The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada’s assisted dying law. The question of whether changes to a country’s assisted dying legislation lead to descents down slippery slopes has also come to the fore—as it does any time (...) a jurisdiction changes its laws. We explore these two questions through the lens of Canada’s experience both to inform Canada’s ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada’s Medical Assistance in Dying law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada’s new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada’s journey supports slippery slope arguments against permitting assisted dying. All data relevant to the study are included in the article. (shrink)

For decades, health professionals have asserted the importance of public participation in interventions for health. Medicine has pursued patient participation in clinical decision-making. In the public health realm, target groups have been asked to assist in the design and implementation of initiatives for health. In practice, however, patients and populations expect health professionals to give advice and - in some cases - to make decisions on their behalf. This implies limits to the ideal of participation. (...) In this innovative work, the author contrasts public and professional understandings of health and the best ways to achieve health. The result is a model of lay participation in the structuring of medical and public health activity. The book is unique due to its policy-applicable, quantitative studies and its theoretical analysis of works by René Dubos and Aaron Antonovsky. It will be of value to professionals in health promotion, health education, medical anthropology, and social epidemiology. (shrink)

In The legal determinants of health: Harnessing the power of law for global health and sustainable development, Gostin et al. provide a sustained account of how law can and should be used as an instrument of health promotion. We pick up on the themes of this report with a specific focus of the importance of abortion for women’s sexual and reproductive health and the impact that particular ways of framing abortion in law can have on (...) the lives of women and girls. In this short comment, we wish to emphasize that abortion regulations need to move beyond frameworks based on narrow understandings of harm towards more progressive agendas that take into account the social determinants of health in order to reduce barriers to care. This contribution is particularly relevant to the Commission’s criticism that those ‘[l]aws that stigmatise or discriminate against marginalized populations are especially harmful and exacerbate health disparities’. (shrink)

To provide effective care physicians must attend, not just to medical issues, but also to the social determinants of health — racial factors, food insecurity, housing instability, transportation barriers and beyond. Social determinants also include a largely underrecognized dimension: legal vulnerabilities such as rental evictions and debt adjudications. Yet rarely do medical trainees have an opportunity to witness legal vulnerabilities, firsthand.

The pervasive effects of early childhood experiences on health at older ages, documented with methods from life course epidemiology, have served to refocus many public health efforts towards understanding the impact of both cumulative disadvantage and what are known as "sensitive periods" and "critical periods" in shaping health trajectories. While the impact of early childhood experiences has been well-studied, much less attention has been focused on other periods of the life course that might also serve as critical (...) junctures in shaping exposures and risks, periods that may also influence biological pathways leading to poor health in late life. This is especially important as we examine social and economic... (shrink)

Amidst the climate of crisis surrounding the rise in opioid-related overdose in the USA, early in 2019, Google and Deloitte launched ‘Opioid360’. Here came a platform combining browser histories, credit, insurance, social media, and traditional survey data to sell the service of risk calculation in population health. Opioid360's approach to automating risk calculation not only promised to identify persons ‘at risk’ of opioid dependence, but also paved the way for broader applications anticipating common chronic diseases and coordinating logistical operations (...) involved in pandemic response. Beginning with this experimental platform, this paper develops an analysis of the Big Data mode of risk calculation - an epistemological and political shift that involves technology companies, investors, insurers, governments, and public health institutions. The analysis focuses on the re-emergence of ‘social determinants of health’ in the rhetoric accompanying novel analytic platforms that estimate, calculate, and compute individual health risks. While the treatment of SDOH has always been a site of political contestation within the discipline of public health, powerful interests are crystallising around the concept and instrumentalising it in platforms that sell algorithmic prediction. Silicon Valley's breed of asset-oriented technoscience appears not only to be amplifying the behaviouralist elements of public health. Among the stakes of the Big Data mode is the paradoxical retreat from changing social conditions that contribute to the prevalence of health and illness in populations; and instead, the promotion of an apparatus for pricing and exchanging individual risk or excluding from services those who bear risk most acutely. (shrink)

