Health and Social Justice
Envision a society in which all people have the ability to achieve the central health capabilities of avoiding premature death and es-capable morbidity and where everyone has comprehensive health insurance and access to high-quality health care.
This vision is the animating principle behind the health capability paradigm, a unique new approach where not just health care, or the right to health alone, but health and the capability for health itself are moral imperatives. Ruger has been developing this health capability paradigm for over 15 years.Her innovative approach bridges the gaps at the interdisciplinary intersection of ethics, economics, political science, law and human rights, with practical and theoretical applications for the financing and delivery of health care and public health.The health capability paradigm provides philosophical justification for the direct moral importance of health, health capability, and the right to health, as well as a theoretical basis for prioritizing needs and allocating resources.
There are no guarantees of good health, but society can, if it will, design and build effective institutions and social systems, structures and practices, that support all citizens in the pursuit of central health capabilities.
Key tenets of this theory, which emphasizes responsibility and choice for health, include health agency, shared health governance, incompletely theorized agreements, and internalized public moral norms to guide social choice and collective action, and a joint scientific and deliberative approach to decision-making that incorporates medical necessity, medical appropriateness, and shortfall equality. This paradigm integrates both procedural and consequential approaches to justice, and emphasizes the critical roles of both moral and political legitimacy.
We can no longer afford to ignore human suffering. This book weaves together a number of disparate constructs and original insights to produce a foundation new framework for thinking about and taking action to achieve health and social justice— the health capability paradigm.
The International Covenant on Economic, Social and Cultural Rights (ICESCR), ratified by 160 States, confers on all human beings the core entitlements essential to human fulfillment, e.g. the rights to work, social security, family life, education and participation in cultural life.
Although all are vital, the ICESCR’s guarantee of “the right of everyone to the enjoyment of the highest attainable standard of physical and mental health” may be the most fundamental.1 Why is this so?
Health has special meaning to individuals and communities at large. Good health is necessary for human well-being, providing intrinsic value for comfort, contentment and pursuit of the joys of life. But good health does more than that.
It is important in allowing individuals to exercise a range of human rights – both civil and political (e.g. physical integrity, personal security, political participation), social and economic (e.g. employment, education and family life). Just as important, health is necessary for well-functioning societies.
If a population does not have a decent level of health, it is very difficult to ensure economic prosperity, political participation, collective security and so forth.
Jennifer Prah Ruger is one of a handful of scholars who have been steadfast in defending the right to health and the imperative of reducing unconscionable health inequalities around the globe. Her latest book, Health and social justice, stands, by far, as her most systematic and vital contribution.
In this seminal work, Ruger presents a theory of health and social justice, which she calls the “health capability paradigm” – whereby she says that all people should have access to the means to avoid premature death and preventable morbidity.
Hers is a vision that incorporates the philosophical, economic and political to make a compelling case that all societies (through public–private partnerships) can design and build effective institutions and systems to achieve health capabilities. Although she focuses (perhaps overly so) on the provision of medical care, Ruger offers a rich explanation of the essential drivers of health, such as surveillance, preventive measures, clean air, safe drinking water and nutritious food.
In the book’s foreword, Amartya Sen helpfully distinguishes “good health policy” from “good policy for health”, explaining that it is the latter that is needed for health justice. This supports the World Health Organization’s (WHO’s) “all-of-government” or “health-in-all-policies” approach, recognizing that the health sector is not the only contributor to good health.
The WHO Commission on the Social Determinants of Health concluded that “the social conditions in which people are born, live and work are the single most important determinants of good health or ill health, of a long and productive life, or a short and miserable one”.2 Ruger does not shy from the imperative of resource redistribution – from the rich to the poor and the healthy to the sick – offering a cogent pathway on how redistribution can take place in society.
The health capability paradigm envisions “shared health governance” where researchers, health insurers, governments, health professionals and citizens work together to build consensus around health priorities – including the legislative process, coalition building, citizen participation and commitment. Adopting a theory of “incompletely theorized agreement”, Ruger argues that constituent members of society do not need to agree on every element to reach consensus about key health goals. Priorities would include child/maternal health, alleviating hunger, and supply of safe drinking water.
If society ensures health capabilities, individuals have a corresponding obligation to take personal responsibility, Ruger argues. Individuals have an obligation to use their “health agency” to pursue good health, for example, by eating nutritional foods, engaging in physical activity and complying with medical advice.
