What Is Health Equity?

By Erika Blacksher, PhD
John B. Francis Chair, Center for Practical Bioethics

A flower balanced between 2 rocks with the title what is health equity.

Notions of health equity and health justice are often used but rarely defined. When they are defined, those definitions are often subject to debate. Just as there is no agreement as to the nature of justice, so too there is no agreement as to what exactly health equity or health justice is. Philosophers and bioethicists, among others, have been working these past 30 years to establish an answer but consensus is not on the horizon.

What Is a Health Disparity?

One place many begin is to establish what constitutes an absence of health equity, or a health disparity. One of the earliest definitions asserted that “systematic” and “avoidable” differences in health are unjust and unfair,[i] but the authors offered no explanation as to what constitutes a systemic or avoidable difference in heath and no ethical argument as to why such conditions might make health inequalities unjust or unfair. The latter would have required a theory of justice.

Subsequent analyses built on that effort. Braveman and Gruske argue that health inequalities are unjust when they are (1) systematic and (2) afflict social groups that already burdened by social disadvantaged.[ii] By systematic they mean that the inequalities are not random or occasional but rather persistent and significant. By socially disadvantaged they mean to refer to groups that are, for example, minoritized on the basis of race and ethnicity, economically marginalized and excluded, or marginalized on the basis of gender, sexual identity, geography, ability, religion and so on.

Those ideas overlap with the definition of a health disparity posited by Healthy People 2020, the U.S. federal government’s decennial initiative to improve the nation’s health. Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with economic, social, or environmental disadvantage. Health disparities affect groups of people who have systematically experienced greater social or economic obstacles to health based on their racial or ethnic group, religion, socioeconomic status, gender, age, or mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”[iii]

Whether such definitions hold up to scrutiny is unclear.[iv] But they do capture key moral intuitions that surround the idea of health disparities. One such intuition is that adding preventable disease, disability, and premature death to the burdens of those who are already living and laboring under difficult conditions is doubly unfair. A second is that that social, economic, and environmental conditions, and by implication the decisions and policies we make as societies that create those conditions, are to blame for these health afflictions. But these definitions and intuitions beg many questions: What does health have to do with justice? Is there something special about health in considerations of justice? Who is responsible for health? Individuals or society? Which health inequalities constitute health inequities, and why? Philosophers and bioethicists have been busy developing answer, often by adapting existing theories of justice to address these questions.

Why Is Health a Matter of Justice?

Philosophers and bioethicists have answered this question in different ways. For some, what makes health special to justice is that people need some level of mental and physical health to carry out their life goals.[v] The burdens of disease and disability can prove insurmountable obstacles to our life plans, and may even dramatically cut short those plans if we die prematurely. On this view, health matters to justice instrumentally; that is, it matters not in itself but rather because of what it enables a person to do. Having some threshold level of health allows a person to pursue their goals, whatever those are. Another way to answer this question is to argue that health matters to justice because it is intrinsically valuable. On this view, the value of health lies not in what it enables a person to do but in the direct contribution health makes to human wellbeing. Those who answer the question this way do not deny that health is also instrumentally valuable, but argue that health matters in itself, because it is a basic human capability or facet of well-being, and that justice secure intrinsic goods.[vi],[vii],[viii],[ix] Indeed, some argue that health matters to justice precisely because it is both intrinsically and instrumentally valuable in human lives.[x]

Who Is Responsible for Health?

Establishing that health is relevant to considerations of justice does not tell us what health equity or health justice is. It only tells us that it may be appropriate to think that health matters to justice and that all should have the opportunity to be healthy. One can still ask and many do, Who is responsible for health? Is health an individual responsibility, a societal responsibility, or a shared responsibility?

To answer the question, some point to reliable predictors and patterns in health as proof that society’s institutions, policies, and practices are to blame for preventable disease and early death. For example, education and income levels (or “socioeconomic status”) and ascribed racial identity (e.g., Black, White, Hispanic, Indigenous) are potent predictors of health and longevity. Additionally, these differences in health often follow a gradient pattern, such that with each increase or decrease in advantage (e.g., education or income level) there is an accompanying increase or decrease in health.[xi],[xii] Studies in the United Kingdom established the social gradient in health decades ago,[xiii] and hundreds of studies since have established this social patterning in health since for many health outcomes, including in the United States. These patterns do not prove causality but they do support a growing body of evidence that various forms of social and economic disadvantage are implicated in health differences between social classes and racial groups.[xiv],[xv],[xvi],[xvii]

Such patterns suggest causal pathways that link “upstream” drivers to health outcomes, including physiological mechanisms, but they do not definitively answer questions about responsibility for health. Preventable disease and premature death have many causes, including individual behaviors, thus leaving room for debate about which of those causes matter most.[xviii] The question of whether and, if so, when societies should or should not hold individuals responsible for poor health remains the subject of study and debate.[xix]

What Is Health Injustice?