It is natural to think that there is a tight connection between whether someone is responsible for some outcome and whether it is appropriate to hold her accountable for that outcome. And this natural thought naturally extends to health: if someone is responsible for her health, then, all else being equal, she is accountable for it. Given this, some have thought that responsibility for health has an important role to play in distributing the benefits and burdens of (...) healthcare. But there is a reason for caution. That health is influenced by social, economic, and environmental factors is a matter of consensus. And some have argued that in light of these social determinants of health, individuals are not typically responsible for their health, rendering inappropriate policies that employ a responsibility‐for‐health criterion. This debate implicates a number of overlapping concepts and questions that are often difficult to pull apart. And I worry that those who maintain that social determinants undermine responsibility for health have latched on to the wrong target. The social determinants of health are relevant to such policies, but, I argue, not by globally undermining responsibility. Rather, social determinants are sometimes responsibility‐undermining, sometimes responsibility‐preserving, and often relevant to whether we should hold individuals accountable for their health regardless of their responsibility. This calls for a more nuanced appraisal of the ways in which the social determinants of health are relevant to such policies. And here I attempt to provide one. (shrink)

A growing body of empirical research examines the effects of the so-called “social determinants of health” on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the fairness of particular health inequalities; and (...) second, the policy recommendations issued on this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended—such as improving people's living conditions and reducing inequalities in wealth and power—are justified in their own right, the way these recommendations are tied to health is problematic. (shrink)

Introducción: se presenta un ensayo cuyo objetivo es fijar posiciones frente al resumen del Informe de la Comisión sobre Determinantes Sociales de la Salud (CDSS) proponer las acciones políticas que los movimientos sociales en salud deben emprender. Análisis: las recomendaciones de la CDSS no enfocan el problema en toda su compleja naturaleza y en especial desconoce la influencia decisiva de la formación económica social sobre la situación crítica de la salud en el mundo. Acción: se propone la unidad de los (...) movimientos sociales que actúan en el campo de salud para luchar contra los efectos de las políticas económicas y sociales dominantes en el mundo: reducción del papel del estado, privatización de servicios, desregulación laboral, privatización de la seguridad social, políticas migratorias y otras. Denunciemos toda política neoliberal en relación con la salud, practiquemos la solidaridad con los que luchan contra esas políticas, derrotemos el monopolio mediático neoliberal, enfocar el problema de los DSS como asunto político social, no técnico y defendamos el papel protagónico del estado, único capaz de asegurar servicios de salud al alcance de todos. Conclusión: "Nuestro deber es luchar", como nos advirtió Fidel Castro. Introduction: An essay is presented in order to set positions against the Report´s summary of the Commission on social determinants of public health (CSDPH) that suggests the political actions to be undertaken by Health social movements. Analysis: The CSDPH recommendations do not focus the problem in all its complex nature and do not recognize the decisive influence of the social economic formation on the critical situation of Health in the world. Action: unity of social movements acting in the field of health to fight against the effects of the dominant economic and social policies of today´s world: reduction of the role of the State, privatization of services, labour deregulation, privatization of social security, migratory policies and others. We denounce any neo-liberal policy in relation to Health. Let´s support those who struggle against those policies; let´s defeat the neoliberal media monopoly, let´s focus on the problem of social determinants as a sociopolitical issue , not as a technical one; let´s defend the leading role of the State, the only one capable to ensure health services to everyone. Conclusion: As Fidel Castro expressed: "Our duty is to fight. (shrink)

