consideration of fairness. To show the importance of fairness, he utilized a thought experiment (Rawls, 1971). In this experiment, he posed the question: If a group of people were behind a veil of ignorance, knowing nothing about their own specific characteristics (age, gender, race, wealth, ability, religion, likes and dislikes, plans for the future, and so on), what kind of social contract would they adopt before their actual characteristics were revealed? Not knowing, for example, whether one is rich or poor, deaf or hearing, one might want to both protect oneself by setting rules to minimize vulnerability as well as maximize opportunity along a variety of dimensions.

Based on this thought, Rawls came to the conclusion that two general principles would emerge from deliberations behind the veil of ignorance. The first is that “Each person is to have an equal right to the most extensive basic liberty compatible with a similar liberty for others” (Rawls, 1971, p. 302). The second principle, which he refers to as the “difference principle,” is that social and economic inequalities are to be arranged so that they are to be of the greatest benefit to the least-advantaged members of society. Also, offices and positions must be open to everyone under conditions of fair equality of opportunity. Thus, in Rawls’ analysis, there is a balance of individual liberties with equality of opportunity, with particular attention to reducing inequities.

From this critical view, rewards should be provided to the extent they reduce inequities or benefit the least advantaged. Doctors should receive greater income than many other people, if and only if that is what it takes to provide adequate health care for the least advantaged. Furthermore, one should not be able to buy one’s way into better health care or to advantageous social positions that create privilege over others. From Rawls’s perspective, health equity would reside in policies and practices that accorded the most disadvantaged access to

opportunities for healthy development, health care and awareness, and quality of life and longevity that align with the most privileged in society (Braverman, 2006). To advance this school of thought, research is needed to identify factors and processes that would enable and improve the circumstances of the disadvantaged and evaluate practice and policies to determine the extent to which they are designed to do so.

The Capabilities Approach

Martha Nussbaum, a senior member of the philosophy faculty at the University of Chicago, and Nobel Prize–winning economist Amartya Sen developed and use the capabilities approach “to provide the philosophical underpinning for an account of core human entitlements that should be respected and implemented by the governments of all nations, as a bare minimum of what respect for human dignity requires” (2007, p. 70). Rather than using the conventional liberal language of human rights, Nussbaum promotes “an approach that focuses on human capabilities, that is, what people are actually able to do and to be, in a way informed by an intuitive idea of a life that is worthy of the dignity of the human being” (2007, p. 70). Nussbaum explicitly places the central human capabilities as “the source of political principles for a liberal pluralistic society” (2007, p. 70). She notes that a list of central capabilities will always be a work in progress, but offered this one in 2007:

1. Life (ability to live a life of normal length)
2. Bodily Health (ability to have good health with adequate nourishment and shelter)
3. Bodily Integrity (ability to move freely from place to place, be secure from violent assault, and have opportunities for sexual satisfaction and reproductive choice)
4. Senses, Imagination, and Thought (ability to use the senses, imagine, think, and reason in a way cultivated by adequate education to be creative in context of freedom of expression; ability to enjoy pleasure and avoid nonbeneficial pain)
5. Emotions (ability to love, grieve, experience longing, gratitude, and justified anger; having emotional development not blighted by fear and anxiety)
6. Practical Reason (ability to form a conception of the good and to plan one’s own life)
7. Affiliation (ability to engage in various forms of social interaction and feel empathy; ability to freely assemble and engage politically with others; having the social bases of self-respect and nonhumiliation, which entails

nondiscrimination on bases of gender, race, sexual orientation, ethnicity, age, religion, and so on)

8. Other Species (ability to live with concern for animals, plants, and the environment)
9. Play (ability to laugh, play, and enjoy recreation)
10. Control over One’s Environment (political: ability to participate effectively in political decisions that govern one’s life; ability to hold property on an equal basis with others; ability to seek employment on an equal basis with others and work as a human being, using practical reason and in meaningful relationships with others)

The capabilities approach posits that social justice entails society offering all individuals the opportunity to develop, utilize, and put into effect these essential capabilities, regardless of happenstance of birth, including social standing or inherent abilities. This means that equity implies differential opportunity as needed to compensate for or minimize advantages and disadvantages of persons and stations. An important ethical implication of that society is that it must be embraced by a majority, if not all, and is one that advances equity in status or outcome. Like Rawls, proponents of the capabilities approach embrace fairness as a countervailing or additional consideration along with individual liberty in determining justice and equity.

