health care and equality of opportunity

H A S T I N G S C E N T E R R E P O R T 21March-April 2007

In many civilized societies, universal access tohealth care—or, at least, to a decent minimum ofhealth care—is regarded as a requirement of jus-

tice. Indeed, for many, its status as a requirement ofjustice may be fairly described as axiomatic. Still,even those who already subscribe to this consensus(as I do) may hope that a more articulate rationalecan also be provided. One prominent rationale ap-peals to a principle of “equality of opportunity.”1 Itsrough idea is that good health is required to secureindividuals in the share of opportunity, whatever it isexactly, that they are due under the principle ofequality of opportunity. Furthermore, since access toa decent minimum of health care is manifestly re-quired to secure an individual’s good health, access tohealth care will likewise be required for everyoneunder the same principle.

My aim here is to argue that, despite appearances,an equality of opportunity framework actually failsto supply us with the desired rationale. I shall arguethat when due account is taken of important data onthe so-called “social determinants” of health, the con-clusion to which the equal opportunity frameworkleads is that universal access to health care is not re-quired by justice. I do not mean to endorse this con-clusion; instead I think we should seek an alternativerationale for the requirement of universal access. Nei-ther do I mean to impugn the equal opportunityprinciple. As a matter of justice, I believe in bothuniversal access to health care and equality of oppor-tunity. I simply contend that the one does not followfrom the other. Not all good things grow on the sametree.

The Equality of Opportunity Rationale

To set the stage, let me bring the idea of an equalopportunity account into better focus. Any

principle of equality of opportunity will assign each

One widely accepted way of justifying universal access to health care is to argue that access to

health care is necessary to ensure health, which is necessary to provide equality of opportunity. But the

evidence on the social determinants of health undermines this argument.

HEALTH CAREand

Equality of Opportunity

b y G O P A L S R E E N I V A S A N

Gopal Sreenivasan, “Health Care and Equality of Opportunity,”Hastings Center Report 37, no. 2 (2007): 21-31.

22 H A S T I N G S C E N T E R R E P O R T March-April 2007

individual a protected share of oppor-tunity. The equality of opportunityrationale for universal access to healthcare begins from that protected share.We can refer to it as the individual’sfair share of opportunity. Differentprinciples will define this share differ-ently. But the aim of the argument isto extend the moral protection ac-corded an individual’s fair share ofopportunity to a share of health care.

The central insight on which theargument rests is that there is a stronginstrumental connection betweengood health and an individual’s (ef-fective) opportunities: without goodhealth, an individual would havemarkedly fewer opportunities.2 Inthat sense, protecting an individual’shealth is required in order to main-tain her existing share of opportuni-ties. Not only is this point difficult todeny, but it also holds for a very widerange of interpretations of what an“opportunity” is. This makes it possi-ble for the argument to proceed de-spite the fact that few advocates forequality of opportunity are very spe-cific about the nature of the relevantopportunities.3

What the equal opportunity ac-count infers from its central insight isthat individuals require good healthin order to maintain their fair share of

opportunity. Let’s call the “magni-tude” of health required to maintainan individual’s fair share of opportu-nity a “fair share of health.” The firststep in the argument is thus from afair share of opportunity to a fairshare of health. To end up with a ra-tionale for universal access to healthcare, we still need a further step, fromhealth to health care. Continuing theinstrumental strategy, we must beable to affirm that individuals requireaccess to health care in order to securetheir fair share of health. But this isperfectly intuitive. The cumulativeupshot of the argument, therefore, isthat each individual requires a fairshare of health care to retain her fairshare of opportunity.

So conceived, the equal opportu-nity rationale is simple and appealing.Unfortunately, it is also invalid. De-spite the connection between healthand opportunity, we are not entitledto infer “violation of equal opportuni-ty” merely from “loss of health.” Tobe sure, someone in ill health willhave fewer opportunities than whenshe was in good health, but this showsonly that health was required tomaintain her existing share of oppor-tunity. Since that share may well haveexceeded her fair share, it does notfollow that she now has less than her

fair share of opportunity. It may sim-ply be that illness has reduced the op-portunities she had in excess of herfair share.

To license the inference from lossof health to violation of equal oppor-tunity, the argument has to establishthat the opportunities an individualstands to lose with a loss of health willleave her with less than her fair shareof opportunity. I know of only onedemonstrably successful way to estab-lish this crucial point. It requires that“equality” of opportunity be inter-preted in relative terms, so that a “fairshare of opportunity” is defined incomparison to the shares held by oth-ers in society: each person’s share ofopportunity ought to be (more orless) the same as everyone else’s share.4

Let me explain how this interpreta-tion enables us to restore the validityof the equal opportunity rationale.

On the relative interpretation, anindividual’s fair share of opportunityrefers, by definition, to other people’sopportunities. Her share has to bemore or less the same as theirs. Thiscomparison to others makes it possi-ble to locate the lower limit on a fairshare of opportunity by combiningtwo known quantities. The firstquantity is supplied by the relevantothers—for example, by the averagelevel of opportunity in society. Thesecond quantity is the permissiblevariance in a fair share—the “more orless” in “more or less equal,” whichcan be estimated. Combining thesetwo quantities tells us that no one’slevel of opportunity is permitted tofall below the average by more thanhalf of the permissible variance in afair share.

To generate a valid rationale for ac-cess to health care, it only remains toestablish that the “magnitude” of op-portunity that a given individualstands to lose with a loss of health willdrop her below this permissible lowerlimit. In that case, a loss of health willindeed leave her with less than her fairshare of opportunity. A rough andready argument along the requiredlines is not difficult to supply. Thefollowing premises would suffice: The

Figure 1. Social gradient in total mortality, Whitehall 25-year follow-upC. van Rossum et al., “Employment Grade Differences in Cause Specific Mortality,” Journal of Epidemiologyand Community Health 54 (2000): 181. Figure reproduced with permission from the BMJ Publishing Group.


magnitude of opportunity that indi-viduals stand to lose with a loss ofhealth will leave them far below theaverage, whereas the permissible lowerlimit on their fair share of opportuni-ty is not far below the average. De-spite their vagueness, these premisesare fairly plausible, and they licensethe rationale’s crucial inference fromloss of health to violation of equal op-portunity.

