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Abstract In this article, we argue that apart from evaluating the causes and the social determinants of health inequalities, an evaluation of the effects of health inequalities is due. For this, we propose the ideal of relational equality as an evaluative framework, and test to what extent health inequalities threaten this ideal of a society of equals. We identify three ways in which they do (i.e. via unequal risks to stigmatization, unequal risks to unemployment and unequal risks to unequal pension enjoyments) and argue that these risks are especially great for those lower down the socio-economic strata. We thus conclude that equality in health is instrumental to social justice, and that socio-economic inequalities in health are not only unjust due to their causes but also due to their consequences. We continue to argue that our instrumental approach opens a perspective to mitigate the identified injustices by changing society, rather than reducing inequalities in health, and argue that this is an advantage in the light of the realistic assumption that (part) of the socio-economic health inequalities will persist. The article thus offers a complementary approach to both the evaluation and the mitigation of the injustice of socio-economic inequalities in health. Introduction A large amount of epidemiological literature shows the persistence of inequalities in health within countries among people with different socio-economic status. Notably, the two longitudinal Whitehall Studies have found a systematic correlation between the employment grades of civil servants and disease prevalence and mortality rates (Smith et al., 1990). This reveals what is known as the ‘social gradient in health’: the lower in the hierarchy of social stratification, the higher disease prevalence for various (chronic) diseases and thus the higher mortality rates. Since the first Whitehall Study, many more studies confirmed the relation between (healthy) life expectancy and socio-economic status, generally indicated by occupational, income or educational level (Marmot and Wilkinson, 1999; Hatzenbuehler et al., 2013; Marmot, 2017). For a few decades, reducing socio-economic inequalities in health has been on the agenda of policymakers (Mackenbach and Stronks, 2002). One motivation for tackling health inequalities may be that public investments should be made where the most health gains can be made. The intuition that these systematic inequalities in health are unjust is arguably another. Thus far, the question of why these inequalities in health are unjust has been primarily answered by judging the unjust distribution of the ‘causes of the causes’, i.e. their social determinants (Whitehead, 1990; Daniels et al., 1999; Daniels, 2008). This focus on causes is indispensable for our moral evaluation. For instance, it seems morally relevant to know to what extent health inequalities are the result of deliberately chosen behaviour (Stronks and Gunning-Schepers, 1993). Also, if health inequalities stem from other social injustices, such as unfair inequalities in (access to) income, this should play an important role in our explanation of why they are unjust (Daniels, 2008). Yet focussing merely on causes leaves out of sight the injustices that potentially result from health inequalities. This blind spot deserves more attention, given that socio-economic inequalities in health are persistent and have proven to be very hard to reduce (Link and Phelan, 1995; Mackenbach et al., 2017). In this article, we thus start arguing that in addition to an evaluation of the causes, an evaluation of the consequences of health inequalities is due, calling this ‘instrumental’ evaluation. The consequences of health inequalities can be argued to be unjust for several reasons. For instance, health problems generally negatively affect a person’s well-being, and if well-being is considered to be a demand of justice, health inequalities are unjust if they result into unequal or insufficient well-being. Also, the effects of health inequalities on material distributions are relevant for most accounts of social justice. In this article, we specifically adopt relational egalitarianism as our evaluative framework, following earlier explorations of the merits of this approach for our thinking about health and justice (Pogge, 2006; Voigt and Wester, 2015; Kelleher, 2016). Kelleher (2016) and Pogge (2006) have shown how relational egalitarianism could be a fruitful framework to problematize (socio-economic) health inequalities based on their causes, but our focus here will be the evaluation based on their consequences. Considering the potentially negative effects of health inequalities on relational equality contributes to a completer story of why systematic inequalities in health are unjust. Based on the literature on the effects of poor health, we illustrate this by discussing three examples of how socio-economic inequalities in health evidently threaten the ideal of relational equality: unequal risks of stigmatization, unequal risks of unemployment and unequal chances to enjoy a (relatively) equal number of pension years. These are examples for which there is clear empirical evidence for concluding that they threaten a society of equals; we do not claim that these are the only ones. Subsequently, in the light of the realistic expectation that some degree of socio-economic health inequalities will persist, the outlook of relational equality provides us prospects of addressing unjust consequences. We show for each of the three examples of health inequality-related injustices how relational equality could be partly restored by changing social circumstances. Evaluating Socio-Economic Health Inequalities in the Light of Relational Equality As said, the debate on the fairness of socio-economic health inequalities has primarily focused on a normative evaluation of their causes. Yet, regarding health more generally, other consequence-oriented arguments have been made that explain why health is of instrumental value for justice. Notably, Venkatapuram (2011) argues in Health Justice that apart from its intrinsic value, being healthy is crucial for a decent human life. And in Just Health, Daniels (2008) argues that health is of special moral importance for fair equality of opportunity. Both accounts take health as being instrumental for what an individual—given a certain understanding of justice—should be able to do and be. This article scrutinizes the hypothesis that also equality in health is instrumental for justice, and that socio-economic inequalities are unjust because they lead to relational injustices. We thereby test a specification of the more general thesis formulated by O’Neill (2008), who suggests that ‘it is a deep social fact’ that the realization of an egalitarian society, i.e. a society in which people can live together as