Jennifer Prah Ruger has undertaken application of the capabilities approach to health and health care. In her 2010 book Health and Social Justice, she wrote of “the need for all individuals . . . to understand the obligations each of us has to help realize the right to health for every individual in every society in the global community” (Ruger, 2010, p. 122).

Ruger’s statements constitute a philosophy that comes closest to that expressed in the definition offered by Braverman (2006), which defined health equity as a basic human right with the benchmark being the quality of health opportunity, care, and well-being enjoyed by the more privileged but with particular interest in the needs of the disadvantaged.

These two poles—libertarianism and modern liberalism—approach the promotion of freedom quite differently and, in turn, have different implications for what constitutes social justice and how health equity should be viewed. Such implications lean toward one side or the other in primary orientation but include compromising views or mixed principles. These variants include how much fairness is located in individual choice versus individual, equal-opportunity access and how regulation of commerce and personal behavior affects equality and justice in health opportunities, access to care, and outcomes.

COMMUNITY-CENTRIC PHILOSOPHIES

Most cultures in the history of humanity have been community-centric in some sense, rather than individual-centric. Some of these are small-scale tribal hunting and gathering societies, Buddhist and Confucian cultures, and socialist and communist state societies. Yet, across these community-centric societies, differences in social organization and the role of government vary enormously. These philosophies each put primary value on the flourishing of the community rather than starting with and giving primacy to the individual. Within this, there is variation, though, in how individual and collective endeavors are seen as contributing to the full realization of human potential.

Tribal Social Organization

Societies with a relatively low level of technology and, hence, productivity of labor, whether they are limited to hunting and gathering or utilize primitive horticulture among their means of subsistence, require all able-bodied individuals to cooperate in producing what they need as a community to survive. Having no surplus production, such societies cannot engage in commodity exchange. Individual choice or liberty is not considered essential or even relevant. An example barely surviving today is the Bambuti people of the tropical rainforest in the Congo (Mukenge, 2002; Turnbull, 1961), who live in bands of a few dozen people. The Bambuti are an egalitarian society in which the band is the highest form of social organization. Men and women basically have equal power. Issues are discussed, and decisions are made by consensus at fire camps; men and women engage in the conversations equivalently. If there is a disagreement or offense, then the offender or uncooperative member may be banished, beaten, or scorned (Mukenge, 2002).

While such organization and its implied political philosophy may seem irrelevant to American society and the issue of health equity, the pure egalitarianism and paramount interdependency are useful to highlight. A major issue within health equity–definition discussions and in policies related to health care is shared interdependency—how much health of the other is each person’s concern and how health standing and health costs to the society are affected by recognizing that interdependency.

Confucianism

Confucianism, with its roots in Chinese feudal culture several centuries BCE, continues to have influence even after the remarkable political and economic revolutions in China during the last century (Rosemont, 1991). A central concept

is that if people behave morally in their personal lives, then the life of the nation would be orderly and peaceful. The political order rests on the moral conduct of individuals that translates to societal moral order. A central Confucian concept is what is known in Western society as The Golden Rule: “Never impose on others what you would not choose for yourself.”

For Confucians, this rule is the foundation of a harmonious and, therefore, healthy society. The objective was to enable a harmonious, healthy society, not simply the personal ethic of treating others as you would like to be treated. Under the feudal society in which Confucian philosophy formed and became influential, a harmonious society meant that everyone should know their place in the hierarchy and organization based on ancestry, gender, land ownership, and other status considerations. Thus, it was less about equity than about working in one’s assigned role and place to maintain the order.