There are a number of important links and similarities between public health and safety. In this extended essay, Gregg D. Caruso defends and expands his public health-quarantine model, which is a non-retributive alternative for addressing criminal behavior that draws on the public health framework and prioritizes prevention and social justice. In developing his account, he explores the relationship between public health and safety, focusing on how social inequalities and systemic injustices affect health outcomes and crime (...) rates, how poverty affects brain development, how offenders often have pre-existing medical conditions (especially mental health issues), how involvement in the criminal justice system itself can lead to or worsen health and cognitive problems, how treatment and rehabilitation methods can best be employed to reduce recidivism and reintegrate offenders back into society, and how a public health approach could be successfully applied within the criminal justice system. Caruso's approach draws on research from the health sciences, social sciences, public policy, law, psychiatry, medical ethics, neuroscience, and philosophy, and he delivers a set of ethically defensible and practically workable proposals for implementing the public health-quarantine model. The essay begins by discussing recent empirical findings in psychology, neuroscience, and the social sciences that provide us with an increased understanding of the social and neurological determinants of health and criminal behavior. It then turns to Caruso's public health-quarantine model and argues that the model provides the most justified, humane, and effective approach for addressing criminal behavior. Caruso concludes by proposing a capability approach to social justice grounded in six key features of human well-being. He argues that we cannot successfully address concerns over public health and safety without simultaneously addressing issues of social justice—including the social determinants of health (SDH) and the social determinants of criminal behavior (SDCB)—and he recommends eight general policy proposals consistent with his model. (shrink)

Background - Early adulthood is the developmental stage during which, for the first time, an individual can independently choose their own lifestyle. For the future health of a young adult, it is important that they incorporate healthy behaviors from different health dimensions into their lifestyle. Analyzing the foregoing issue gives rise to a fundamental question: did intensive social changes experienced after Poland’s accession to the European Union lead to changes in different aspects of a healthy lifestyle? Method - (...) The presented study involved 504 people. The research data was collected in two separate measurements in 2003 and 2013. Subjects were asked to complete sets of questionnaires which measured: health behaviors, health beliefs, social influence, intention. Results - Statistical comparison of means tests and regression equations were conducted. Results demonstrate that young adults were similarly engaged in pro-health activities in both 2003 and 2013. A detailed analysis of health lifestyle factors shows that young adults from the 2013 group care more about their diet, physical activity, and more frequently undergo preventive medical health examinations. Moreover, significant changes in healthy lifestyle factors were reported. The most important observation concerned the changes in health beliefs. Beliefs derived from a holistic-functional model of health played a major role in the 2003 group, whereas in the 2013 group beliefs close to the biomedical model of health were more important. Conclusions - Analyses demonstrate changes in detailed healthy lifestyle factors. At the same time, no significant differences in global measures of concern for one’s health were observed. Importantly, results show modifications in healthy lifestyle factors. It is suggested that the observed differences stem from the social change of the last decade. (shrink)

Recent epidemiological research on the social determinants of health has been used to attack an important framework, associated with Norman Daniels, that depicts healthcare as special. My aim is to rescue the idea that healthcare has special importance in society, although specialness will turn out to be mainly limited to clinical care. I build upon the link between Daniels's theory and the work of John Rawls to develop a conception of public justification liberalism that is suitable to the (...) field of justice and health. I argue that, from the perspective of public justification liberalism, (clinical) healthcare deserves special status. (shrink)

Both gender and the law are significant determinants of health and well-being. Here, we put forward evidence to unpack the relationship between gender and outcomes in health and well-being, and explore how legal determinants interact and intersect with gender norms to amplify or reduce health inequities across populations. The paper explores the similarities between legal and health systems in their response to gender—both systems portray gender neutrality but would be better described as gender-blind. We (...) conclude with a set of recommendations to address both law and gender in implementing the work of the Lancet Commission on the legal determinants of health to improve health outcomes for all, irrespective of gender. (shrink)

Political theorists generally defend the moral importance of health care by appealing to its purported importance in promoting good health and saving lives. Recent research on the social determinants of health demonstrates, however, that health care actually does relatively little to promote good health or save lives in comparison with other social and environmental factors. This article assesses the implications of the social determinants of health literature for existing theories of health (...) care justice, and outlines a new approach that can justify publicly subsidized comprehensive health care despite its limited contribution to good health. Even if health care plays a relatively limited role in promoting good health, it remains morally important because of the care it provides to individuals. As such, it can be justified in terms of care ethics. When health care is justified primarily in terms of care rather than health, however, the goals of a just health-care system shift. The measure of a just health-care system is no longer strictly its ability to generate good health outcomes but also its ability to provide individuals with accessible, good quality daily care. This different focus has important consequences for the way we think about the institutions of a just health-care system as well as for the delivery and allocation of medical goods and services. (shrink)