equals, requires that inequalities in conditions (e.g. in health) are eliminated (O’Neill, 2008: 128). We take this notion of a ‘deep social fact’ as a helpful step in the evaluation of socio-economic inequalities in health. For if we endorse the idea that people should be able to live together as equals, we need to know how deep this social fact is when it comes to inequalities in health. That is, to what extent do inequalities in health threaten the ideal of a society of equals, and if so, how? To answer this question, first more should be said about how to understand this ideal of a society of equals. As O’Neill (2008) points out, ever since Rousseau, arguments to reduce inequalities have been motivated by several egalitarian values such as equal status, non-domination, self-respect and the absence of discrimination. By understanding equal distribution patterns of instrumental (or in O’Neill’s words, ‘non-intrinsic’) value, rather than as an end in itself, O’Neill joins a family of views that goes under the header of ‘relational egalitarianism’ (Anderson, 2010; Schemmel, 2011; Voigt and Wester, 2015; Kelleher, 2016). For relational egalitarians, the general guiding idea is that ‘in an egalitarian society people should relate to one another as equals or should enjoy the same fundamental status’ (Arneson, 2013: §4). For this reason, relational egalitarians argue that society’s institutions should be ‘designed to foster and reflect such attitudes’ (Miller, 2017: §6.3). When we speak in this article of relational equality, we have in mind this rather broad egalitarian ideal of a society of equals. Following Anderson (2010), we take the demand of ‘interpersonal justification’ as central to relational egalitarianism. According to this view, principles of justice must be justifiable to others with whom we stand in morally relevant relations. Since inequalities should accord with the principles of justice endorsed, inequalities are unjust if they cannot be interpersonally justified. This generally forbids that an inequality ‘reflects, embodies, or causes inequality of authority, status, or standing’ (Anderson, 2010, 2). Thus conceived, relational egalitarians take it that any inequalities in social standing that are caused by systematic inequalities in health cannot be justified and should thus be addressed.1 While we will not argue for this here, we assume that the rationale of interpersonal justification is central to most of the relational egalitarian approaches that are recently distinguished in the literature (Voigt and Wester, 2015; Kelleher, 2016), in so far each of these relational strands take justice as ‘a disposition [of agents, including institutions] to treat individuals in accordance with principles that express, embody and sustain relations of social equality’ (Anderson, 2010: 2). As we will argue, the perspective of relational equality reveals courses of action to mitigate unjust effects of persistent socio-economic health inequalities. But before we can start to think about mitigating injustices, we need to know if and how health inequalities threaten relational equality—or positively, to test whether it is a deep social fact that equality in health fosters relational equality. For this purpose, a broad and abstract ideal will not do. And so, to know what possibly indicates the absence of relational equality, we do make use of specific relational egalitarian arguments that have been formulated by others. Since we rely on Anderson’s account of relational equality, it makes sense to start with what she thinks is required by relational justice. In her well-known paper ‘What’s the point of Equality?’, Anderson endorses the capabilities approach, and argues: negatively, people are entitled to whatever capabilities are necessary to enable them to avoid or escape entanglement in oppressive relationships. Positively, they are entitled to the capabilities necessary for functioning as an equal citizen in a democratic state. (Anderson, 1999: 316) According to Anderson, functioning as an equal citizen involves functioning as a human being, as a political agent and as an equal in civic society more broadly conceived, such as in the system of cooperative production. While the capabilities she lists are not extensively argued for, they give some guidance to see what is practically required to enable people to live as equals in society, and thus to indicate when health inequalities entail a risk—for the least healthy—of being deprived of the capabilities needed to function as equals. For a more specific account of oppressive relationships, we use—like Anderson—Young’s (1990) characterization of ‘five faces’ of oppression (i.e. powerlessness, marginalization, violence, exploitation and cultural imperialism) in the context of 20th-century welfare states. Regarding the examples we discuss, we show that unequal vulnerability to oppression lurks as a direct consequence of systematic health inequalities, and as such impede people to ‘develop and exercise one’s capacities and express one’s experiences’ (Young, 1990: 37). Each of the three examples we discuss can in principle be analysed with Anderson’s capabilities and Young’s notions of oppression, as they indicate the implications of health inequalities for the quality of social relations, and the kind of opportunities individuals have. However, their accounts do not satisfactorily deal with the implications of health inequalities for other unequal distributions. We therefore rely on Schemmel’s argument, who explains a concern for distributions as a concern for the social bases of self-respect. According to him, as self-respect enables people to conceive of themselves as ‘free and effective agents’ (Schemmel, 2011: 366), relational egalitarians should ‘seek to equalize the social bases of self-respect for all members of society’ (Schemmel, 2011: 367). This is consistent with the demand of interpersonal justification, for without this sense of self-worth, people cannot be expected to consider themselves as worthy of making claims to others, ‘on an understanding of themselves as free, equal and mutually accountable persons’ (Anderson, 2010: 3). As such, the distribution of the burdens and benefits of social cooperation constitute part of the social bases of self-respect. Finally, we should note that when we consider the effects of systematic health inequalities, we talk about inequalities between groups, which means that we cannot but speak in terms of risks and chances at a group level. Crucial for our analysis is therefore that we assume that we cannot speak of relational equality, if people—by belonging to some statistical group—are systematically at risk of being oppressed and/or of not being respected as equals. Of course, actual disrespect and oppression of individuals is the primary concern for relational equality. Yet unequal vulnerability to oppression and disrespect also implies