Now, although it is the most famil-iar interpretation of equality of op-portunity, the relative interpretation isnot strictly compulsory. For presentpurposes, however, the fact that itdemonstrably restores the validity—and therefore, the appeal—of theequal opportunity rationale for uni-versal access is sufficient reason toadopt it.5 From here on, then, I shallunderstand fair shares of opportunityas relative shares.

At this point we should also note afurther consequence of adopting thisinterpretation, which is that fairshares of health also have to be under-stood as relative shares. This followsbecause the moral significance ofhealth derives, on the equal opportu-nity account, simply from its connec-tion to a fair share of opportunity.Variations in health matter, in otherwords, only insofar as they have an ef-fect on opportunity. Yet by the defin-ition above, only relative variations inopportunity affect anyone’s fair shareof opportunity. Accordingly, the onlyvariations in health that matter arerelative variations, since only relativevariations in health produce relativevariations in opportunity.6

In summary, the equal opportuni-ty argument for universal access tohealth care has two main steps. Thefirst step takes us from a fair share ofopportunity to a fair share of health;and the second step takes us from thisfair share of health to a fair share ofhealth care. While it can easily seemthat the challenge for the argumentcenters on the first step, we may nowactually ignore that step. My criticismwill focus entirely on the second step,the most intuitive one. All one willneed to bear in mind is that my target

requires both steps and that the fairshares to which it refers are relativeshares.

Social Determinants of Health

Let us therefore turn to examinethe equal opportunity rationale’s

step from a fair share of health to afair share of health care. Intuitively,this step seems eminently reasonable.But it is instructive to ask why accessto health care should be necessary forconserving one’s fair share of health.The simplest position is that healthcare is the only socially controllable fac-tor that makes a significant causalcontribution to health. Since theother obvious determinants ofhealth—biology and luck—are notsocially controllable, this position iscertainly plausible. Still, I shall arguethat it is false.

The empirical data to which I shallappeal in this connection concernwhat have been called the “social de-terminants” of health.7 These datahave been well known to publichealth researchers for at least twodecades, but have only caught the at-tention of a wider audience relatively

recently.8 The social determinants ofhealth, roughly speaking, are those so-cial factors outside the traditionalhealth care system that have an ef-fect—either positive or negative—onthe health status of individuals in agiven population.

An example will help. Considerthe distribution of class or socioeco-nomic status (SES).9 I chose this ex-ample because there is a lot of data onSES. However, it also has the inde-pendent merit of falling clearly outsidethe health care system, no matter howbroadly the system is plausibly de-fined.

Perhaps the best evidence on therelation between class and healthcomes from the Whitehall studies,conducted in England by MichaelMarmot.10 Between 1967 and 1969,Marmot examined some eighteenthousand male civil servants rangingin age from forty to sixty-nine. Byplacing a flag on their records at theNational Health Service (NHS) Cen-tral Registry, Marmot was able totrack the cause and date of death foreach subject who later died. His dataare unusually good. To begin with,they are generated from data points

Figure 2. Risk factor adjusted social gradient in coronary heart disease mortality, Whitehall 25-year follow-upM.G. Marmot, “Multilevel Approaches to Understanding Social Determinants,” in Social Epidemiology, ed. L. Berkman and I. Kawachi (Oxford, U.K.: Oxford University Press, 2000), 363.Figure reproduced with the permission of Oxford University Press.


on specific individuals. Each datumreports the relation between the classposition of a particular person andthe lifespan (and cause of death) ofthe very same person. By contrast, al-most every other study begins fromaggregate data. In addition, a numberof important background factors areheld constant for this study popula-tion. Notably, all of the subjects arestably employed, live in the same re-gion (greater London), and have freeaccess to health care provided by theNHS.

Figure 1 presents the Whitehalldata after twenty-five years of follow-up. It reports age-adjusted, all-causemortality rate ratios by employmentgrade for three periods of follow-up.11

There are four grades in the BritishCivil Service employment hierarchy:administrative at the top, followed byprofessional/executive, clerical, and“other.” The professional/executivegrade was used as the reference group,so its mortality rate ratio is 1.0 by de-finition.

The striking and important fea-ture of these data is that the relation-ship between employment grade andmortality exhibits a marked gradient.It is natural to think that, below somethreshold of deprivation, there will bedisproportionate ill-health. Yet in thisstudy population, there is no depriva-tion, not even in the lowest grade.They are all government employees,and they all have free access to healthcare. More to the point, however,there is no threshold, either. Rather,there is a step-wise improvement inhealth outcomes as one climbs theclass ladder. During the first nineyears of follow-up, clerical civil ser-vants have a significantly lower mor-tality rate than the “others,” and themortality rate for professionals ismore than a third lower than that forclericals. Most surprising perhaps, themortality rate for administrators is, inturn, a third lower again than that forprofessionals. The gradient does flat-ten in the middle follow-up period,but a clear step-wise patternreemerges after twenty to twenty-seven years of follow-up.

Moreover, these marked gradientspersist even after the mortality rateshave been adjusted for standard riskfactors. For example, standard riskfactors for coronary heart disease in-clude smoking, blood pressure, cho-lesterol and blood sugar levels, andheight.12 Figure 2 presents the White-hall data on mortality from coronaryheart disease, again after twenty-fiveyears of follow-up. It reports relativerates of death from coronary heartdisease by employment grade, withadministrators having a rate of 1.0 bydefinition. The left bar in each pairdisplays the relative rate adjusted forage alone, while the right bar adjustsit for all the standard risk factors.Correcting for standard risk factorsexplains some of the gradient in coro-

nary heart disease mortality, but nomore than a third. The remaininggradient is still marked.

