Justice, Inequality, and Health

First published Tue Dec 23, 2008; substantive revision Wed Aug 27, 2014

Among American men, there is a 15.4 year difference in life expectancy between Asians and high-risk urban blacks, where these groups constitute, respectively, the best-off and worst-off groups of men in the ‘eight Americas’ analysis of mortality in the United States by Murray and colleagues (2006). Among American women, the corresponding difference in life expectancy is 12.8 years, although the worst-off group of women is low-income southern rural blacks (‘America 7’) rather than high-risk urban blacks (‘America 8’). On the face of it, these inequalities in American life expectancy are seriously unjust.

If one turns to the international context, inequalities in life expectancy of a similar magnitude can be observed even between the worst-off countries and the global average: In 2011, life expectancy in 19 countries was 15 years or more below the global life expectancy of 70 years; and this global average was itself 13 years below life expectancy in Japan and Switzerland, which had the highest national averages of all (WHO 2013, Table 1).

But whether the appearances of injustice here will withstand close scrutiny is a separate question. Not all inequalities in life expectancy seem unjust. For example, in 2010, life expectancy for all American women was 80.9 years, whereas for all American men it was only 76.3 years (Wang et al., 2013). Presumably, little (if any) of this 4.6 year inequality in life expectancy represents an injustice. However, if some inequalities in health are not unjust, then inequalities in health are not unjust per se.

So what makes a health inequality an injustice, when it is one? Do health inequalities have some significance in justice that differs from other important inequalities? Or is the injustice of an unjust inequality in health simply due to the application of general principles of equality and justice to the case of health?

To answer these questions, one has to examine two rather different literatures. On the one hand, there is an empirical literature concerning the underlying determinants of health and, on the other hand, there is a philosophical literature concerned with the ethics of population health. The former literature is considerably more extensive and developed than the latter. Even there, however, the answers on offer are hardly complete or fully established.