If there is a reasonable alternative to an inequality that causes undue and preventable harm, regardless of whether that injustice is a result of economic or political, social or institutional systems, structures, or pressures, then the reasonable alternative should be selected to achieve a more just and fair world. The hierarchical structure of our society that as a strategy for survival, however inadequate that strategy proves to be in reality causes unjust inequalities that lead to unjust health inequalities and neither are necessary conclusions. Therefore, as a society we should seek to implement a reasonable alternative, which entails a decentralization of decision making power to distribute control of our lives more broadly because lack of control is the greatest factor contributing to the unjust inequalities in our society.

Either inequalities are just or they are unjust. Inequalities are natural phenomena, so it cannot be the case that they are inherently unjust. For example, the day is naturally warmer than the night, as is the day also brighter than the night, and both are the result of the unequal distribution of the sun shining on different parts of the planet at different times. Gorillas are stronger than chimpanzees as a result of their natural physical compositions. Men can neither give birth to a child, nor can they carry a fetus to term because they lack the necessary physical components to do so. On the other hand, women, by natural physical composition are the sex of our species that bear the burden of both carrying fetuses to term and suffering the pain of giving birth. None of these examples are inherently unjust, because there are yet no reasonable alternatives to them and as such, there is no choice available to augment the distribution of inequalities.  So, if inequalities of themselves are not unjust, then there must be other factors that commingle with inequalities, if people feel they are unjust.

Inequalities are unjust, if they are unnecessary and they are a cause of preventable harm. There is nothing moral or ethical about the day-night dichotomy described above. It is merely a description of what is. The mere fact that gorillas are physically stronger than chimpanzees, or for that matter one human as opposed to another, is also simply a description of the differences between them and as such, there is nothing immoral about the inequalities; in fact, they are amoral. The physical differences between men and women are not of themselves immoral or unjust, they are merely descriptions of what is. However, when natural difference lend themselves to alternative options, such as, who has control of if and when a woman is to carry and bear a child, then morality and justice come into effect. For instance, women in the United States were at one point considered by law as the legal property of the men they were married to, who also had claim to the woman’s reproductive capacity. Women had to fight a long and arduous battle for the right to control their own reproductive rights; i.e., for women to control the decision of if and when to elect to have a child, when to use contraception, and when to have an abortion. The unfair and biased control exercised over women’s sex difference by men was an injustice to women. Since men are not the ones who have to either suffer the pain of carrying a fetus to term or to suffer the pain of birth, and furthermore, since men have no claim to a woman’s body because it is not theirs, men have no right or justification to impose upon any woman that she must bear these burdens against her will if she elects not to suffer them.  The redistribution of decision making authority from men to women over their own bodies was a just redistribution of control.

It is not the existence of physical differences e that makes the circumstances unjust, similar to the fact that natural inequalities are not inherently unjust, but rather, that when as a result of social interventions that exploit those differences and lead to unfair situations wherein harm occurs is what identifies situations as unjust. Therefore, because that which is unjust results from social interactions wherein there are reasonable alternatives that do not lead to harm or lead to less harm, we should obligate the actions and decisions that limit harm, and hold responsible those who violate those obligations and cause harm, while seeking as a positive duty to limit the unfair and unjust harms that occur.

Sex however, is not the only pertinent social factor that leads to unjust inequalities; class and social status are also relevant social considerations that lead to unjust outcomes and situations. Another example of unjust inequalities is one that results from the social hierarchical structure of our society as one of the consequences of the economic system, was revealed by the Whitehall Studies conducted in London.[1]  Michael Marmot, the author of Social Causes of Inequalities in Health, who analyzing the longitudinal Whitehall Studies identified that a person’s belief of a lack of control over their environment was one of the leading factors to diminished health. Marmot found that there is a gradient of mortality when the society is based upon a hierarchical structure of organization wherein each lower stratum has a higher mortality and disease rate than the stratum above it. [2] The Whitehall Study tracked men in white collar positions, none of whom were impoverished and all who were gainfully employed, and this is where the pattern was identified. The pattern was also consistent for the control of one’s living conditions and was exacerbated by economic constraints such as poverty, which reveals that social class; i.e., the social stratum of an entire group of people is vulnerable to this pattern.  After analyzing trends of the identified pattern and how it shifts over time, Marmot correlated these shifts with governmental policy and suggests that: “[i]f it can vary, presumably as the unintended consequence of government policies and other trends, it should be possible to vary it as an intended consequence.”[3] This reveals that the health inequalities observed in the Whitehall Studies are not necessarily inevitable, and because they are not necessarily inevitable that means there may be reasonable alternatives to the socially caused factors for the disparities and as such could be unjust.

It could be argued that the data is wrong, or that there are not reasonable alternatives to select from.  Marmot however, is not the only one who has identified class differences as a relevant factor of health disparities and inequalities, Norman Daniels, has done so as well. Daniels, in the book, A Theory of Justice, in the chapter, “Three Questions of Justice,” identified that class was a greater determinant of health status than race.[4] Given that there are reasonable alternatives to the manner in which health is distributed along economic lines, which is exacerbated by racial and gender factors, Daniels proposes this theory of justice: [5]

Failing to promote health in a population, that is, failing to promote normal functioning in it, fails to protect the opportunity of capability of people to function as free and equal citizens. Failing to protect that opportunity or capability when we could reasonably do otherwise…is a failure to provide us with what we owe each other. It is unjust.