It seems clear, then, that SES ei-ther makes a fairly strong contribu-tion to the distribution of healthacross the population or stands proxyfor something else that does. That is astraightforward consequence of themarked social gradient in health.13

Moreover, this gradient is manifesteven when access to health care isheld constant. We should thereforeconclude that health care is not theonly socially controllable factor thatmakes a significant contribution tohealth.

How Much Does Health CareContribute to Health?

Of course, access to health caremay still be necessary to con-

serve one’s fair share of health, even ifother socially controllable factors alsomake significant contributions tohealth. Hence, by itself, the argumentso far is not sufficient to underminethe equal opportunity rationale foruniversal access. All the equal oppor-tunity rationale requires is that, rela-tive to the other socially controllablefactors, the contribution health caremakes to health is strong enough tomake access to health care indispens-able to a fair share of health. But ishealth care’s relative contribution ascritical as that?

I shall develop my answer instages. I begin by describing a genericscenario in which health care makes aweak contribution to the distributionof health, and the strong contributionthat SES makes or stands proxy for isalso socially controllable. I start with ageneric description because thatmakes it easier to specify where theequal opportunity rationale goeswrong. However, I want to emphasizeat the outset that my scenario is farfrom an idle conjecture. On the con-trary, its defining assumptions areempirically quite realistic, as I shall goon to show.

Let’s say our society does not haveuniversal access to health care: wehave no national health insurance

Socioeconomic status either makes a fairly

strong contribution to the distribution of health

or stands proxy for something that does.

Moreover, the social gradient in health is

manifest even when access to health care is held

constant. Health care is therefore not the only

socially controllable factor that makes a

significant contribution to health.


scheme, and many of our citizens donot have private health insurance.Let’s say, furthermore, that our societyhas a social gradient in health statussimilar to the one exhibited in Figures1 and 2. Now imagine the followingscenario: First, suppose our society in-troduces a national health insurancescheme and this makes no differenceto the social gradient in health—thedistribution of health outcomesacross society remains essentially un-changed. Second, suppose that if, in-stead of introducing a national healthinsurance scheme, we had spent thesame amount of money on equalizingthe distribution of social status—onequalizing the distribution of income,say, or of education—then our soci-ety’s social gradient in health wouldhave been significantly reduced.

In this scenario, our society actual-ly moves its citizens closer to their “fairshare of health” by devoting the entirecost of the national health insurancescheme to ameliorating the social de-terminants of health—closer, that is,than it does by maintaining a nation-al health insurance scheme. It followsthat the equal opportunity accountdoes not require universal access tohealth care.

To defend these two claims, let usfirst ask how, for these purposes, a“fair share of health” should be under-stood. On the equal opportunity ac-count, as we have seen, a fair share ofhealth is the share of health requiredto preserve an individual’s fair share ofopportunity. To illustrate what thismeans, let us make do initially withtwo crude simplifications. (We shallrefine them presently.) Let us say that“fair” means equal and that the“health” required to preserve an equalshare of opportunity is a matter oflifespan. Let us say, in other words,that having a fair share of healthmeans living the average lifespan.

In that case, a society’s citizens arecloser to their fair share of health tothe extent that each of their lifespansapproaches the average—when thereis less variance in the distribution oflife expectancy around the mean. Onthis interpretation, flattening our so-

ciety’s social gradient in mortality isthe same thing as moving its citizenscloser to their fair share of health. Byhypothesis, spending the entire na-tional health care budget on amelio-rating the distribution of social statusflattens the social gradient in mortali-ty, whereas spending it on the healthinsurance scheme does not. Hence,the first course moves the citizens ofour society closer to their fair share ofhealth, and the second does not.

Notice that relaxing the first sim-plification does not affect this conclu-sion. If a fair share need not be anequal share, but only a “more or lessequal” share, then a fair share ofhealth will correspond to a range oflifespans centered on the mean. Inthat case, it will be possible to achievea completely fair distribution ofhealth without altogether eliminatingthe variance in a society’s distributionof life expectancy. This certainlyseems plausible. However, as long asthe actual variance exceeds the vari-ance permitted by fairness, flatteningthe social gradient—and so reducingthe variance in life expectancy—willstill move citizens closer to their fairshare of health.

A similar point can be made aboutthe second simplification. As long asmore sophisticated measures of healththemselves exhibit a marked socialgradient, the conclusion will stand.Presumably, the most sophisticatedmeasures of health will combine mor-tality and morbidity in some fashion.But we need not inquire into the de-tails of the combination here, since itturns out that both of these dimen-sions manifest a steep social gradient.In a subsequent study, “Whitehall II,”Marmot and his colleagues went onto demonstrate that many measuresof morbidity also exhibit a steep socialgradient.14 Moreover, these gradientsin morbidity persist in the face of ad-justment for standard risk factors aswell.15 Replacing “life expectancy”with a more sophisticated measure ofhealth would not, therefore, disturbthe basic conclusion that devotingour society’s entire health care budgetto improving the social determinantsof health does better than running anational health insurance scheme atmoving the citizens closer to their fairshare of health.

Now let me vindicate the two keyassumptions that license this conclu-

Figure 3. Social gradient in relative mortality, English men aged 15-64Black Report, in Inequalities in Health, ed. P. Townsend, N. Davidson, and M. Whitehead (London, U.K.:Penguin Books, 1992), 59. The last data point is taken from M. Whitehead, “The Health Divide,” also in Inequalities in Health, 231.

sion. The first assumption was thatour society introduces a nationalhealth insurance scheme, and itmakes no difference to the social gra-dient in health. This assumption de-scribes what actually happened inBritain in the twentieth century, asdocumented in 1980 by the “Reportof the Working Group on Inequali-ties in Health” (generally known asthe Black Report). Figure 3 presentsmortality data by social class for menfifteen to sixty-four years old in Eng-land and Wales. Social class is mea-sured here in the terms of the U.K.Registrar General’s classificationscheme, which ranges from profes-sional (class I) through to unskilled(class V).

