We have previously explored equality and equity,* but this discussion left out a critical question: that of justice. When is inequality just? Is it ever? Can inequities be just? In particular, how can inequalities and inequities of health be just or unjust? 

Let us begin with the first of these questions: Is inequality just? Is economic inequality just, for example, when it is the result of hard work? Of luck? Of education? Of gender? Of race? It is readily apparent that there is no clear delineation between when an inequality is just or not. Let us take a corollary to economic inequality, health inequity, as another example. It is well recorded that health follows patterns linked to social class, that the more affluent live longer and healthier lives and the indigent just the opposite. It should be clear (I hope) that such inequity is unjust, that to distribute health outcomes based on financial income is, at best, unfair, and, at worst, morally reprehensible. But if health inequity is unjust, is economic inequality? If the effect is unfair, then is the cause unfair as well? Or are they the unfortunate byproduct of an acceptable trade-off, such as the allowance of inequity by virtue of hard work or luck?

To continue with the example of income inequality, one might find it surprising to learn that such patterns of health outcomes, as dictated by class and income, persist even in countries with universal, free healthcare. In fact, international evidence suggests that the greater an inequality in income within a country between the richest and poorest classes, the steeper the gradient of health achievement. Consequently, middle-income groups of a society with a particularly steep gradient of health inequality may face worse than comparable or poorer groups in a society with greater income equality. Such a pattern of income inequality causing health inequalities exists across the income spectrum and throughout the social hierarchy–not merely for the poor alone–and as such repudiate the social darwinist ideas of natural selection. 

It is, by now, readily apparent that inequalities in the distribution of social goods results in inequalities in health. But a health inequality isn’t necessarily a health inequity. Per Whitehead and Dahlgren, an inequality is inequitable when it is avoidable, unnecessary, and unfair. So, is such a health disparity caused by income discrepancy avoidable? Is it unnecessary? And, most importantly, is it unfair? Many, on the final question, would view the health outcomes of poverty as unjust simply because it conflicts with their beliefs about poverty and society’s obligation to meet one’s basic needs, no matter their class. At this point, however, it is important to remember that such health disparities caused by social and economic inequalities persist across the wealth spectrum. One cannot eliminate health inequities by eliminating poverty alone, as the gradient of good health affects people of all socioeconomic classes. Even if we hold the belief that all socioeconomic inequalities are unjust–including those born of hard work and acumen–to eliminate class altogether is a question that goes beyond the realm of health equity. Given finite resources and reasonable constraints, health cannot be the only social good or goal. 

Given just one example, that of economic inequality, it is clear the complexity of ethical inquiry that belies the foundations of health. The line between inequality, inequity, and injustice is unclear at best, however, particularly in the case of health, it remains our ongoing duty to investigate where it lies. Such questions do not have easy answers. Indeed, some of them may have no answer at all. But, while they may not be questions to be resolved, they continue to be questions that deserve to be asked, for both the sake of our principles and our health. 

*From On Equity: “A central distinction of equity is that it is not synonymous with equality. Equality is, sometimes, a facile ideal, one shared by most everybody, albeit in different ways. Take the example of the communist, the promoter of democracy, and a libertarian. Each wants equality of something valuable, central, to their respective political beliefs. The communist wants equality of income; the democrat, equality of political rights; the libertarian, equality of liberty. Each of these ideologies strives for equality of some given variable central to their theory of justice. Equality itself has no teeth. There remains the question of what is being equalized, and how. That is equity.”