This Friday we received the great news that The Netherlands Organization for Health Research and Development (ZonMW) will fund for our research proposal Balancing responsibility for health: ethical dilemmas in policies aiming at promoting health in socioeconomically disadvantaged groups. The 130 k€ grant will enable Beatrijs Haverkamp to do a postdoc study in collaboration with, among others, the City of Utrecht, Pharos, and AmsterdamUMC. The project has practical and theoretical ambitions, and we foresee that the interaction between ethical reflection on (local) health policy practice on the one hand, and analysis of core ideas of social justice will be especially fruitful.
Poorer and lower educated people have a clearly reduced (healthy) life expectancy compared to more affluent and higher educated groups, causing, among others, significant health disparities between neighbourhoods in cities. This is not a new phenomenon. Over the past 35 years, health policies to reduce socioeconomic health inequalities (whether national or local) have had very limited success (Broeders et al. 2018). Recent coalition agreements of several larger cities in The Netherlands again show strong ambitions to reduce socioeconomic health inequalities, but public health professionals on the level of local governments struggle with the question of how to do so.
The failure to reduce health inequalities is not merely a matter of ineffective health interventions, but also of a deep normative uncertainty. Although there is a broad political consensus on the ideal of ‘equal chances to health’ the question of how the governments should realize this ideal will inevitably face ethical dilemmas and trigger normative-political differences.
This project will enable public health professionals on a local government level to articulate and resolve the ethical questions they face while developing and implementing ‘health equity policies’. By developing a non-ideal account of health equity we expect to overcome (or bypass) the political dissensus that often paralyses health equity policy. Our research questions are:
1) what are the ethical dilemmas in local health equity practices, and how should local governments respond to them?;
2) how should we understand the relation between the governmental responsibility for health equity and the responsibility for non-health policy goals?;
3) what could and should citizen consultations mean in the context of health equity policies?
We build on the conclusion of our former research project: that a pragmatic, non-ideal approach of social justice can fruitfully shape and underpin health equity policies. We therefore analyse the ethical issues that characterise local health equity policies by appeal to the non-ideal social justice approaches as proposed by e.g. Elizabeth Anderson and Iris Young. These approaches of social justice provide several diagnostic and clarifying tools. For instance, responsible decision making by civil servants in public health could be served by focusing on how health affects people’s capabilities to function as an equal in society (cf. Anderson 1999; Haverkamp et al. 2018). And Young’s notion of political responsibility helps to demarcate the scope of responsibility for health for several actors, based on the degree of causal connection, interest, privilege, and power.
Our research method has two aspects that will strengthen each other. Practically, we will observe and engage with practices in local health equity policies in the City of Utrecht via four core activities: we will a) facilitate ethical deliberation by public health professionals on the moral dilemmas they face in health equity policies; b) organise discussion groups with socioeconomic disadvantaged citizens on the relation between individual and governmental responsibility for health, c) organise ethical discussions with policymakers and professionals in public health and non-health domains (e.g. poverty, environment) about the role of health equity in non-health policies, d) observe and reflect on local participatory projects in public health to see if and under what conditions they can contribute to social justice and policy legitimacy. Theoretically, we will a) analyse ethical dilemmas that concern the relation between local governmental and individual responsibility for health; b) analyse the question whether or not health equity could trump other governmental objectives in (local) policy making; c) analyse the ethical underpinnings and relevance of the use of citizen consultations for health equity.
Our activities result in an ethical guide for local health equity policies that helps civil servants and policymakers to cope with moral questions in policymaking and -execution by providing clarity about the scope and content of governmental responsibility to reduce health disparities. The theoretical work that underpins the guide will be published via several in-depth papers in peer reviewed journals.