Even if we agree that social institutions, policies, and practices are causally implicated in health inequalities, which health inequalities constitute inequities? When is a health inequality an injustice? There are many health inequalities and many social groups exposed to social harms that contribute to poor health and shorter lives—e.g., chronic poverty, blighted geographies, structural racism, structural sexism, heterosexism, ableism, and so on. What moral grounds justify treating some health inequalities, not as mere differences, but as injustices?

Philosophers and bioethicists propose different answers and those answers are too lengthy and varied to summarize here. Two generalities can be ventured. First, philosophical work on questions of health justice is done using egalitarian theories of justice. Although egalitarian accounts of justice vary considerably, all are concerned with securing the basic conditions of human welfare for all persons. Health, at some level and for varied reasons, is argued to be important to human welfare.

Second, egalitarian theories of justice typically give some priority to those who are very badly off in certain respects. For example, Madison Powers and Ruth Faden argue that the most urgent inequalities to address are those that entail “overlapping social determinants with profound and pervasive effects on a cluster of well-being dimensions.”[xx] This principle may help sort which health inequalities are inequities. But hard questions will remain, because there are many health inequalities that involve multiple and overlapping social determinants that have serious and multiple effects on well-being, which means there are many health inequities. That raises the difficult question of which among them merits priority for society’s resources and action, when not all can be prioritized.[xxi]

Why Should We Care?

Much work on all of these questions remains to be done. But it is important to keep at it because there is much at stake around the world and here at home in the United States. Our nation’s health is characterized not only by longstanding and sizable health inequities but also an overall “health disadvantage” that spans health outcomes across the life course.[xxii] This U.S. health disadvantage refers to the fact that Americans, even the relatively advantaged, experience higher rates of disease and injury and die earlier than people in other high-income countries. Everyone has a stake in improving the nation’s health.

By Erika Blacksher, PhD
John B. Francis Chair, Center for Practical Bioethics

[i] Whitehead M. The concepts and principles of equity in health. Int J Health Serv. 1992;22:429-445.

[ii] Braveman P, and Gruskin S. Defining equity in health. J Epidemiol Community Health. 2003;57:254-258; see also Braveman PA. What are health disparities and health equity? We need to be clear. Public Health Rep. 2014;129(Suppl 2):5–8.

[iii] HealthyPeople.gov. Disparities. Available at http://www.healthypeople.gov/2020/about/disparitiesAbout.aspx. Accessed August 1, 2023.

[iv] Preda A, and Voigt K. The social determinants of health: why should we care? American Journal of Bioethics. ­2015;15;3:25-36.

[v] Daniels N. Just Health: Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press, 2008.

[vi] Sen A. Inequality Reexamined. Harvard University Press, 1998.

[vii] Nussbaum MC. Women and Human Development: The Capabilities Approach. Cambridge, UK: Cambridge University Press, 2000.

[viii] Powers M, and Faden R. Social Justice: The Moral Foundation of Public Health and Health Policy. New York, NY: Oxford University Press, 2006.

[ix] Venkatapuram S. Health Justice. Malden, MA: Polity Press, 2011.

[x] Anand S. The concern for equity in health,” in Public Health, Ethics, and Equity, (eds.) Anand S, Peter F, Sen A. Oxford, UK: Oxford University Press, 2004.

[xi] Link BG, and Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior. 1995;35(extra issue):80-94.

[xii] Braveman PA, Egerter SA, Mockenhaupt RE. Broadening the focus: the need to address the social determinants of health. Am J Prev Med. 2011;40(1S1):S4-S18.

[xiii] Marmot MG, Rose M, Shipley PJ. Employment grade and coronary heart disease in British civil servants. J Epidemiol Community Health. 1978;32:244-249.

[xiv] Krieger N. The ostrich, the albatross, and public health: an ecosocial perspective—or why an explicit focus on health consequences of discrimination and deprivation is vital for good science and public health practice. Public Health Rep. 2001;116:419–23.

[xv] World Health Organization, Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health, final report. Geneva: WHO, 2008.

[xvi] Braveman PA, Cubbin C, Egerter S, Williams DR, Pamuk E. Socioeconomic disparities in health in the United States: what do the patterns tell us. Am J Public Health. 2010;100(S1):S186-S196.

[xvii] Woolf SH, and Braveman P. Where health disparities begin: the role of social and economic determinants and why current policies may make matters worse. Health Affairs. 2011;30(10):1852-1859.

[xviii] Dworkin G. Taking risks, assessing responsibility. Hastings Center Report. 1981;11(5):26-31.

[xix] Seagall S. Health, Luck, and Justice. Princeton, New Jersey: Princeton University Press, 2010.

[xx] Powers and Faden. Social Justice, 2008.

[xxi] Blacksher E. “Redistribution and recognition in the pursuit of health justice,” in Justice in Global Health, eds. Bhakuni H, Miotto L., New York, NY: Routledge. Forthcoming 2024.

[xxii] Woolf SH, and Aron L. (Eds.). (2013). U.S. Health in International Perspective: Shorter Lives, Poorer Health. The National Academies Press.