For this to happen, of course, governments must structure the built environment to make it easy to choose healthy behaviours – such as making fruit and vegetables accessible and affordable.
It is good to imagine a world where society maximizes health and closes the health gap; where all constituent members can build consensus and coalitions; and where individuals accept personal responsibility. Yet, societies often fail to ensure basic survival needs and universal health care.
Constituent members often fail to agree on health priorities, regretfully acting in their self-interest rather than the common good. And often individuals find it exceptionally hard to eat a nutritious diet, exercise and engage in safe sex.
Even if achieving health and health equality are exceedingly difficult, it is reassuring to know that there exist rare scholars.
This is a book that demands attention and determined action, for nothing is more important for the world’s population than the passionate pursuit of health and social justice.
Social justice is the fair and just relation between the individual and society. This is measured by the explicit and tacit terms for the distribution of wealth, opportunities for personal activity and social privileges. In Western as well as in older Asian cultures, the concept of social justice has often referred to the process of ensuring that individuals fulfill their societal roles and receive what was their due from society.
In the current global grassroots movements for social justice, the emphasis has been on the breaking of barriers for social mobility, the creation of safety nets and economic justice.
Social justice assigns rights and duties in the institutions of society, which enables people to receive the basic benefits and burdens of cooperation. The relevant institutions often include taxation, social insurance, public health, public school, public services, Labour law and regulation of markets, to ensure fair distribution of wealth, equal opportunity and equality of outcome.
Interpretations that relate justice to a reciprocal relationship to society are mediated by differences in cultural traditions, some of which emphasize the individual responsibility toward society and others the equilibrium between access to power and its responsible use.
Hence, social justice is invoked today while reinterpreting historical figures such as Bartolomeo de las Casas, in philosophical debates about differences among human beings, in efforts for gender, racial and social equality, for advocating justice for migrants, prisoners, the environment, and the physically and mentally disabled.
While the concept of social justice can be traced through the theology of Augustine of Hippo and the philosophy of Thomas Paine, the term “social justice” became used explicitly from the 1840s.
A Jesuit priest named Luigi Taparelli is typically credited with coining the term, and it spread during the revolutions of 1848 with the work of Antonio Rosmini-Serbati. In the late industrial revolution, progressive American legal scholars began to use the term more, particularly Louis Brandeis and Roscoe Pound. From the early 20th century it was also embedded in international law and institutions; the preamble to establish the International Labour Organization recalled that “universal and lasting peace can be established only if it is based upon social justice.”
In the later 20th century, social justice was made central to the philosophy of the social contract, primarily by John Rawls in A Theory of Justice (1971). In 1993, the Vienna Declaration and Programmed of Action treats social justice as a purpose of the human rights education.
Social justice is an underlying principle for peaceful and prosperous coexistence within and among nations. We uphold the principles of social justice when we promote gender equality or the rights of indigenous peoples and migrants. We advance social justice when we remove barriers that people face because of gender, age, race, ethnicity, religion, culture or disability.
For the United Nations, the pursuit of social justice for all is at the core of our global mission to promote development and human dignity. The adoption by the International Labour Organization of the Declaration on Social Justice for a Fair Globalization is just one recent example of the UN system’s commitment to social justice. The Declaration focuses on guaranteeing fair outcomes for all through employment, social protection, social dialogue, and fundamental principles and rights at work.
The General Assembly proclaimed 20 February as World Day of Social Justice in 2007, inviting Member States to devote the day to promoting national activities in accordance with the objectives and goals of the World Summit for Social Development and the twenty-fourth session of the General Assembly.
Observance of World Day of Social Justice should support efforts of the international community in poverty eradication, the promotion of full employment and decent work, gender equity and access to social well-being and justice for all.
New Vision for the Economy
The world has changed dramatically. We no longer live in a world relatively empty of humans and their artefacts. We now live in the “Anthropocene era” in a full world where humans are dramatically altering their ecological life-support systems.
Our traditional economic concepts and models were developed in an empty world. If we are to create sustainable prosperity, if we seek “improved human well-being and social equity, while significantly reducing environmental risk and ecological scarcities,” we are going to need a new vision of the economy and its relationship to the rest of the world that’s better adapted to the new conditions we face.