unequal opportunity to live on equal standing. We hold that the unequal chance to live on equal standing—as caused by socio-economic health inequalities—is a concern of relational justice as well. This can be illustrated by exploring how systematic health inequalities result in unequal risks of stigmatization, unemployment and enjoyment of pensions. Health-related Stigmatization Many health problems come with stigmatization; hence inequalities in healthy life expectancy will imply inequalities in the risk of being stigmatized. Goffman originally characterized the stigmatized person as being: the stranger (…) possessing an attribute that makes him different from others (…) and of a less desirable kind – in the extreme, a person who is quite thoroughly bad, or dangerous, or weak. He is thus reduced in our minds from a whole and usual person to a tainted, discounted one. (Goffman, 1963: 12) In addition to thinking or viewing a person as inferior, Link and Phelan (2001) point out that it is crucial that when we stigmatize, we also treat the person as inferior. They thus propose a sophistication of Goffman’s account, arguing that ‘people are stigmatised when the fact that they are labelled, set apart, and linked to undesirable characteristics leads them to experience status loss and discrimination’ (Link and Phelan, 2001: 371). Typical stigmatized health conditions that are known for evoking stereotyping and setting the affected persons apart are mental illnesses, leprosy, physical impairments, epilepsy, HIV/AIDS, tuberculosis and infectious diseases (Van Brakel, 2006). Nowadays more attention is also given to stigmatization of chronic conditions which are particularly common among lower socio-economic groups, such as Chronic Obstructive Pulmonary Disease (COPD) obesity and type 2 diabetes (Puhl and Heuer, 2009; Engebretson, 2013). These conditions are strongly related to behaviours, such as unhealthy eating or smoking that are known to be more common in lower socio-economic strata. And so, stigmatization of these conditions is primarily described as a matter of associations with ‘irresponsible’ or ‘risky’ behaviour. For instance, Whittle et al. (2017) describe how in San Francisco, persons living with HIV and/or type 2 diabetes mellitus and having a low-income experience stigmatization that ‘centers on the perception that it is self-inflicted through poor-lifestyle choices’ (Whittle et al., 2017: 10). Similarly, Della et al. (2016) found that in Appalachian Kentucky, within economically disadvantaged groups, both persons being diagnosed with type 2 diabetes mellitus, and persons having obesity perceived stigmatization and could count on moralizing judgments, such as accusations of being ‘lazy, irresponsible, and overindulgent’. Also, Berger et al. (2011) found that patients suffering COPD—often ‘self-imposed’ by smoking—experience stigma, as they are blamed by healthcare providers and internalized stigma in the form of self-blame. Such ‘blame-based’ stigmatization of health problems could be explained by neoliberal rationality. In the context of public health, neoliberal discourses are understood as shifting ‘the onus of responsibility from the state to the individual’ (Carey et al., 2017: 756), and as causing a so-called ‘life style drift’: the tendency in health policies to shift the focus from on the social determinants of health to individual behaviour. Lifestyle drift often comes with a move from policies aimed at the population as a whole, to targeting only the most vulnerable groups (Carey et al., 2017), such that especially lower socio-economic groups are blamed for their health problems. A consequence of this is that those who fail to live as responsible healthy citizens may expect ‘public disdain and reproach for being a part of societal problems’ (Ayo, 2012: 104). Moreover, the blame-based stigmatization of illness related to behaviours that prevail under lower socio-economic groups can be explained further if we acknowledge that stigmatization presupposes unequal power relations. That is, to set others effectively apart as inferior requires social, economic, political and/or cultural power. Link and Phelan (2001, 376) illustrate this by discussing possible attitudes of mentally ill patients to their physicians and clinical staff: patients may distinguish certain staff members from others, by labelling the ones they do not like (‘pill pushers’), stereotype them as arrogant and cold, ridicule them and treat them differently by being uncooperative. Despite that all components of stigmatization are in place, the patients do not have the power to let the ridiculed physicians end up as a stigmatized group. To see whether stigmatization can occur, crucial questions are: Do the people who might stigmatize have the power to ensure that the human difference they recognize and label is broadly identified in the culture? Do the people who might confer stigma have the power to ensure that the culture recognizes and deeply accepts the stereotypes they connect to the labelled differences? Do the people who might stigmatize have the power to separate ‘us’ from ‘them’ and to have the designation stick? And do those who might confer stigma control access to major life domains like educational institutions, jobs, housing, and health care in order to put really consequential teeth into the distinctions they draw? (Link and Phelan, 2001: 376) It is likely that these questions can be answered positively regarding higher socio-economic groups, as higher educated groups generally occupy positions like those of healthcare professionals, healthcare insurers and policymakers. As such, lower educated people are generally subjected to what those in more powerful positions judge to be blameworthy health conditions.2Carey et al. (2017) thus provokingly suggest that if obesity would have primarily affected high income groups, it would likely be framed more easily as a social problem requiring government responsibility. So, socio-economic inequalities in health imply an unequal risk of being stigmatized via stigmatized health problems. Of specific relevance for the health deprivations of lower socio-economic groups is that—given that they are strongly related to unhealthy behaviours and given that neoliberal discourses dominate—these groups are at risk of ‘blame-based’ health stigmatization. This risk is particularly high because the power to decide which behaviour-related conditions are blameworthy is generally at the side of the socio-economic ally better-off. Stigmatization immediately harms relational equality. If we consider for instance the capability ‘to be accepted by others, such as the ability to appear in public without shame, and not being ascribed outcast status’ (Anderson, 1999: 318), we can see that stigmatization severely diminishes this capability. As Schemmel (2011) explains, stigmatization ruins the social bases of a person’s