The mortality data in Figure 3 arereported as standardized mortality ra-tios (SMRs). The SMR for a given so-cial class is a ratio of two mortalitylevels: the actual number who died inthat class, and the number whowould have died in it had the classhad the same mortality rate as thepopulation as a whole. By definition,the SMR for the population as awhole is one hundred. Thus, an SMRgreater (or lesser) than one hundredindicates that the mortality rate in therelevant social class is greater (or less-er) than it is in the population as awhole (and by how much).

The series begins in 1930-32 andruns through 1976-81. The NationalHealth Service (NHS) was intro-duced in July 1948, just before thesecond data point (1949-53). Anyway you look at it, the introductionof the NHS is at least consistent witha widening of the social gradient inmortality.16

Of course, this is not to say thathealth care makes no difference to lifeexpectancy at all. We need to distin-guish between absolute levels of lifeexpectancy (or mortality) and relativelevels. The data in Figure 3, as indeedin Figures 1 and 2, are relative mor-tality data. They represent the mortal-ity rates of a given social class relativeto those of the population as a whole.These data clearly suggest—or at leastare surprisingly consistent with thehypothesis—that universal access tohealth care in Britain did very little toequalize relative levels of life ex-pectancy across its various social class-es.17 Nevertheless, it remains possiblethat universal access to health caremade an important contribution toabsolute levels of life expectancy inthis period, even for social classeswhose relative mortality level did notimprove. To assess this possibility, weneed to examine absolute mortalitydata.

Figure 4 presents mortality data bysocial class, in a slightly longer time

frame, for men and married womenin England and Wales. Again, socialclass is measured by the RegistrarGeneral’s classifications. But here themortality rates are reported in ab-solute terms, as deaths per one hun-dred thousand per year. There is aclear decline in absolute mortality forall social classes, at least over the firsthalf of the century, even though thereis also a gradient across classes. This iscertainly consistent with the hypothe-sis that health care makes an impor-tant contribution to absolute life ex-pectancy.

For our purposes, however, the rel-evant data are those presented in Fig-ure 3. As I emphasized at the very be-ginning, the fair shares of opportuni-ty—and so of health—on which theequal opportunity account focusesare defined in relative terms. As far asrelative levels of health are concerned,we really should conclude that thecontribution made by universal accessto health care is weak. I shall return tothis point.

The second assumption was thatif, instead of introducing a nationalhealth insurance scheme, we hadspent the same amount of money onequalizing the distribution of socialstatus, then our society’s social gradi-ent in health would have been signif-icantly reduced. I shall have to leavethis assumption closer to the status of


Figure 4. Social gradient in absolute mortality, England and WalesM.G. Marmot et al., “Social/Economic Status and Disease,” Annual Review of Public Health (1987): 117. Figure reproduced with permission from Annual Reviews.


a conjecture. But let me at least bol-ster it with a few remarks. To beginwith, given that Britain actuallyspends almost 7 percent of its grossdomestic product on the NHS, whatthis assumption supposes is thatspending almost 7 percent of Britain’sGDP on equalizing the distributionof some core component of social sta-tus there would do significantly morethan nothing to reduce the social gra-dient in health status.

Now in order to consider the evi-dence for this proposition, we need tospecify a core component of socialstatus. In principle, we are free tospecify whichever componentpromises to be the most efficaciouslever for policy purposes. But here weare seriously hampered by the primi-tive state of our understanding of thepathways through which SES affectshealth.18 So we have to fall back onincome, the component of SES thathas received the most attention, de-spite the fact that it is presumably afairly crude health policy lever.

No one denies that equalizing thedistribution of income in a societywill improve average life expectancyprovided that the relationship betweenindividual income and individual lifeexpectancy is causal and “concave”—meaning that there are diminishingmarginal returns of health toincome.19 Thus, the second assump-tion will be confirmed—at least inprinciple—if the relationship be-tween individual income and individ-ual life expectancy is causal and con-cave.20 Most people agree that the re-lationship between individual incomeand life expectancy is indeed concave,and there is also clear empirical evi-dence that it is.21

Both of the assumptions that de-fine my generic scenario turn out,therefore, to be plausible and realistic.What I concluded on their basis wasthat a society does more to move itscitizens toward their fair share ofhealth when it devotes the equivalentof the health care budget to improv-ing the social determinants of healththan when it runs a national healthcare system.

It follows, I also said, that an equalopportunity account does not requireuniversal access to health care. In fact,a stronger contention can be defend-ed. In the Britain we have described,an equal opportunity account re-quires that society spend none of itshealth budget on health care and allof it on ameliorating the social deter-minants instead. That is because thegoal of health policy, on the equal op-portunity account, is to provide eachcitizen with a fair share of opportuni-ty. The goal, in other words, is a dis-tribution of opportunity in which each

citizen’s share is as close as possible tothe fair share. As far as health is con-cerned, this means a distribution inwhich each citizen’s share of health isas close as possible to the fair share. Inthe Britain described, that distribu-tion is achieved by devoting theequivalent of the entire NHS budgetto ameliorating the social determi-nants. Accordingly, that is what theequal opportunity account requires.

What complaint of justice can beraised against the failure to providehealth care? On the equal opportuni-ty account, variations in access to carematter only insofar as they have animpact on the distribution of oppor-tunity; and they can do that only in-sofar as they have an impact on thedistribution of health. Yet by hypoth-esis, failure to provide health care hasno adverse impact on the distributionof health. Hence, on the equal oppor-tunity account, no complaint of jus-tice can be raised against the failure to

provide health care. A fortiori, nonecan be raised against the failure toprovide universal access to healthcare.