Although the federal government and several state governments have recognized that structural discrimination limits less privileged groups’ ability to be healthy, the measures adopted to eliminate health disparities do not address structural discrimination. Historical and modern-day structural discrimination in employment has limited racial and ethnic minority individuals’ economic conditions by segregating them to low wage jobs that lack benefits, which has been associated with health disparities. Health justice provides a community-driven approach to transform the government’s efforts to (...) eliminate health disparities, by acknowledging the problem of structural discrimination; empowering less privileged groups to create and implement structural change; and providing support to redress harm. (shrink)

The nursing community in the United States polarized in September 2020 between Dawn Wooten's whistleblowing about forced hysterectomies at an immigration center in Georgia and the American Nurses Association's refusal to endorse a presidential candidate despite the Trump administration's mounting failures to address the public health crisis posed by the COVID‐19 pandemic. This reveals a need for more attention to political aspects of health outcome inequities. As advocates for health equity, nurses can join in recent scholarship and (...) activism concerning the political determinants of health. In this paper, we examine recent work on the political determinants of health with an aim to add two things. First, we seek to build further on the notion of “political” determinants of health by distinguishing policy and governance structures from dynamics of politicization through appeal to critical disabilities studies. Second, we seek to apply this further nuanced approach to challenge rhetorical uses of “vulnerable populations,” where this phrase serves to misrecognize systemic institutionalized forces that actively exploit and marginalize people and groups. By refocusing attention to political systems organized around and perpetuating inequitable health outcomes, nurses and other health care professionals—as well as those whom they serve—can concentrate their effort and power to act on political determinants of health in bringing about more equitable health outcomes. (shrink)

The WHO Commission on the Social Determinants of Health revealed that there is a 28-year disparity between the life expectancy in the poorest postcode and the richest postcode of Glasgow (CSDH, 2008). There are two sets of questions that it is important to ask about health inequalities like these: first, epidemiological questions about the mechanisms that cause inequalities in health and the measures that are effective in reducing them. Second, normative questions about which inequalities in (...) class='Hi'>health are wrong and why they are wrong. The papers in this symposium result from the inaugural conference of UCL's Centre for Philosophy, Justice and Health (CPJH) and focus on the relationship between these epidemiological and normative questions. (shrink)

Social determinants of health are a subject of growing interest, yet criticisms have emerged about the way determinants are conceptualized in nursing. A tendency to focus on readily observable living conditions and measurable demographic characteristics can divert attention, it has been said, from the less visible underlying processes which shape social life and health. To illustrate how the analytic perspective determines what becomes visible or invisible as a “determinant” in health, this paper presents a case (...) exemplar. Drawing from news reports and research in real estate economics and urban policy analysis, it explores a single local infectious illness outbreak through a series of progressively more abstract units of inquiry, considering mechanisms of lending and debt financing, housing supply, property valuation, tax policy, change in the structure of the financial industry, and international patterns of migration and capital flow, among other factors, which contributed in various ways to creating unsafe living conditions. An analytic exercise calling attention to dynamism and complexity in social processes, the paper offers a political‐economy‐based approach that serves as a cautionary note against oversimplification in discussions of health causality. (shrink)

There is much discourse and focus on the social determinants of health, but undergirding these multiple intersecting and interacting determinants are legal and political determinants that have operated at every level and impact the entire life continuum. The United States has long grappled with advancing health equity via public law and policy. Seventy years after the country was founded, lawmakers finally succeeded in passing the first comprehensive and inclusive law aimed at tackling the social (...) class='Hi'>determinants of health, but that effort was short-lived. Today the United States is faced with another fork in the road relative to the advancement of health equity. This article draws on lessons from history and law to argue that researchers, providers, payers, lawmakers and the legal community have a moral, economic and national security imperative to address not only the negative outcomes of health disparities, but also the imbalance of inputs resulting from laws and policies which fail to employ an equity lens. (shrink)

