Biomedical Ethics: Assignment Week 5

Chapter 18

Equality and Inequality in American Health Care

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Health Inequalities and Inequities

• Some people are healthier than others. • These differences are closely associated with

social characteristics such as race, ethnicity, gender, location, and socioeconomic status.

• Knowledge and understanding of health inequalities has increased.

• Healthy People 2010 seeks to eliminate health disparities.

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What are Health Inequities?

• First, health must be defined. • Narrow definitions focus on the absence of

disease. • More expansive definitions of health may

include happiness, freedom from disability, quality of life, and the capacity to lead a socially meaningful and economically productive life.

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Assessing Health Status

• There are many ways to assess health status. • The most common health indicators are

mortality, survival, life expectancy, disease incidence, and disease prevalence.

• More expansive measures may include physiological indicators of overall health, self- rated health status, and sense of well-being, and social connectedness and productivity.

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Measures of Health Care

• Discussions of health inequalities may also utilize measures of health care, including rates of diagnosis, treatment, cost, insurance coverage, quality, survival, symptom reduction, or some other health outcome measure.

• Health inequalities should be distinguished from inequalities in health care.

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Inequality

• A health inequality is a descriptive term that may refer either to the total variation in health status across individuals within a population, or to a difference in average or total health between two or more populations.

• It involves comparing population averages.

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Health Inequities

• Health inequity is a normative term that refers to a difference that is judged to be morally unacceptable.

• While all health inequities are by definition health inequalities, not all health inequalities are health inequities.

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Health Inequities

• Determining whether a particular inequality (or class of inequalities) constitutes an inequity requires a moral judgment based on a priori beliefs about justice, fairness, and the distribution of social resources.

• Relative social position of different populations assists defining inequity.

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Health Inequities

• Rawls’ principles of social justice and difference is used.

• Health inequalities may indicate that a given population has disproportionately suffered international military and economic exploitation, inequitable distribution of economic resources, or historical patterns of race-based economic and social injustice.

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Health Inequities

• Drawbacks of using a population approach include:

• The a priori identification of disadvantaged populations may be contentious or arbitrary.

• Neglect of situations in which a genuinely unjust distribution of health may benefit those in socially superior positions.

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Health Inequities

• A more common definition of health inequity focuses on the causes and consequences of a given health inequality.

• A systematic health inequality is one that consistently affects two or more populations and is not the result of random variation.

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Health Inequities

• Avoidability has several components. • Health inequities must be technically

avoidable; a successful means of reducing the inequality must exist.

• They must be financially avoidable; sufficient resources exist to rectify the inequality.

• They must be morally avoidable rectifying the inequality must not violate some other social value, such as liberty or distributive justice.

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Health Inequities

• Unjust cause is also a criterion. It can include: – Health-damaging behavior where the

degree of choice of lifestyles is severely restricted.

– Exposure to unhealthy, stressful living and working conditions.

– Inadequate access to essential health and other public services.

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Health Inequities

• Problems with the cause definition are: – The degree to which many high-risk health

behaviors are “freely chosen” is a topic of considerable debate.

– The most significant problem with this definition is that many health problems have multi-causal etiologies.

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Measurement

• Determining whether a specific situation is inequitable requires that the health status of at least two populations be measured and compared.

• You must determine which populations to compare and

• The most appropriate measures that should be used in comparing these populations.

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Measurement

• Populations should differ in ways that are socially or morally important.

• Establish a comparison group that serves explicitly as a reference against which one or more populations are compared.

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Measurement

• Criteria for a comparisons group could be: – Total population average. – The best-off population. – The most socially advantaged population. – Some independently-defined target rate.

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Measurement

• A wide variety of statistical measures of inequality are available, from simple averages to sophisticated measures of total inequality.

• The absolute difference is a number resulting from subtraction of the numerical measure of one group’s health status from another.

• The relative difference is a ratio resulting from division of the numerical measure of one group’s health status from another.

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Reduce or Eliminate Health Inequalities

• Consider the relationship between equality of treatment and equality of outcomes.

• Horizontal equity refers to the equal allocation of resources across a population.

• Vertical equity refers to the allocation of different resources for different levels of need.

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In Summary…

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