Objections and Replies

Simply implausible. One immedi-ate objection may be that it is simplyimplausible to suppose that the opti-mum allocation of a fixed health bud-get would allocate nothing to tradi-tional health care. Even if the datashow that the contribution healthcare makes to the distribution of

health is weak relative to other social-ly controllable factors, that hardly es-tablishes that a society should spendnothing on health care.

This objection makes two impor-tant mistakes. First, it wrongly sup-poses that my argument offers its ownpolicy prescription (on the basis ofthe data reviewed). But I am not ar-guing for or against any policy; I amsimply scrutinizing the policy com-mitments of the equal opportunityaccount. My aim is to identify thepolicy that follows from the data,given that account’s goal of achievingthe best distribution of health out-comes (and ignoring all other goals).

Second, the objection trains its at-tention on the wrong policy question.The dramatic scenario from the previ-ous section, in which nothing is allo-cated to health care, illustrates theequal opportunity account’s answersto two policy questions at once. Onequestion is how best to allocate a

A society does more to move its citizens toward

their fair share of health when it devotes the

equivalent of the health care budget to

improving the social determinants of health than

when it runs a national health care system. It

follows that equal opportunity does not require

universal access to health care.


fixed health budget between healthcare and the social determinants ofhealth. The other question is whetheraccess to health care should be pro-vided to everyone. In addition to beingdramatic, the previous scenario hadthe advantage of making the answerto the second question (no) especiallyclear: distribution of a zero budget ev-idently provides no health care toanyone. However, while the objectionfocuses on the first question, only thesecond matters for our purposes. Mycentral conclusion is simply that theequal opportunity account does notrequire that access to health care beprovided to everyone.

What bears particular emphasishere is that my conclusion in no waydepends upon the point contested bythe objection. To make this clear, letus stipulate that the optimum subdi-vision of the health budget allocatessomething (rather than nothing) tohealth care. We still have to face thecritical question of how these re-sources should be distributed acrossthe citizenry, thereby determiningtheir access to health care.22 Is the bestdistribution of health outcomes se-cured by making health care availableto everyone? In other words, does theequal opportunity account requireuniversal access to health care?

Why should we believe that itdoes? Even when our attention is re-stricted to socially controllable fac-tors, the final distribution of healthoutcomes in society must now be seenas the result of a package of distribu-tions: as the joint upshot of a distrib-ution of health care and a distributionof the social determinants of health.The effects of a given distribution ofhealth care, so far as the final upshotin health is concerned, are thereforemediated by the distribution of socialdeterminants with which it is pack-aged (and vice versa). This introducesthe possibility of trade-offs within agiven package: one person’s relativedisadvantage with respect to a distrib-ution of health care, say, may be offsetby a relative advantage with respect toa complementary distribution of thesocial determinants. Moreover, since

it is relative advantage that is at issue,this offsetting can be achieved eitherby changing the person’s own ab-solute position or by changing the ab-solute position of others. It seems,then, that various packages of distrib-utions (of health care and of the socialdeterminants) can result in the samefinal distribution of health outcomes.There is no reason to suppose that thebest final distribution results from adistribution of health care that makesat least some health care available toevery citizen.

In fact, since universal access tohealth care has as little effect on thesocial gradient in mortality as we haveseen, there is good reason to supposethat certain groups could be excludedfrom health care altogether—eitherrandom groups (blondes, people withodd social security numbers) or moreplausibly, nonrandom groups (therich, the suburban, the impreg-nable)—and this without adverse ef-fects on the final distribution of healthoutcomes. Indeed, if the resourcessaved by excluding some people fromhealth care are put to use in effective-ly promoting health by other means,this new package may well result in abetter final distribution of health out-comes.23

In any case, a distribution ofhealth care that has no adverse effectson the final distribution of healthoutcomes, and hence none on the dis-tribution of opportunity, is unim-peachable from the standpoint of jus-tice according to an equal opportuni-ty account. Since the evidence sug-gests that a distribution of health careexcluding some citizens from healthcare altogether cannot be impeachedon these terms, it still follows that anequal opportunity account does notrequire universal access to health care.

Britain is a special case. Variousempirical objections can also belodged against this claim. Some maywonder, for example, whether Britainis a special case, perhaps because of itsentrenched class divisions. But this isnot plausible. I concentrated onBritain for two main reasons: the

unique character of the Whitehallstudies, which allows us to sidestepthe many problems associated withaggregate data, and the exceptionaltime span for which reliable publichealth statistics are available there.But for the record, a marked socialgradient in mortality has been docu-mented in many countries,24 includ-ing Sweden, Canada, the Nether-lands, and Australia.25 In Canada,where we also have data that addressthe issue, the introduction of univer-sal access to health care did not re-duce the mortality gradient either.26

NHS access is not really universal.Another empirical objection onemight raise is that Britain’s NationalHealth Service does not really provideuniversal access to health care in therelevant sense. If the NHS does notactually provide everyone with com-parable access to health care, thenperhaps the persistence of the socialgradient in mortality in Britain can beexplained away by reference to the re-maining inequalities in access tohealth care. This objection is nottaken very seriously in the publichealth literature.27 The consensus inthat literature is that most of the im-provements in mortality over the pastcentury and a half are not the result ofadvances in medical care.28 It is alsodoubted that the inequalities in accessto health care remaining under theNHS suffice to explain much of thegradient in mortality.

This skepticism is fully consistentwith the available evidence. For exam-ple, employing utilization of generalpractitioner and outpatient services asa proxy for access to health care, onestudy found “little inequality in accessto care” in Britain for the period from1984 to 1994,29 confirming earlierfindings to the same effect.30 Morespecific evidence comes from studiesof mortality in England and Walescaused by conditions newly amenableto medical intervention.31 Between1961 and 1981, the decline in relativemortality from conditions newlyamenable to intervention does notappreciably favor the higher occupa-


tional classes.32 By contrast, in thesame period, the decline in relativemortality from conditions notamenable to medical intervention sig-nificantly favors the higher occupa-tional classes; and these conditionsalso account for a much greater pro-portion of total mortality.33 Thismakes it difficult to attribute verymuch of the widening social gradientin mortality under the NHS to resid-ual inequalities in access to healthcare.