self-respect. An important social mechanism in this regard is the existence of social status norms, of which stigmas are typical instances. Such norms can be acted upon—thereby (unintentionally) treating others as inferior to ourselves. And they can be internalized—leading to feelings of shame, and eventually to withdrawal from social or public life, i.e. to marginalization (cf. Young, 1990, see next paragraph). Knowing that the condition you have is stigmatized by the society or community you live in may lead to ‘anticipated’ stigma: the belief that one will likely be discriminated or otherwise negatively treated (Quinn and Earnshaw, 2011). Both experienced and anticipated stigmatization can be understood as instances of Young’s fifth face of oppression: violence. By being violated Young means that either you are actually violated or you live in the fear of being violated. And this need not be physical violence but may also involve ‘harassment, intimidation or ridicule’ (Young, 1990: 61). We can thus see that in a society with socio-economic inequalities in health, in combination with prevailing health-related stigmas, power differences between socio-economic groups and neoliberal norms of individual responsibility, lower socio-economic groups have a substantial higher risk of being stigmatized, and thus of being oppressed and of losing one’s self-respect via health-related stigmatization. Of such a society, we cannot speak of as a society of equals. Health-related Unemployment On a more practical level, inequalities in healthy life expectancy are an immediate threat to people’s standing as equals in the system of labour. For whether physically impaired, chronically ill or suffering mental health problems, all these conditions have been shown to have a negative effect on a person’s ability to work. Barnes (2000) notes for instance that ‘people with accredited impairments are substantially more likely to be unemployed and/or underemployed than contemporaries without perceived impairments’ (Barnes, 2000: 445). Denton et al. (2013) confirm this, finding that ‘involuntary retirement’ from the labour force was eight times higher among Canadians with a disability than for those without. Minton et al. (2012) show that economic inactivity and unemployment is much higher among people with chronic or long-term illness, than among those without. Similarly, Schuring et al. (2007) found that in 9 of 11 European countries, perceived poor health was a risk factor for those being unemployed to stay unemployed and that in 7 of the 11 countries, perceived poor health was a risk factor for becoming unemployed. Regarding mental illness, the Organisation for Economic Co-operation and Development mentions that employment rates are 10–15 per cent lower for those with common mental disorders than for those without, and for severe mental disorders, employment rate is even 25–35 per cent lower. Moreover, the chances to unemployment are higher: two to three times for those with a common mental disorder, and six to seven times for those with a severe mental disorder (OECD, 2012). Studies like these do not only show that health problems diminish an individual’s chances on employment status but also that the system of labour is competitive, and generally organized in ways that advantage those who are presumed to be most productive, i.e. the mentally healthy and able-bodied. It thus appears that in the system of labour, health is a ‘positional good’, for which it matters how it is distributed, and so it is that equality in health matters (cf. Axelsen and Nielsen, 2015). As with health-related stigmatization, it appears that the risk of health-related unemployment is especially great for lower socio-economic groups (Schuring et al., 2007; Denton et al. 2013). This is understandable, as ‘higher socioeconomic status’ is not simply a matter of education and income level but embodies several advantages that help to stay employed or find work again after long-term illness, such as ‘resources of money, knowledge, power, prestige, and beneficial social connections’ (Hatzenbuehler et al., 2013: 814). Also, it seems easier for higher educated professionals—when faced with illness—to switch to less demanding (knowledge) work, than it is for non-professional or manual workers to switch to less demanding work in case of health problems. Moreover, employees in lower paid jobs generally have low degrees of job autonomy (Eurofound, 2003), due to which employees have fewer opportunities to (re-)organise their work such that their being ill does not immediately render them ‘useless’. For relational equality, the problem is that being involuntarily unemployed implies being excluded from the system of labour, and thus being deprived from a capability such as ‘occupational choice’ (Anderson, 1999: 318). In addition to that, being unemployed makes one dependent on welfare benefits. In this regard, Young’s diagnosis of marginalization as a common form of oppression within welfare states is—almost 30 years and an economic crisis later—still highly relevant. Young defines marginalized persons as those ‘the system of labor cannot or will not use’ (Young, 1990: 53) and argues that they, by being dependent of welfare benefits, risk losing their status as an equal: Today the exclusion of dependent persons from equal citizenship rights is only barely hidden beneath the surface. Because they depend on bureaucratic institutions for support or services, the old, the poor, and the mentally and physically disabled are subject to patronizing, punitive, demeaning and arbitrary treatment by the policies and people associated with welfare bureaucracies’. Being a dependent in our society implies being a legitimate subject to the often arbitrary and invasive authority of social service providers and other public and private administrators who enforce rules with which the marginal must comply. (Young, 1990: 54) That this is an actual issue today, is shown by, e.g., the study by Whittle et al. (2017) that reports how persons without jobs or with low-income jobs are treated in humiliating ways when applying for welfare benefits. And so, in a society with socio-economic inequalities in health, in combination with a competitive system of labour that is (primarily) focused on productivity and where lower-paid jobs come with lower job autonomy, lower socio-economic groups have a substantially higher risk of unemployment, and thus of losing one’s position as an equal in the system of labour. This is at odds with the ideal of a society of equals, as the higher risk of getting unemployed for lower socio-economic groups indicates unequal opportunities for different socio-economic groups to keep their equal standing. Unequal Pension Enjoyments A last salient inequality resulting from socio-economic inequalities in life expectancy is the fact that lower socio-economic groups risk enjoying fewer pension