Among the most harrowing visuals of Britain’s ongoing ‘cost of living crisis’ are the security tags that began to appear on cheese, butter, chicken, sweets and infant formula milk in 2022. A week’s worth of formula milk—the sole or main food of the vast majority of infants for the first 6 months of life—now costs between £9.39 and £15.95.1 Low-income households are entitled to a ‘Healthy Start’ welfare payment, intended to avert malnutrition among the poorest children, but the weekly allowance (...) is just £8.50.2 There are reports of parents watering down formula, skipping or limiting feeds and initiating early weaning, all of which jeopardise the health of infants, with potentially lifelong consequences.3 No determinant of health is more critical than food. A 2019 study found that diet is the most significant risk factor for non-communicable disease, and that one in five deaths globally could be prevented by improving nutrition.4 Globally, 1 in 10 people cannot meet their daily energy needs,1 and the proportion of undernourished people is rising.5 In more than 50 countries, most of them in Africa, over a quarter of children are stunted or wasted due to undernourishment, with long-term effects on their cognitive and physical development. These are not problems of absolute scarcity; enough food is produced globally to feed ten billion people.6 In the UK, there is, at any given moment, sufficient food on supermarket shelves to meet the calorie and nutrient needs of the population. Yet the equivalent of nearly 200 million meals a year are discarded,7 while almost a quarter …. (shrink)

The nursing community in the United States polarized in September 2020 between Dawn Wooten's whistleblowing about forced hysterectomies at an immigration center in Georgia and the American Nurses Association's refusal to endorse a presidential candidate despite the Trump administration's mounting failures to address the public health crisis posed by the COVID-19 pandemic. This reveals a need for more attention to political aspects of health outcome inequities. As advocates for health equity, nurses can join in recent scholarship and (...) activism concerning the political determinants of health. In this paper, we examine recent work on the political determinants of health with an aim to add two things. First, we seek to build further on the notion of “political” determinants of health by distinguishing policy and governance structures from dynamics of politicization through appeal to critical disabilities studies. Second, we seek to apply this further nuanced approach to challenge rhetorical uses of “vulnerable populations,” where this phrase serves to misrecognize systemic institutionalized forces that actively exploit and marginalize people and groups. By refocusing attention to political systems organized around and perpetuating inequitable health outcomes, nurses and other health care professionals—as well as those whom they serve—can concentrate their effort and power to act on political determinants of health in bringing about more equitable health outcomes. (shrink)

Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature (...) on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio‐environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups. (shrink)

Globalization, a process characterized by the growing interdependence of the world's people, impacts health systems and the social determinants of health in ways that are detrimental to health equity. In a world in which there are few countervailing normative and policy approaches to the dominant neoliberal regime underpinning globalization, the human rights paradigm constitutes a widely shared foundation for challenging globalization's effects. The substantive rights enumerated in human rights instruments include the right to the highest attainable (...) level of physical and mental health and others that are relevant to the determinants of health. The rights stipulated in these documents impose extensive legal obligations on states that have ratified these documents and confer health entitlements on their residents. Human rights norms have also inspired civil society efforts to improve access to essential medicines and medical services, particularly for HIV/AIDS. Nevertheless, many factors reduce the potential counterweight human rights might exert, including and specifically the nature of the human rights approach, weak political commitments to promoting and protecting health rights on the part of some states and their lack of institutional and economic resources to do so. Global economic markets and the relative power of global economic institutions are also shrinking national policy space. This article reviews the potential contributions and limitations of human rights to achieving greater equity in shaping the social determinants of health. (shrink)

In their article, Cho and Martinez-Martin (2023) argue that developers and users of digital simulacra for modelling health and disease should involve a continued focus on causality of health states...