SES is no better. Finally, one mayobject that insufficient causality hasbeen demonstrated in the relationshipbetween life expectancy and any com-ponent of social status to make equal-izing the distribution of some suchcomponent (for example, income) areliable means of reducing the socialgradient in health. The second as-sumption defining my generic sce-nario therefore lacks adequate empiri-cal support. Hence, the most that fol-lows from the argument above is thatthe equal opportunity rationale failsto license spending the health budgeton either policy—neither on univer-sal access to health care nor on im-proving the social determinants ofhealth.

Having myself described the sec-ond assumption as a conjecture, I canaccept most of this objection. (Thereis room to dispute where the balanceof empirical plausibility lies, but noneed to settle the matter here.) Forpresent purposes, the important thingis to appreciate that the assumptioncontested by the objection is, strictlyspeaking, dispensable in my critique.What the objection rightly concedesis itself enough to undermine theequal opportunity rationale.

Recall that, according to the equalopportunity account, the followingcondition is both necessary and suffi-cient to support a given health policy:implementing the policy improvesthe relative distribution of health—and so, of opportunity—in society.Since universal access to health caremakes no difference to the social gra-dient in health, and hence none to

the relative distribution of opportuni-ty, this policy does not satisfy the ac-count’s necessary condition. As a re-sult, it remains true that the equal op-portunity argument fails to licenseuniversal access to health care—andthis given only the first “assumption”(really, an uncontested fact) definingthe generic scenario above. Now if theobjector is right, the argument alsofails to license spending on the socialdeterminants. However, this is coldcomfort, as it leaves in place the con-clusion that the equal opportunity ac-count provides no rationale for univer-sal access to health care, which is thebottom line of my critique.

Naturally, since my claim is funda-mentally empirical, it remains open

to being overturned, either by newfacts or by a more comprehensive ac-counting of the old facts. One way oranother, then, it may yet be estab-lished that the best final distributionof health outcomes is secured by uni-versal access to health care after all.Still, a rather detailed empirical casewill be required to establish this. Inthe meantime, we should believewhat the mass of available evidenceplainly indicates—namely, that thebest final distribution of health doesnot require universal access to healthcare.

What about the AbsoluteInterpretation?

As should now be clear, the deci-sive philosophical feature making

the equal opportunity account vul-nerable to my empirical critique isthat its notion of a fair share of op-

portunity, and therefore of health, hasbeen interpreted as a relative share.That is why the relevant data are to befound in Figure 3 rather than Figure4. An obvious reaction is to wonderwhether the account can be rescuedby interpreting equality of opportuni-ty in absolute terms instead.

The answer depends on whether avalid argument can be preservedunder the absolute interpretation. Aswe saw at the beginning, a valid equalopportunity argument for universalaccess to health care has to establishthat the opportunities an individualstands to lose with a loss of health willleave her with less than her fair shareof opportunity. Thus, to preserve theargument’s validity, we must at least

be able to locate the permissible lowerlimit of an individual’s fair share ofopportunity.34 The signal advantageof the relative interpretation was itsdemonstrable ability to set this lowerlimit by means of tractable compar-isons with others in the society.

On the absolute interpretation, bycontrast, an individual’s fair share ofopportunity must be defined withoutrecourse to comparisons with others.Hence, to specify the permissiblelower limit of “opportunity” in ab-solute terms, one must first define anoncomparative scale of opportunityand then locate a given individual’spermissible lower limit somewhere onthat scale. I am not sure how to dothis.35 The challenge is exacerbated bythe fact that one must discharge thesetasks while eschewing not only explic-it comparisons (reference to other in-dividuals), but also implicit ones (ashappens when one refers to a given

Since universal access to health care has so little

effect on the social gradient in mortality, there is

good reason to suppose that certain groups

could be excluded from health care altogether

without adverse effects on the final

distribution of health outcomes.


society, for example).36 As yet, no onehas even attempted to make this in-terpretation work. For the time being,then, the absolute interpretation ismore of an aspiration than a complet-ed argument.

New Frameworks

Let us take stock. The equal oppor-tunity argument for universal ac-

cess to health care has two basic steps.Each step is beset by a significant dif-ficulty. The first step is the inferencethat anyone who suffers a loss ofhealth also suffers a violation of herfair share of opportunity. Unfortu-nately, this inference is invalid unlessthe permissible lower limit on the in-dividual’s fair share of opportunityhas been suitably located. We can lo-cate a serviceable lower limit by rely-ing on our sense of the permissiblevariance in a person’s relative share ofopportunity, but this means we mustinterpret “fair share” in relative terms.

The second step is the inferencethat anyone entitled to a fair share ofhealth is also entitled to a fair share ofhealth care. This inference is licensedby the intuitively plausible premisethat access to health care is necessaryto conserve an individual’s fair shareof health. However, when a fair shareis a relative share, and we take ac-count of some little-appreciated butwell-established facts about the socialdeterminants of health, this premiseturns out to be false. The best finaldistribution of health turns out to beconsistent with some citizens havingno access to health care at all.

Either way one interprets it, then,the equal opportunity argument failsto yield a rationale for universal ac-cess. Under the absolute interpreta-tion, the first step is invalid, andunder the relative interpretation, thesecond step requires a false premise.

But let me be clear. This critique isby no means an indictment of thepolicy of universal access. I continueto believe firmly that universal accessto health care is a requirement of jus-tice. The present analysis simplydemonstrates that appeals to equality

of opportunity—attractive thoughthey may be—are of no use in justify-ing this widespread conviction. Weneed an alternative rationale, whichwe shall do better to seek in a differ-ent framework altogether.