years than higher socio-economic groups. For instance, in The Netherlands, at the age of 65, persons with only primary education have a remaining life expectancy of 18.5 years, whereas persons with an academic degree may expect to live another 22.1 years (CBS, 2017). This gap in life expectancy implies that those in the lowest socio-economic positions are likely to enjoy substantially fewer years living in retirement than those in the highest socio-economic positions, if the age of receiving a pension is based on the average life expectancy of the population as whole. The fact that socio-economic health inequalities result in unequal pension enjoyments can easily be perceived as unjust, and hence this may be a good illustration of an instrumental evaluation of health inequalities. However, compared to stigmatization and unemployment, it may be less evident that unequal prospects on equal pension enjoyment are an issue for relational justice.3 It may seem more intuitive to understand unequal pension enjoyments as a distributive injustice, especially if we consider pensions as a means to provide in your material needs after working life. For most relational egalitarians, it is indeed unclear that unequal pension enjoyments matter. The ‘distribution’ argument generally used by relational egalitarians is that inequalities in wealth and income should be avoided to avert relations of oppression (Anderson, 1999; Scheffler, 2003), and this does not apply to unequal pensions in terms of amounts of pension payments. That is, would we—for the sake of the argument—assume that everyone receives the same amount of pension per month, then those living longer receive in total more pensions than those with a shorter life. Yet it is unlikely that this material inequality would lead to unequal power relations, for the simple fact that being oppressed assumes being alive. However, there seems to be a way to see it as a relational injustice if we focus on inequalities in duration of pension enjoyments. We should thereby consider the issue as an issue of equal standing in the system of labour, such that we can understand the opportunity to enjoy a state pension for a certain number of years as a specific realization of the capability ‘to receive (…) recognition by others of one’s productive contributions’ (Anderson, 1999: 319).4 In a situation in which one group risks enjoying their pension for a substantially smaller number of years than another group, we should at least conclude that people’s productive contributions are not equally recognized. Still, this does not necessarily imply a relational injustice. For instance, Anderson—who is primarily concerned with sufficient capability levels, i.c. receiving ‘sufficient recognition’—will not be bothered by unequal retirement prospects. Schemmel’s (2011) argument for equal distributions provides a way to see unequal prospects on equal pension enjoyments as problematic for relational justice. He argues that relational egalitarians should care about equal distributions of the goods produced by social cooperation, because ‘range constraints’ on these goods express equal standing: if the basic structure has to display egalitarian concern for the participants in the enterprise of social cooperation that it regulates (…) it has to aim at distributing advantages and disadvantages that are socially produced equally. (Schemmel, 2011: 371) Following this line of argumentation, state pensions—and the number of years they can be enjoyed—can be taken as such jointly produced advantages, as citizens contribute their share for state pensions by income taxes. And so, in a situation of systematic socio-economic inequalities in life expectancy and in case there is a one-size-fits-all pension scheme, the lowest educated and manual workers or non-professional workers, i.e. the groups with an, on average, lower life expectancy, are not respected as equals. Still, we may wonder if we can also speak of a relational injustice here if the causes of health disparities are not unjust from a relational perspective. For instance, it seems less plausible that diminished pension enjoyments due to diseases with clear natural causes are unjust. Although it remains to be seen whether relational egalitarians have good reasons to think socio-economic health inequalities are unjust based on their causes, but this is certainly not inconceivable (cf. Voigt and Wester, 2015; Kelleher, 2016). Socio-Economic Health Inequalities and Clustered Disadvantage We have started with the question of whether there is indeed a ‘deep social fact’ that connects equality in health with relational equality. We have presented and discussed evidence for this thesis by focusing on three exemplary ways in which health inequalities entail unequal risks of losing equal standing. Specifically, inequalities in healthy life expectancy imply unequal risks of being stigmatized, implying the risk of being deprived of the capability to appear in public without shame, and of being violated; they further imply unequal risks of unemployment, implying the risk of being deprived of the capability to occupational choice, and of being marginalized; and finally, inequalities in mere life expectancy imply unequal chances to equal pension enjoyments, implying—arguably—the risk of not receiving equal recognition for one’s productive contributions by others and thus of not being respected as equals. We have also indicated that especially socio-economic health inequalities threaten relational equality as the impact of health problems appear to be fiercer for those positioned in lower socio-economic strata than for those higher positioned. Considering the higher risk of experiencing health-related stigmatization, this seems primarily due to the inequalities in the power to stigmatize that come with the division of labour between different socio-economic groups. Considering the higher risk of health-related unemployment, this can be understood in the light of the diagnosis made by for instance Wolff and De-Shalit (2007) of ‘clustering disadvantage’. That is, disadvantages in personal, social and material circumstances tend to converge, and some of them likely interact in corrosive ways (see also Marmot and Wilkinson, 1999; Powers and Faden, 2006). The corrosiveness of disadvantages can be (partly) explained by what Wolff and De-Shalit call ‘inverse cross-category risk’, meaning that being disadvantaged in one respect may ‘force’ people to take risks in another, thereby ending up more disadvantaged. For instance, whereas being ill for a longer period of time easily leads to unemployment, this risk is higher when one’s income is low: someone with asthma and little to spent may invest in better housing insulation to make her respiration problems bearable, but this may come at the cost of not investing in training for physically less demanding work, needed to stay employed. It also