One of the major issues in the manner in which health care and health in general is distributed across and throughout a society is that access tends to be delineated by economic capacity to purchase; that is, spending power. The problem with this as Daniels asserts is that it causes us to “treat health care as a commodity,” as something that is not of “special importance” to society, but that is not the reality.[6] However, Daniels observes that as a society goods, such as jobs and education, are distributed “very unequally across subgroups that differ by race, ethnicity, gender, or class.”[7] One’s position or stratum in the hierarchical structure directly correlates with one’s ability to control one’s environment and the circumstances of the conditions of their environment because success in the economic structure of the market is dependent upon one’s ability to purchase. This market structure however, fails Daniels’ theory of justice because the economic bar to access limits the opportunity for people to function as free and equal citizens.

Margaret Whitehead has also observed health disparities that directly relate to the social stratum people belong to. In Whitehead’s article, The Concepts and Principles of Equity and Health, it is noted that “there is consistent evidence that disadvantaged groups have poorer survival chances, dying at a younger age than more favoured groups.”[8] One of the reasons for this difference that Whitehead identifies is that there are inequalities in access and quality of health services and that “those most in need of medical care, including preventive care, are least likely to receive a high standard of service.”[9] Whitehead lists seven “differentials” that will help to clarify whether inequalities are unnecessary and unfair, or simply are inequalities:[10]

(1) Natural, biological variation.

(2) Health-damaging behavior if freely chosen, such as participation in certain sports and

pastimes.

(3) The transient health advantage of one group over another when the group is first to adopt a

health-promoting behaviour (as long as other groups have the means to catch up fairly soon).

(4) Health-damaging behavior where the degree of choice of lifestyles is severely restricted.

(5) Exposure to unhealthy, stressful living and working conditions.

(6) Inadequate access to essential health and other public services.

(7) Natural selection or health-related social mobility involving the tendency for sick people to

move down the social scale.

The first three Whitehead suggests are simply inequalities or are acceptable and I would agree as it is similar to what I have argued above. However, the last four differentials all share relevance to the type of unjust inequalities that can be distinguished among the social strata of the hierarchical structure of society.  In particular to Marmot’s discussion is (5), “exposure to unhealthy, stressful living and working conditions” because it pertains to the lack of control one has the capacity to express over their environment that leads to health inequalities.

It does not appear as though the data is incorrect since similar data has been identified by multiple sources and they draw very similar conclusions, so the remaining objections to the inequalities being unjust will fall upon the reasonableness of the alternatives. To deny that there are alternative social structures is to deny the reality of the world in which we live because not all societies have such stark hierarchical structures.  In addition to that, it is possible to craft social and economic policies that will have the effect of leveling-up the least-well-off, the lower strata, and to raise their standard of living and personal control of their environments to a more equitable distribution.  It would further be possible to augment the capitalist structure of the political system so that more participation from a broader spectrum of the population would result in a greater sense of control of their lives. A system of collective ownership with collective bargaining could be instituted for how companies organize themselves, thus providing people with more control over their working environments.  In fact, Whitehead recommends “decentralizing power and decision making” as one of the core actions to be taken to mitigate unjust inequalities within society.[11]

If it is argued that these recommendations are unfair because they suggest a shift in culture and that it is not right to seek to change culture, then the most obvious response is that culture, by definition, is a social strategy for survival. Because culture is a strategy that means it is an institution, a human creation and as such was not inevitable, but rather, something that can both grow and change. It further means, that because it can grow and change that there are potential alternatives as have just be evinced, and that because it is social it is the factor earlier identified that if harm results, is the factor responsible for the injustice. Therefore, if the culture is unjust and there is a reasonable alternative, and there is, then there is also an obligation to strive toward that alternative in order to limit the harms resulting from the inequalities inherent in the current culture.

The goal is not to create a completely egalitarian society or to rid the world of all inequalities, but rather to seek a more just society for all members.  In regard to this Whitehead wrote: “[w]e will never be able to achieve a situation where everyone in the population has the same level of health, suffers the same type and degree of illness and dies after exactly the same life span. This is not an achievable goal, nor even a desirable one.”[12] It is however the goal, to respect the humanity and the dignity of each and every human being, to honor the agency and the autonomy of every person, and to accept that we all need to feel as though we have control over our own lives. The reality is that we all have a shared interest in seeking to achieve the greatest possible aggregate health because that is something that is necessary for us all to flourish, which is what I believe the true definition of justice is. Conversely, that which intervenes in the best possible, or the greatest potential for the flourishment of all people is unjust if there is a reasonable alternative to select. Many of the inequalities that exist today, when measured by the differentials proposed by Margaret Whitehead reveal them to be unjust. Thus, we as a society should seek to limit their impacts by reducing the impacts of the hierarchical structure of our society.

[1] Marmot, Michael “Social Causes of Inequality in Health.” In Public Health Ethics and Equity, edited by Sudhir Anand, Fabienne Peter, and Amartya Sen, 37-61. (New York: Oxford University Press, 2004), 38.

[2] Ibid.

[3] Marmot, 41

[4] Daniels, Norman. A Theory of Justice. (New York: Cambridge University Press, 2008), 14.

[5] Ibid.

[6] Daniels, 20.

[7] Daniels, 13.

[8] Whitehead, Margaret, “The Concepts and Principles of Equity and Health,” Health Promotional International vol 6 (1991), 218.

[9] Ibid.

[10] Whitehead, 219.

[11] Whitehead, 223.

[12] Whitehead, 219.