Recent frameworks, models, and reports highlight the critical need to address social determinants of health for achieving health equity in the United States and around the globe. In the United States, data play an important role in better understanding community‐level and population‐level disparities particularly for local health departments. However, data‐driven decision‐making—the use of data for public health activities such as program implementation, policy development, and resource allocation—is often presented theoretically or through case studies in the (...) literature. We sought to develop a preliminary model that identifies the factors that contribute to data‐driven decision‐making in US local health departments and describe relationships between them. Guided by implementation science literature, we examined organizational‐level capacity and individual‐level factors contributing to using data for decision‐making related to social determinants of health and the reduction of county‐level disparities. This model has the potential to improve implementation of public health interventions and programs aimed at upstream structural factors, by elucidating the factors critical to incorporating data in decision‐making. (shrink)

Most donated organs in the United States come from brain dead donors, while a small percentage come from patients who die in “controlled,” or expected, circumstances, typically after the family or surrogate makes a decision to withdraw life support. The number of organs available for transplant could be substantially if donations were permitted in “uncontrolled” circumstances–that is, from people who die unexpectedly, often outside the hospital. According to projections from the Institute of Medicine, establishing programs permitting “uncontrolled donation after circulatory (...) determination of death,” or uDCDD, throughout the United States has the potential to provide 22,000 more donation opportunities annually. In contrast, U.S. controlled donation after circulatory determination of death, or cDCDD, cases have increased progressively over the past decade from 87 to 848 donors, but currently account for only 10.6 percent of all deceased donors. Following the IOM recommendations, several projects exploring the feasibility of uDCDD were funded by the federal government, including a grant from the Health Resources and Services Administration that supported a pilot project in New York City in which the authors of this article participated.A key feature of our protocol, and indeed of many uDCDD protocols, is the initiation of preservation methods such as chest compressions and extracorporeal membrane oxygenation shortly after death in order to perfuse and preserve the donor's organs. Critics of uDCDD argue that the means of determining death deviates from generally ascribed principles. They assert that reinstituting circulation in order to preserve organs has the effect of “undoing” the prior determination of death. The result is that cDCDD is widely accepted and practiced routinely even though it only marginally increases the number of organs available for transplantation, and uDCDD is widely considered unacceptable despite being ethically embraced and proven to significantly increase organ donation opportunities in other countries. This article explores the evolution of this counterintuitive state of affairs and calls for a policy that, in line with the IOM report, allows for both cDCDD and uDCDD protocols. (shrink)

Variability in the symptom experience in patients diagnosed with chronic conditions may be related to social determinants of health (SDoH). The purpose of this critical review was to (1) summarize the existing literature on SDoH and symptom clusters (i.e., multiple, co‐occurring symptoms) in patients diagnosed with common chronic conditions, (2) evaluate current variables and measures used to represent SDoH, (3) identify gaps in the evidence base, and (4) provide recommendations for the incorporation of SDoH into future symptom cluster (...) research. We identified 118 articles including information on SDoH in chronic condition symptom cluster research. Articles primarily focused on cancer populations. Few articles had the explicit purpose of investigating relationships between SDoH and symptom clusters, and the inclusion of SDoH was often limited to variables used to describe samples. Future studies should be designed to “move beyond Table 1” in their utilization of SDoH as variables and examine relationships between SDoH and symptom clusters. Attention should be paid to the appropriateness of measures being used to collect information on SDoH, and analysis methods that estimate causal connections between variables should be considered. Research regarding the relationship of SDoH with symptom clusters in patients with chronic conditions has the potential to reveal mechanisms of symptom disparities and guide changes to alleviate these disparities. (shrink)

In 2005, the relative risk of death was 30% higher for African Americans than White Americans, with differences in cardiovascular mortality accounting for the largest portion of this disparity (Cen...

This is a short postscript to the Public Health Ethics special issue on the legal determinants of health. We reflect briefly on emerging responses to COVID-19, and raise important questions of ethics and law that must be addressed; including through the lens of legal determinants, and with critical attention to what it means to protect health with justice.