works the other way around: some advantages may be ‘fertile’ (Wolff and De-Shalit, 2007). Being in good health and being well-educated likely stir the advantage of having a satisfying and well-paid job. All in all, for people in lower socio-economic strata, the prospects of standing as an equal in society is—(partly) due to their diminished prospects of a long and healthy life—much worse than for higher socio-economic groups. If a society of equals is aspired, socio-economic health inequalities and their effects on the opportunities to equal standing deserve attention by policymakers. Mitigating Injustices of Persisting Inequalities in Health In this last section, we argue that considering health equality to be instrumental for justice offers more than a complementary approach to the evaluation of the causes of health inequalities. Focusing on the consequences of health inequalities for equal relations also offers a way to address the unjust effects of socio-economic health inequalities. Whereas a cause-oriented approach naturally seeks a solution in, e.g., a fairer distribution of the social determinants of health, or in facilitating people’s healthy behaviour, to achieve equality in health, our instrumental approach takes equality in health as a means to relational equality, suggesting that there might be other ways to achieve the latter goal. We can see this if we understand the discussed threats to relational equality due to health inequalities, as also due to the fact that societies and labour systems are organized and structured such that they facilitate ‘healthy’ (generally, higher educated) people, and disadvantage unhealthy (generally, lower educated) people. That is, public pension schemes based on population’s average life expectancy, prevailing health stigmas, and labour systems disadvantage groups with a lower healthy life expectancy. This shows that changes in social structures could (partially) restore relational equality. This perspective is promising if we recognize that it is realistic to assume that part of the socio-economic inequalities in health will persist, even if great efforts are taken to reduce them. One reason for this is that socio-economic health inequalities seem to have ‘fundamental causes’, meaning that higher socio-economic status comes with more material and non-material resources to utilize opportunities to improve health and avert disease, and so, health inequalities between socio-economic groups are expected to persist (Link and Phelan, 1995; Mackenbach et al., 2017). Examples of non-material resources are cultural and social norms that shape health-related behaviours (Burnett and Veenstra, 2017), which are important determinants of socio-economic health inequalities (Van Lenthe et al., 2004). Fully controlling people’s behaviour is both impossible and undesirable: it would be tremendously costly to set legal limits to for instance alcohol, fat and sugar intake, and to control whether people obey these norms. More importantly, implementing and controlling such legislation would interfere with people’s autonomy and privacy to a degree many would find unacceptable. Second, the question of what a just distribution of the social determinants of health exactly entails—i.e. what equality of opportunity requires, and what a just distribution of wealth and income should entail is—and will be—subject to political dispute. For instance, libertarians tend to think that all that equality of opportunity in education requires are non-discrimination acts, whereas social democrats may argue for more proactive policies to counteract implicit norms and other exclusionary mechanisms. Moreover, even if there would be agreement on these normative questions, inequalities in socio-economic positions will most likely persist, given inequalities in people’s talents, skills and motivations. It is in the light of this realistic assumption that we will sketch for each of the identified threats to relational equality ways to restore the latter by adjusting how individuals are treated by society and in the system of labour, rather than by restoring individuals’ health. We will thereby discuss proposals that have already been made by others, in practice and in empirical and normative studies on pensions, work and stigmatization. Equal Pension Enjoyment We start with the last example discussed, as here we can see most concretely how relational equality can be achieved even if socio-economic inequalities in health persist. If equal prospects on equal pension enjoyments can be taken as a means to recognize people’s contributions to the system of cooperative production, and thereby express equal respect to each individual, and if socio-economic inequalities in life expectancy are a relational injustice based on their causes, then relational equality could be restored by accounting for the persistence of these inequalities in the set-up of public pension schemes. In the light of rising average life expectancies, the future of pension schemes is hotly debated in many welfare states. In this context, several proposals have been made to ensure fair pensions for groups with a lower life expectancy than average. In fact, as Wester and Wolff (2010) show, many European countries already provide the opportunity to withdraw from the workforce to those working in hazardous occupations, such as miners and workers in heavy industries. Also, in The Netherlands, socio-economic health inequalities are taken into consideration in the debate on the future of public retirement schemes, whereby pension enjoyment in terms of life years is generally focused upon. For instance, the Dutch branch of KPMG (a consulting company) has proposed to make public pension age dependent on education level achieved at the age of 35, and the correlating life expectancy for that group. Taking as a basis national statistics of life expectancy related to education level, rather than type of occupation, they propose that everyone should have achieved the same percentage of his/her life expectancy at the moment the pension starts (KPMG, 2017). Moreover, The Netherlands Interdisciplinary Demographic Institute as well as the Dutch Health Council recently argued that the lower health levels of lower educated groups should be accounted for in reformations of Dutch public pension schemes (De Beer and Van der Gaag, 2018; cf. Burdorf, 2013; cf. Lammers and Kok, 2017). Regardless of whether one agrees with the suggestion that unequal prospects on equal pension enjoyments are a relational injustice, these proposals can be said to be in itself relational egalitarian. For while they emphasize a fair distribution of the burdens and benefits of the system of cooperative production, these proposals are relational egalitarian in the sense that they aim to recognize the groups with a lower life expectancy as equals in the formation of policies and social arrangements. Or, to use