In addition to concern for social and political harmony, a key concept that places Confucianism as a community-centric philosophy is its understanding of personal identity. In contrast to individual-centric, rights-oriented concepts of justice and equity, Confucianism defines persons as the sum of their relationships and roles in family, community, and society (Rosemont, 1991). A person is defined, first of all, as the child of their parents, then as the sibling of their brothers and/or sisters, then by who they have as friends, neighbors, which teacher they are the student of, who they are the colleague of, the boss they are the underling of, and through numerous other relationships. Identity does not emanate from personality or individual choice and proclivities, but is intimately tied to and the sum of one’s relationships in the family and community.

Applied to health equity, what is of interest here is what promotes and maintains order in society. Healthy development opportunities, health education and care, and differences in health status, risks, and outcome are all judged by how these may affect the overall success and capability of the group or society. Individual status is of importance only in how it enables or impedes that overall status. Perhaps most relevant to the health equity discussion in this country is the justification of less concern for particular individuals based on an implicit assumption that inequity may not translate to harm overall, whereas from an individual-oriented perspective, this would be seen as inhumane or discriminatory.

Buddhism

Buddhism is another philosophical perspective that may be informative for addressing social justice and health equity. Within Buddhism, many branches and sub-branches of philosophy have sprouted, emphasizing different traditions.

Some focus on the importance of individuals’ ethical life choices, while others stress communal well-being. Across Buddhism there are threads connecting the well-being of the global community to the individual’s decisions and actions. An example of this kind of thought in Buddhist tradition is an apocryphal story of a monarch who provided no help for the poor (Ling, 1993). So, poverty was widespread. A poor man was arrested for theft and brought before the king. The man told his story of need, and the king gave him money. So, more and more poor people committed theft in order to receive money from the king. To abate this, the king ordered his men to cut off the heads of thieves. Thieves then armed themselves to fight the king’s men. So, from indifference to the poor grew theft, murder, runaway violence, and the shortening of life spans. The story goes on, introducing a host of other social evils, all spawned from indifference to the poor. The lesson, of course, is that society must, for its overall well-being, care for the poor.

This notion that there is interconnection among all people, that circumstances of one affect and are the concern of the others brings a humanitarian orientation to conversations about health and well-being. More specifically, Buddhism emphasizes how incorrect perceptions of others underlie hatred, violence, and unconcern (Hanh, 2006). This is an understanding of health equity that extends beyond equal rights or individual opportunity to view one’s health and well-being as not separable from any other person’s. From this approach, taking care of other people’s health is, at the same time, taking care of our own health. This philosophy can be seen as influential, if not overt, in many models of health equity.

Utilitarianism

Utilitarianism is a community-centric European philosophy. Popularly known as the philosophy of “the greatest good for the greatest number,” the idea is that what is desirable in specific situations and the world in general is whatever maximizes pleasure and minimizes pain (Sandel, 2009). While having appeal in providing a simple maxim, utilitarianism faces three challenges in its application. First, there is the question of defining “the good.” What is considered pleasurable or desirable by some may not be by others. And, of course, there is the question of by whom and how that judgment is rendered. A subset of this school of thought argues that one can discriminate between higher and lower pleasures. However, as applied to health equity, the challenge remains that, of multiple potentially desirous results, utilitarianism offers little guidance on what is good.

The second challenge of utilitarianism is measurement. If we are to maximize utility in society or even a local community, we must have a way to measure and compare utility among individuals. While some things that affect utility are

commensurable, e.g., the number of calories a person has access to daily, others clearly are not. A person has a unique array of needs and preferences. Groups of people also vary in their definition of utility, e.g., in types of cuisine or art. So, if we are to use scarce societal resources to maximize overall utility, how do we assign relative values? How value is assigned has implications for equity, of course, but also determines the degree to which equity will be realized (measured as achieved). Utilitarianism leaves this dependent on how one defines good.

The third major issue, one which has perhaps kept utilitarianism from being embraced at a societal level, is the question of means. A classic case is that of the sailors adrift in a lifeboat. As their rations ran low, they considered turning to cannibalism, so that at least some of them might survive longer with the hope of rescue. Classic utilitarianism provides no rules other than the aggregation of utility. Nothing is forbidden if it increases aggregate utility. When added to the uncertainty about how to determine what is good and how achieving that good is to be measured, lack of definition about means renders the application of utilitarianism to understanding health care equity as social justice minimally, if at all, useful.

