By Madison Powers and Ruth Faden
Oxford University Press
Why is public health a moral concern? Consider the following: “It is estimated that each year as many as twenty million people in severe poverty in the developing world die young, by the standards of the rest of the world, from malnutrition and diseases that can be inexpensively prevented or treated.” (pp. 90-91).
The authors, both professional philosophers (Powers at Georgetown’s Kennedy Institute of Ethics and Faden at Johns Hopkins’s Berman Institute of Bioethics) draw upon the literatures of bioethics, economics, philosophy, medicine, and public health in proposing a nonideal theory of justice, offering “ ... practical guidance on which inequalities matter most when just background conditions are not in place.” (p. 30), as opposed to competing theories of justice, such as that proposed by John Rawls, which concern themselves with distributive principles operating within a just social structure. Distributive justice concerns itself with access to scarce resources. Powers and Faden do not assume ideal distributive principles.
Powers and Faden posit health as one of six “core dimensions of well-being,” including personal security, reasoning, respect for others and self respect, attachment, and self-determination. These dimensions, of which health is no more important than any of the others, “ ... are not reducible to what mature, autonomous ... adults can choose; they refer also to the underlying unchosen conditions that determine the extent to which we are able to flourish.” (p. 78). They acknowledge that their dimensions are arbitrary but represent “ ... a useful set of criteria for illuminating the requirements of justice within public health and health policy and beyond.” (p. 78).
In Chapter 3, “Justice, Sufficiency, and Systematic Disadvantage,” Powers and Faden present a framework of four scenarios which they use to illustrate how social determinants (such as the criminal justice system or pathways of economic distribution) affect each of the six dimensions. They offer scenarios of “densely woven patterns” (p. 72) of systematic disadvantage and provide illustrative examples. Powers and Faden cogently formulate their sufficiency theory of justice, drawing upon Harry Frankfurt’s work. Sufficiency principles are open to criticism, though. Paula Casal noted that such principles “ ... do not favor the elimination of inequality, nor do they regard benefiting the less well off as generally more important than benefiting the better well off.” (Casal, 2007, 296).
Chapter 5, “Medical Care and Insurance Markets,” will be slow going for readers lacking academic training in economics, but Powers and Faden thoroughly explain economic concepts. They summarize moral criticisms of markets and discuss potentials of market failure. The key to understanding this section rests in their explanation of Kenneth Arrow’s 1963 article, “Uncertainty and the Economics of Medical Care”, which appeared in the American Economic Review. Powers and Faden note that “Arrow’s extraordinary contribution was to apply principles of microeconomics in order to show how markets for medical care and health insurance differ from ordinary markets for other goods and services.” (p. 105).
A pervasive theme is the authors’ concern for children, as group members, “ ... whose prospects for well-being, not only in childhood but throughout life, are at risk because of the locking in of systematic constraints at an early age.” (p. 870). If children experience an insufficiency of well-being in any of the six dimensions of well-being as they progress through developmental stages, the detrimental effects will last a lifetime.
Powers and Faden identify their readers as public policy decision makers, but Social Justice can be profitably read by graduate students, scholars and practitioners in half a dozen disciplines. The authors draw upon the works of Aristotle, Jean-Jacques Rousseau,
John Stuart Mill, Amyarta Sen, and many others in their superlative arguments for an imperfect theory of justice.
Reviewed by Charles Thurston
The University of Texas at San Antonio
Casal, P. (2007). Why sufficiency is not enough. Ethics, 117