the words of Schemmel (2011: 367), these proposals ‘express equal standing’ and ‘display an egalitarian concern’ to all participants in the system of labour. Reducing Risks of Health-related Unemployment In case unemployment and dependency on public benefits due to health problems are unavoidable, it is key that people are treated respectfully. As Wolff (1998) argues, a revaluation of an ‘egalitarian social ethos’ is due here, meaning that policymakers and legislators both consider fair distributions, and values such as respect for privacy and trust. Yet this egalitarian ethos is only helpful at the point that people are unemployed and apply for welfare benefits. But perhaps more can be done to prevent health-related unemployment in the first place, to protect people’s equal standing in the system of labour and prevent marginalization. Defenders of the social model of disability and the disability movement have emphasized that the risk of unemployment that comes with disability is not merely due to the individual’s physical or mental impairments, but the result of the interaction between the individual’s environment and the impairment. That is, the eventual unemployment is a misfit between the job—i.e. the required skills and the work environment—and the individual’s physical or mental abilities (Beatty and Joffe, 2006). Also cultural and environmental factors are seen as important causes of the marginalized position of persons with a disability. For instance, Barnes (2000: 445) argues that ‘the pursuit and maximization of profit, waged labour and competition between individual workers’ form the dominant values that have informed the meaning of work in western societies since the 18th century. According to Barnes, it is due to these values that people with physical or mental impairments are effectively disadvantaged in the system of labour.5 He calls for an improvement of the position of disabled persons, by challenging and reformulating ‘the meaning and organization of work’ (Barnes, 2000: 449). While competition and productivity are key characteristics of a free labour market, it is worthwhile considering how egalitarian values like participation on equal footing could have a more central role. In fact, as Barnes shows, steps have already been taken in this respect. So-called ‘welfare-to-work’ programmes help unemployed to find work, by training and/or by paying employers a fee, and some progress is made in making buildings and transport systems better accessible for more people. In case of persisting health inequalities, the task is to continue these developments, and to do this by explicitly considering those who risk becoming chronically ill or impaired later in life. A motivating perspective in this regard is offered by Beatty and Joffe (2006). They summon employers to treat persons with a chronic illness as a ‘unique diversity category’ in the sense that those persons will all face issues in terms of ‘privilege, power, inequality, and stigmatisation’ (Beatty and Joffe, 2006: 188). Chronic illnesses exist in various degrees, and symptoms—often pain and/or a lack of energy—are notably unpredictable and can vary from day to day. Medication obviously can play an important role in suppressing these symptoms, but if they could do so perfectly, there would not be a risk of unemployment. We can thus imagine all kinds of practical adaptations that could be made: from adjustable furniture and controllable temperature at the workplace, to flexibilization of working hours and working at home, to a redistribution of responsibilities and tasks. Considering inequalities in health between groups helps to see that it is more than an individual affair. Although successful prevention of health-related unemployment should ultimately take into account individual health needs and individual work tasks, conceiving it merely as individual issues ignores the significant role that employers could play. Apparently, employees with a chronic illness are reluctant to discuss their condition out of fear for discrimination, credibility and/or reputation damage, and so they do not actually discuss with their employers what adjusted work conditions they need to keep their job (Beatty and Joffe, 2006). Rather than waiting for employees to ask for adjustments, Beatty and Joffe (2006) argue that employers should proactively develop policies that demonstrate compassion, and willingness for flexibility in terms of tasks and work conditions. By making publicly clear what steps employees can take in case of enduring illness, an environment could be created in which people feel safe to discuss what they need to stay at work. Now, many of the measures that Beatty and Joffe (2006) mention seem to be achievable for professional jobs where employers have relatively high levels of job autonomy. As we mentioned above, for ‘non-professional workers’, working hour flexibility is usually a matter of ‘one-way flexibility’ and that ‘junior, relatively unskilled, and peripheral workers are least able to control their working arrangements’ (Peper et al., 2005: 5). And so, addressing health-related unemployment by adjusting working conditions requires most efforts for lower paid jobs that demand less educational degrees. Reducing Risks of Health-related Stigmatization Although health-related stigmatization is a universal and cross-cultural phenomenon, the values that stir it and the degrees of stigmatization differ. Alonso et al. (2009) report for instance a strong relation between mental disorders and stigmatization in all European countries but find differences in degrees of stigmatization between countries. This suggests that stigmatization is persistent yet could be reduced in so far social and cultural norms are changeable. With regard to particular stigmatized diseases, several strategies have proven to be effective. Formally, stigmatization can be addressed by legislation. Ratifications of the UN Convention of Rights of Persons with Disabilities, and laws like the Equality Act 2010 (UK) and the Mental Health Parity Act (US), do not only protect persons against discrimination but also communicate that people with mental or physical impairments should not be discriminated. Less formally, public campaigns can help reducing stigmatization by showing that stigmatizing is a matter of injustice, and by informing what stigmatized health conditions entail. Also, making people familiar with stigmatized conditions by interpersonal contact has been proven to be an effective means against stigmatization (Cummings et al., 2013). Regarding the combined stigmatization of socio-economic position and health instigated by neoliberal discourses, the task for public health policies seems to be to refrain from merely emphasizing individual responsibility for health and aim to avoid the above-mentioned ‘lifestyle drift’. Carey et al. (2017) suggest therefore to frame obesity as a problem