My own view on this is that first we must define what we mean by 'health'. I've
been influenced by Alan Williams arguments on this; i.e. health is best defined
as a person's lifetime health experience, which can be measured in terms of life
expectancy or quality-adjusted life expectancy, rather than health at a specific
point in time (Williams, A., 1997, Intergenerational equity: an exploration of
the ?fair innings? argument. Health Economics 6, 117-132). For example, you
could have an elderly person in poor health and a middle-aged person in better
but less than perfect health. If you define health at a specific point in time,
the elderly person seems more deserving of attention with respect to their
health than the middle aged person. However, the elderly person could have had a
very healthy life, whereas as the middle aged person may have been dogged by ill
health since birth. Is it not fairer then to devote more attention to the middle
aged person, who has not had, and may never get, a 'fair innings'?
After defining health as lifetime health experience, we can compare health
across groups. The average life expectancy in the higher social classes is much
higher in the UK than in the lower social classes: health is unequal across
these groups. Whether health is also deemed inequitable perhaps depends on the
particular set of ethical principles to which one adheres. I prefer Rawlsian
theory (Rawls, J., 1972, A theory of justice. Oxford University Press, Oxford),
which, in very basic terms, says that if we do not know who we are going to
become (i.e. we could become a millionaire or a pauper) we would choose to make
the position of the worst off person in society as good as possible. If we adopt
this line of reasoning as our theory of justice and apply it to health, we may
be able to accept some inequality in society, but we are less likely to accept
substantial and/or increasing inequality across groups. Epidemiologists are far
better informed than I am, but it seems to me that health inequality across
certain groups in the UK is substantial and increasing. To me, it seems
ethically justifiable to attempt to reduce these inequalities. They are unjust
(to a Rawlsian like myself) and hence inequitable.
I've touched a bit on philosophy and epidemiology. I'd be interested to hear
what real philosophers or epidemiologist (or anybody else for that matter) may
think?
Adam
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