Socialism and Communism

The global struggle between capitalism and communism was arguably the most important political phenomenon of the 20th century. So, the relevance of communism to a discussion of visions of social justice is beyond doubt. Also, socialism remains a major political philosophy affecting the discourse about health care equity, here and in other countries. For example, in many Western industrialized countries, health care is a governmental service offered as part of the state social contract with the citizens.

Communist philosophy envisions the abolition (through class struggle) of the divide between individual and community interests, indeed between those of the individual and the species, and the rise of a corresponding ethos free of greed and envy—from each according to their ability, to each according to their need—an ethos of true equity based on advanced technology maximizing the effective use of the world’s resources (Singer, 1980). In such a world, the state as an armed force to do policing and fight wars would be unnecessary and would “wither away.”

Equity is paramount, at least in principle or aspiration. All have equal access to social and economic resources, and, therefore, the opportunity for equitable outcomes. As applied to health equity, it would mean focusing on consistency of health-promoting and health care systems, as well as provision of care as needed, not based on privilege or standing.

Socialism is a political philosophy that has been defined in varying ways over time and place, and carries different connotations in different historical contexts.

Socialism usually refers to a political theory of social organization that advocates that the means of production, distribution, and exchange should be owned or regulated by the community as a whole. Thus, health care and health management within a range of socialistic perspectives can be state owned and managed or could be private or a mix of private and state, but with ultimate regulation and determination of goals in regard to equity under the control of the state (representing the community as a whole).

Today, it is common to refer to the health care systems of a number of capitalist nation-states, particularly in Europe, as socialist because of the high level of state support for health care and social welfare. What seems accurate and particularly relevant to perspectives and models of health equity and related social justice in this country is the viewing of commodification of health care as inappropriate or contrary to justice (Pellegrino, 1999). This is similar to how various institutions in our country, such as public education, roadways, fire and police protection, and air and water safety, function and are viewed as something one’s access to is independent of economic or political standing. As there are many who think that health equity rests on movement to a single-payer state-supported approach, the implications of this philosophy for the means and ends related to health equity deserve careful consideration. Most fundamentally, it is the assumption that health care should not be a matter of personal economic exchange, but seen as a right of membership in society, with equity in access and quality as fundamental to social justice.

CONCLUSION

As the discourse about health equity and its relation to social justice proceeds, it seems valuable to consider the implications of philosophical roots of some of the competing ideologies and positions regarding equity and social justice. Recognizing the relevance of various cultural approaches to balancing societal and individual needs can only make our deliberations more transparent, lucid, and powerful and, therefore, strengthen democracy. Acknowledging these approaches can advance our understanding of ways to address and apply diverse values as well as clarify the implications of different policy ideas.

As we have attempted to delineate briefly, a major distinction between philosophies and related definitions of health equity and strategies to achieve it is the extent to which society values individual freedom and choice over group well-being. A closely related distinction is the relative emphasis on broad and even access to resources versus variation related to choice or personal capabilities. A third major consideration is the role of the government in managing the means to equity and in ensuring its realization.

While the dominant political ideology in America today is liberalism, we have recently seen a range of popular variants from Donald Trump’s populism to Bernie Sanders’s socialism. There are many different interpretations of liberal ideology in health equity and social-justice discourse and multiple other philosophies that are relevant. In working to develop coherent policy based on social justice or equity, it can only help to draw on as wide as possible a range of human wisdom as we can.

As the question of how to overcome and rid our society of inequities due to discrimination and other historical legacies in health, perhaps more careful consideration is needed of what is meant by equity, how that relates to concepts of justice, and how that translates to policy and action. How can innovative policies drawing on a wide range of cultural and philosophical traditions improve our discourse while fitting practically into our existing social and political context? How might research help determine which approaches to equity in health opportunities, access to care, quality of care, and life quality and longevity actually will provide improvements by bringing the status of disadvantaged groups up to that of the more privileged and thereby realize social justice?

REFERENCES