of society as whole, not as a problem of specific groups, to make it easier accepted that obesity should be addressed by governments, rather than by individuals. This could help to prevent the stigmatization that lower socio-economic groups appear to experience when the phenomenon of socio-economic health inequalities is covered in the media (Smith and Anderson, 2018). Since those who are disadvantaged in terms of socio-economic conditions have overall less control over the factors that influence their health, lower socio-economic groups risk to be unjustly blamed for ending up unhealthy. Those in the position to influence which health conditions are considered blameworthy (e.g. the higher educated healthcare professionals, medical teachers, and policymakers) are also in the position to counteract the health-related stigmatization of those in lower socio-economic strata. Ultimately, their concern should be to treat people as equals, despite of their health problems. Conclusion We have argued for an instrumental evaluative approach that assesses to what extent socio-economic inequalities in health threaten relational equality. Instrumental evaluation—which takes equality in health not of intrinsic, but of instrumental value—is understood as complementary to evaluations of the causes of health inequalities. We have shown how inequalities in (healthy) life expectancy threaten relational equality in at least three ways: via the risk of fewer years of pension enjoyment, via the risk of health-related stigmatization and via the risk of health-related unemployment. We have described these effects of health inequalities as relational injustices by indicating how the least healthy are at risk of being oppressed, notably by violence and marginalization, and of not being respected as an equal in the system of labour. Since disadvantages cluster, the risks of these injustices are especially great for those in lower socio-economic strata. In addition, we have argued that these threats to relational equality are not simply due to inequalities in health but also to the ways in which contemporary welfare states are generally structured and organized. Acknowledging this opens a way to mitigate these injustices by adjusting social circumstances, rather than people’s health, e.g. by adjusting pension schemes, addressing health-related stigmatization and adjusting work conditions. Also regarding mitigating injustices, the most efforts are to be made in relation to those in the lower socio-economic strata: when faced with health problems, the barriers to equal standing are greater for those with a lower level of education and/or income than for higher socio-economic groups. We conclude with two possible objections. First, some readers will hear the echo of the social model of disability in these proposals to focus on circumstances, rather than on health conditions. And, just like the social model of disability may have gone too far in blaming society rather than health conditions (Shakespeare, 2012), the worry here may be that our approach provides a license to stop investments in public health and medical treatment, or to stop worrying about the social determinants of health. We have indeed argued that flexible public pension schemes should be considered, that society wide efforts are to be made to address health-related stigmatization and that there is an agenda for both employers and employees to explore what efforts can be made to protect employment among those with health problems, and that the need to make these efforts is especially high for those lower down the socio-economic scale. However, we have done so in the expectation that some degree of socio-economic inequalities in health will persist, and in the assumption that simultaneously efforts are made to bring people’s health to the best attainable level. That is, if health problems are caused by the absence of proper nutrition, hygiene, healthcare, medication, etc., it would be wrong and pointless to only take refuge to changing people’s circumstances for the sake of their equal standing. The here defended instrumental approach should thus by no means be taken as a permit to stop investments in healthcare or public health measures. Second, one may object that our analysis pictures the problems of socio-economic health inequalities in a too linear way. We have indeed conceptually discerned the causes and social determinants of health inequalities from their consequences, to distinguish different types of normative arguments and different directions of mitigating injustices. But as empirical studies and the clustering of disadvantage show: addressing causes and addressing consequences will in practice strengthen each other. That is, the here discussed proposals to restore relational equality will likely improve health itself, given what we know about the negative health effects of stigmatization (cf. Hatzenbuehler et al., 2013), unemployment (cf. Schuring et al., 2007) and working in hazardous conditions (cf. Wester and Wolff, 2010 Indeed, in Norman Daniels’s words, ‘justice is good for our health’! Footnotes 1. We thus reject the luck egalitarian objection that inequalities in equal standing caused by health inequalities that stem from free choices would be justifiable. Not only because it is unlikely that systematic inequalities in health stems from truly free choices but also because we concur with Anderson that the implications of this view are too harsh (Anderson, 1999: 2006). 2. Examples of such ‘blame-based’ stigmatization are conditional clauses—e.g. losing weight and quit smoking—for medical treatment and health insurance (Schmidt, 2008; Campbell, 2017). 3. We thank the reviewers and editor of Public Health Ethics for insisting on this point and for indicating the complexities that come with this example. 4. One could object that pensions were never meant to serve this function, as pension age was originally set at ages that people would be expected to die, and thus only serve the needs in the very latest days of people’s life. But this would ignore the change of meaning that pension schemes have undergone, and that it functions nowadays much more as a social right. 5. Barnes thereby echoes Young’s definition of exploitation as a modern form of oppression in the sphere of labour: ‘Exploitation enacts a structural relation between social groups. Social rules about what work is, who does what for whom, how work is compensated, and the social process by which the results of work are appropriated operate to enact relations of power and inequality’ (Young, 1990: 49–50). Acknowledgements We thank the two anonymous reviewers and the editor of Public Health Ethics for their helpful questions and comments. 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Public Health Ethics – Oxford University Press
Published: Nov 1, 2018
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