This article provides a critical analysis of ‘the legal’ in the legal determinants of health, with reference to the Lancet–O’Neill report on that topic. The analysis shows how law is framed as a fluid and porous concept, with legal measures and instruments being conceived as sociopolitical phenomena. I argue that the way that laws are grounded practically as part of a broader concept of politics and evaluated normatively for their instrumental value has important implications for the study of (...) law itself. This, in turn, has implications for how we approach the transdisciplinary ambitions that form a key part of the report’s recommendations to enhance law’s capacity to promote better, more equitable population health at local, national, international and global levels. (shrink)

In May 2009 the World Health Assembly passed a resolution on reducing health inequities through action on the social determinants of health, based on the work of the global Commission on Social Determinants of Health, 2005–2008. The Commission's genesis and findings raise some important questions for global health governance. We draw out some of the essential elements, themes, and mechanisms that shaped the Commission. We start by examining the evolving nature of global (...) class='Hi'>health and the Commission's foundational inspiration – the universal pattern of health inequity and the imperative, driven by a sense of social justice, to make better and more equal health a global goal. We look at how the Commission was established, how it was structured internally, and how it developed external relationships – with the World Health Organization, with global networks of academics and practitioners, with country governments eager to spearhead action on health equity, and with civil society. We outline the Commission's recommendations as they relate to the architecture of global health governance. Finally, we look at how the Commission is catalyzing a movement to bring social determinants of health to the forefront of international and national policy discourse. (shrink)

On August 28, 2008, Michael Marmot, Chair of the Commission on Social Determinants of Health, formally handed over the Commission’s Final Report to Margaret Chan, the Director-General of the World Health Organization, at the Palais des Nations in Geneva. It was a significant moment. Dr. Chan addressed a hall packed with representatives of the world’s communications media in a speech that was remarkably direct. Dr. Chan reiterated the Commission’s position that to improve health and health (...) equity action needs to be taken not just across the health sector but across all social and economic policy areas, and stated, “Social deprivation is not a matter of fate. It is a marker of policy failure.” This was a bold statement from one of the world’s leading diplomats. Policy failure! The phrase echoes the Commission’s assertion that “a toxic combination of poor social policies, unfair economic arrangements and bad politics is killing people on a grand scale.” The Commission’s messages are far reaching. (shrink)

This study uses data from the Ghana Demographic and Health Survey of 1993 to examine factors determining the use of maternal–child health services in rural Ghana. The MCH services under study are: use of a doctor for prenatal care; soliciting four or more antenatal check-ups; place of delivery; participation in family planning. Bivariate and multivariate techniques are employed in the analyses. The analyses reveal that the use of MCH services tends to be shaped mostly by level of education, (...) religious background and region of residence, and partially by ethnicity and occupation. The implications of these results are discussed. (shrink)

The present article identifies how social determinants of health raise two categories of philosophical problems that also fall within the smaller domain of ethics; one set pertains to the philosophy of epidemiology, and the second set pertains to the philosophy of health and social justice. After reviewing these two categories of ethical concerns, the limited conclusion made is that identifying and responding to social determinants of health requires inter-disciplinary reasoning across epidemiology and philosophy. For the (...) reasoning used in epidemiology to be sound, for its scope and (moral) purpose as a science to be clarified as well as for social justice theory to be relevant and coherent, epidemiology and philosophy need to forge a meaningful exchange of ideas that happens in both directions. (shrink)

In this article, we suggest that the evidence regarding the social determinants of health calls for a deep re‐thinking of our understanding of distributive justice. Focusing on John Rawls's theory of distributive justice in particular, we argue that a full reckoning with the social determinants of health requires a re‐working of Rawls's principles of justice. We argue first that the social bases of health – a Rawlsian conception of the social determinants of health (...) – should be considered a social primary good. We argue second that including the social bases of health as a social primary good would lead the parties to the original position to choose an additional principle of justice and assign it lexical priority over Rawls's second principle. According to this principle, inequalities in people's share of the social bases of health are to be arranged so as to improve the health status of those least advantaged on the social health gradient. -/- . (shrink)

The paper describes a project in which the thesis of the social determinants of health is used in order to help identify groups that will be among the least advantaged members of society, when disadvantage is understood in terms of lack of genuine opportunity for secure functioning. The analysis is derived from the author's work with Avner de-Shalit in Disadvantage (Oxford University Press, 2007).