Acknowledgments

This paper was first written when Iwas on the faculty in the Departmentof Clinical Bioethics at the NIH. Iwould like to acknowledge a great andspecial debt to Ezekiel Emanuel, whoheads that department. Without thewonderfully stimulating and supportiveenvironment his department offered orthe continuing inspiration and mentor-ship he provided, this paper would notexist. Earlier versions were presented ina philosophy colloquium at the Univer-sity of Toronto and to the PhilamoreSociety. I am grateful to both audi-ences, as well as to Dan Brock, TomHurka, Henry Richardson, and ananonymous referee for helpful com-ments and suggestions. I am especiallygrateful to Norman Daniels, who was avisiting fellow at NIH during my firstyear there, for very helpful writtencomments and discussion.

References

1. This rationale is invoked, for example,by the official commentary on Article 12 ofthe “International Covenant on Economic,Cultural, and Social Rights,” which en-shrines a “right to health.” See GeneralComment 14, “The right to the highest at-tainable standard of health,” Part I, sec. 8.U.N. Committee on Economic, Cultural,and Social Rights. E/C.12/2000/4. See alsoN. Daniels, Just Health Care (Cambridge,U.K.: Cambridge University Press, 1985).

2. Compare Daniels, Just Health Care,27: “[My] account turns on this basic fact:impairments of normal species functioningreduce the range of opportunity open to theindividual in which he may construct his‘plan of life.’”

3. Consider John Rawls’s principle of fairequality of opportunity, which requires po-sitions and offices in society to be open toall. Even though Rawls does not say a lotabout how to interpret “opportunities toachieve positions and offices,” it is intuitive-ly clear that, without good health, an indi-vidual would have markedly fewer of them.J. Rawls, A Theory of Justice, rev. ed. (Cam-bridge, Mass.: Harvard University Press,1999), sections 11-17.

4. The alternative is to interpret it in ab-solute terms. In that case, each individual’sfair share of opportunity is defined non-comparatively—that is, without reference toanyone else. I return to consider this alter-native at the end. On the distinction be-tween relative and absolute interpretationsof equality, see D. Parfit, Equality or Priori-ty? (Lindley Lecture, University of Kansas,1991).

5. A good case can also be made that tex-tual indications in Daniels’s seminal versionof the argument favor the relative interpre-tation. See Daniels, Just Health Care, 45:“Because meeting healthcare needs has animportant effect on the distribution of op-portunity, the healthcare institutions areregulated by a fair equality of opportunityprinciple.” Compare also pages 33-34.

6. Imagine a world with only two inhab-itants, Billy and Bob. Suppose they both ex-perience the same loss of health and conse-quently the same loss of opportunity. Theirrelative shares of opportunity remain un-changed, so neither has a claim under theequal opportunity principle. In that case,their absolute loss of health is morally irrel-evant, at least as far as this principle is con-cerned.

7. For an introduction, see P. Townsend,N. Davidson, and M. Whitehead, eds., In-equalities in Health (London, U.K.: PenguinBooks, 1992); M. Marmot and R.G.Wilkinson, eds., Social Determinants ofHealth (Oxford, U.K.: Oxford UniversityPress, 1999); and R.G. Evans, M.L. Barer,and T.R. Marmor, eds., Why Are Some Peo-ple Healthy and Others Not? (New York: deGruyter, 1994).

8. They would not come as news toDaniels himself. See N. Daniels, B.Kennedy, and I. Kawachi, “Why Justice IsGood for Our Health: The Social Determi-nants of Health Inequalities,” Daedalus 128,no. 4 (1999): 215-51. More recently, otherphilosophers have begun to attend to thesedata, but their attention does not extend tothe implications to be established here. SeeS. Anand, F. Peter, and A. Sen, eds., PublicHealth, Ethics, and Equity (Oxford, U.K.:Oxford University Press, 2004).

9. I leave open the question of whetherSES itself makes a causal contribution tohealth, or whether it is merely a proxy forother factors that do. It seems likely thatSES—a composite measure if ever there wasone—is largely a proxy, though in fact thisis not altogether uncontroversial. In anycase, the identification of the “pathways”through which SES affects health is some-thing of a fledgling enterprise. See N.E.Adler and J.M. Ostrove, “SocioeconomicStatus and Health: What We Know andWhat We Don’t,” in N.E. Adler et al., eds.,Socioeconomic Status and Health in Industri-al Nations: Social, Psychological, and Biologi-


cal Pathways (New York: New York Acade-my of Sciences, 1999), 3-15.

10. For the original study, see M.G. Mar-mot et al., “Employment Grade and Coro-nary Heart Disease in British Civil Ser-vants,” Journal of Epidemiology and Commu-nity Health 32 (1978): 244-49. Twenty-five-year follow-up data are presented in C. vanRossum et al., “Employment Grade Differ-ences in Cause Specific Mortality,” Journalof Epidemiology and Community Health 54(2000): 178-84.

11. A mortality rate ratio reports the pro-portion of deaths in a given group dividedby the proportion of deaths in the referencegroup.

12. This is not a random example. Coro-nary heart disease accounted for 43 percentof the deaths in the Whitehall study at tenyears of follow-up. M.G. Marmot, M.J.Shipley, and G. Rose, “Inequalities inDeath—Specific Explanations of a GeneralPattern?” Lancet 323 (1984): 1003.

13. Unless, of course, the gradient can beexplained away. But that strategy has notfared very well, as the discussion of risk fac-tors partly illustrates. See also my replies toobjections below.

14. See M.G. Marmot et al., “Health In-equalities among British Civil Servants: TheWhitehall II Study,” Lancet 337 (1991):1387-93; and M.G. Marmot, “Social Dif-ferentials in Health within and betweenPopulations,” Daedalus 123, no. 4 (1994):203.

