The Normative Significance of Social Determinants of Health

Abstract

In this paper I critically discuss the normative significance of so-called social determinants of health and their use in public health policy. I will highlight certain possible and real misperceptions that are common in public health research and public health policy. After introducing the concept of the social determinants of health, the first issue I discuss concerns the confusion surrounding the notion of health in public health. Public health is mainly concerned with health dispositions or risks. This is different from a concern for people being unhealthy in the sense of suffering from a disease. The difference is important for the notion of health inequalities as well. In order to deem some people less healthy than others, a gradual concept of health is needed. Once the two concepts of health are confused, it is more difficult to acknowledge normative differences between being unhealthy and being less healthy. I submit that public health policies tend to exploit the common attitude towards diseases, namely that they ought to be treated and that they establish claims of justice. It is then another step of public health practitioners to campaign against social conditions that lead to certain health inequalities, which are deemed unjust. In other words, public health allows a normative argument, via the value of health, against specific social conditions. I reject this approach and allow only an indirect role for inequalities of health dispositions in an account of social justice. They might be regarded as symptoms of social ills, but they are not, according to my mind, as such unjust. Injustice in social conditions needs to be established in its own right, not mainly via its impact on health dispositions in specific populations. In the final section I hint towards an alternative, a noncomparative theory of social justice, which aims at enabling citizens to make healthy choices, but is not per se interested in comparative differences between people.