The government recognizes that social factors cause racial inequalities in access to resources and opportunities that result in racial health disparities. However, this recognition fails to acknowledge the root cause of these racial inequalities: structural racism. As a result, racial health disparities persist.

This paper is the second of two in a series. In our first paper, we presented a social justice framework emerging from an extensive literature review and incorporating core social determinants specific to mental health in the age of COVID-19 and illustrated specific social determinants impacting mental health (SDIMH) of our resettled Bhutanese refugee population during the pandemic. This second paper details specific barriers to the SDIMH detrimental to the basic human rights and social justice of (...) this population during this pandemic. The SDIMH, as described, further informs the need for social justice measures and cultural humility in mental healthcare, public health, law, and community engagement. This work concludes with a proposed call to action toward mental health improvement and fair treatment for refugee populations in three core areas: communication and education, social stigma and discrimination, and accessibility and availability of resources. (shrink)

Philosophy of epidemiology has recently emerged as a distinct branch of philosophy. The field will surely benefit from pluralism, reflected in the broad range of topics and perspectives in this special issue. Here, I argue that a healthy pluralistic field of philosophy of epidemiology has social responsibilities that require the field as a whole to engage actively with research on social determinants of health and health disparities. Practicing epidemiologists and the broader community of public health scientists (...) have gradually acknowledged that much of their attention ought to be paid to these, i.e. inequitable between-population health variations that largely reflect the world’s inequitable distribution of resources and social conditions. The paper illustrates how and why health disparities and social determinants of health, through no ill will, become de facto secondary concerns in Alex Broadbent’s field-defining Philosophy of Epidemiology, showing the ease with which these topics can be incidentally sidelined. As means for philosophy of epidemiology to meet its social responsibility obligations, I suggest philosophy of epidemiology expand its attention to two particular lines research. First, the paper discusses Geoffrey Rose’s concept of “causes of incidence”—causes of disparities between populations—and argues for the importance of engaging with these causes. Second, the paper argues for the value of engaging with Bruce Link and Jo Phelan’s “fundamental causes” model of how flexible social resources serve as buffers from harms, generating a plethora of shifting and locally-contingent health effects. (shrink)

This article introduces a special issue on the legal determinants of health, following the publication of the Lancet–O’Neill Institute of Georgetown University Commission’s report on the subject. We contextualize legal determinants as a significant and vital aspect of the social determinants of health, explain the work of the Lancet–O’Neill Commission and outline where consequent research will usefully be directed. We also introduce the papers that follow in the special issue, which together set out in greater (...) detail the work of the Commission and critically engage with different aspects of the report and the application of its findings and recommendations. (shrink)

The nascent for-profit psychedelic industry has begun to engage in corporate practices like funding scientific research and research programs. There is substantial evidence that such practices from other industries like tobacco, alcohol, pharmaceuticals and food create conflicts of interest and can negatively influence population health. However, in a context of funding pressures, low publicly funded success rates and precarious academic labor, there is limited ethics guidance for researchers working at the intersection of clinical practice and population health as (...) to how they should approach potential financial sponsorship from for-profit entities, such as the psychedelic industry. This article reports on a reflective exercise among a group of clinician scientists working in psychedelic science, where we applied Adams’ (2016) PERIL (Purpose, Extent, Relevant harm, Identifiers, Link) ethical decision-making framework to a fictionalized case of corporate psychedelic financial sponsorship. Our analysis suggests financial relationships with the corporate psychedelic sector may create varying degrees of risk to a research program’s purpose, autonomy and integrity. We argue that the commercial determinants of health provide a useful framework for understanding the ethics of industry-healthcare entanglements and can provide an important population health ethics lens to examine nascent industries such as psychedelics, and work toward potential solutions. (shrink)