15. Marmot, “Social Differentials inHealth within and between Populations,”212.

16. More recent evidence suggests thegradient has continued to widen. M. Shawet al., “Increasing Mortality Differentials byResidential Area Level of Poverty: Britain1981-1997,” Social Science and Medicine 51(2000): 151-53.

17. The qualification is required becauseit is always at least possible that relative lev-els of life expectancy in Britain would havebecome even more unequal had the NHSnot been introduced. There is no evidence tosupport this. But strictly, the possibility canonly be excluded by a controlled study,which plainly cannot be run. However, inthis case, note that other data suggest a sim-ilar conclusion for a different country(Canada) at a later date.

18. A similar point is made by A. Deaton,“Policy Implications of the Health andWealth Gradient,” Health Affairs 21, no. 2(2002): 21.

19. For a nice illustration, see H. Grav-elle, “How Much of the Relation betweenPopulation Mortality and Unequal Distrib-ution of Income Is a Statistical Artefact?”British Medical Journal 316 (1998): 382-85.As Deaton observes, the expression “statisti-

cal artefact” is unfortunate because it sug-gests “that there is no real link between in-come inequality and health, and that redis-tributive policy cannot improve averagepopulation health. This is far from thecase.” A. Deaton, “Health, Inequality, andEconomic Development,” Journal of Eco-nomic Literature 41 (2003): 118.

20. Of course, redistributing income maynot improve average life expectancy in prac-tice, even if this relationship is causal andconcave. One reason is that not everythingtaken from the rich may wind up in thepockets of the poor: the proverbial redistrib-utive bucket may be leaky. Deaton refers tothis as “dead-weight loss”; “Policy Implica-tions,” 23.

21. See M. Wolfson et al., “Relationshipbetween Income Inequality and Mortality:Empirical Demonstration,” British MedicalJournal 319 (1999): 953-55; and alsoDeaton, “Health, Inequality, and EconomicDevelopment,” 115-18, and Figure 2. No-tice that most of this literature focuses onwhether equalizing income promotes aver-age life expectancy. My assumption requiresonly that greater income equality improvethe relative mortality levels of the worse off.There is no specific evidence demonstratingthat the relationship is causal. That is why Idescribe the second assumption as closer toa conjecture.

22. In this context, a policy that merelypermits citizens to spend private resourceson health care still counts as “distributing”resources to them for the provision of healthcare.

23. Compare J.P Mackenbach, K.E.Stronks, and A.E. Kunst, “The Contribu-tion of Medical Care to Inequalities inHealth,” Social Science and Medicine 29, no.3 (1989): 376: “A truly egalitarian healthcare policy, aiming at the equalization ofhealth status in the population, wouldtherefore require a radical redistribution ofmedical care in favor of those most in need.”

24. See J. Fox, ed., Health Inequalities inEuropean Countries (Aldershot, U.K.:Gower, 1989); and N.E. Adler et al., “So-cioeconomic Status and Health: The Chal-lenge of the Gradient,” American Psychologist49 (1994): 15-24.

25. D. Vågerö and O. Lundberg, “HealthInequalities in Britain and Sweden,” Lancet334 (1989): 35-36; J.P. Mackenbach,“Socio-Economic Health Differences in theNetherlands: A Review of Recent EmpiricalFindings,” Social Science and Medicine 34(1992): 213-26; G. Turrell and C. Mathers,“Socioeconomic Inequalities in All-Causeand Specific-Cause Mortality in Australia:1985-1987 and 1995-1997,” InternationalJournal of Epidemiology 30 (2001): 231-39.

26. R. Wilkins, O. Adams, and A.Brancker, “Changes in Mortality by Income

in Urban Canada from 1971 to 1986,”Health Reports 1, no. 2 (1989): 137-74.

27. See Marmot, “Introduction,” to Mar-mot and Wilkinson, Social Determinants ofHealth, 2-3; and Marmot, “Social Differen-tials in Health within and between Popula-tions,” 200-201.

28. See T. McKeown, The Role of Medi-cine (Princeton, N.J.: Princeton UniversityPress, 1979).

29. M. Whitehead et al., “As the HealthDivide Widens in Sweden and Britain,What’s Happening to Access to Care?”British Medical Journal 315 (1997): 1006-1009.

30. See M. Blaxter, “Equity and Consul-tation Rates in General Practice,” BritishMedical Journal 288 (1984): 1963-67.

31. Mackenbach et al., “The Contribu-tion of Medical Care to Inequalities inHealth,” 369-76.

32. Ibid. Mackenbach et al. found thatthe corresponding decline does favor thehigher occupational classes between 1931and 1961. However, this period is largelyprior to the creation of the NHS. Moreover,the differential decline in question is over-whelmed by the differential decline in rela-tive mortality from conditions notamenable to medical intervention.

33. For a graphic presentation of thesedata, see M. Marmot, M. Bobak, and G.Davey Smith, “Explanations for Social In-equalities in Health,” in Society and Health,ed. B. Amick et al. (Oxford, U.K.: OxfordUniversity Press, 1995), Figure 6-13, p. 197.

34. This is not sufficient to preserve theargument’s validity. The location of the per-missible lower limit also has to make it plau-sible that a loss of health threatens to leavean individual with less than her fair share ofopportunity. Not any old location will do.

35. It is far from clear, for example, howan absolute scale of opportunity would beconstructed from Daniels’s account. For auseful critical discussion of the indetermina-cy in Daniels’s notion of opportunity, albeitin a different context, see E.J. Emanuel, TheEnds of Human Life (Cambridge, Mass.:Harvard University Press, 1991), 129-35.

36. Daniels is explicit that his fair sharesof opportunity are defined relative to a givensociety. This implicit comparison in his def-inition is not motivated under the absoluteinterpretation, which is one of my reasonsfor not attributing that interpretation tohim; Just Health Care, 33-34.

health care and equality of opportunity

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