Book Review

Just Health: Meeting Health Needs Fairly

N Engl J Med 2008; 358:1310-1311March 20, 2008

Article

Just Health: Meeting Health Needs Fairly
By Norman Daniels. 397 pp. New York, Cambridge University Press, 2008. $80 (cloth); $29.99 (paper). ISBN: 978-0-521-87632-2 (cloth); 978-0-521-69998-3 (paper).

Many important issues of health policy, such as whether government should provide universal health insurance, raise fundamental questions about the proper scope of government and the fair allocation of resources in society. Norman Daniels's new book, Just Health, presents a carefully reasoned approach to answering such questions.

The book is by design a successor to an earlier work, Just Health Care (New York: Cambridge University Press, 1985), in which, as the title indicates, Daniels focused on equity in the provision of health care. In the more than two decades since the earlier work's publication, extensive research has shown that although health care is important, health status depends heavily on factors such as education, the environment, behavior, and socioeconomic status. One of Daniels's principal goals in Just Health is to integrate these insights into his analysis. The result is a much more comprehensive study of the role that health should play in social policy, broadly defined to include even the economic and political structures of society.

The book consists of three parts. Part I is a presentation of Daniels's overall theory of just health. Part II is a discussion of possible challenges to the theory, such as how it deals with questions of intergenerational equity. Part III is an illustration of how the theory operates in particular contexts, such as in the reduction of health disparities among social groups. The principles set forth are intended to apply to societies at all levels of development, from affluent industrialized nations to low-income countries, and the book concludes with an interesting discussion of international health inequalities and global justice.

The heart of the book is part I, which addresses what Daniels calls the “fundamental question” of social justice for health: “What do we owe each other to promote and protect health in a population and to assist people when they are ill or disabled?” His approach is to subdivide this question into three “focal questions” and to address each one separately. First, what is the special moral importance of health? Second, when are health inequalities unjust? Finally, how can health needs be met fairly when it is not possible to satisfy them all?

Daniels's answer to the first question relies on the principle of equal opportunity. Regardless of their political persuasion, many would consider inequalities in achievement to be unfair if they result from barriers to opportunity rather than differences in talent and effort. Daniels argues that because poor health impairs normal functioning, it is an impediment to opportunity. The protection of normal functioning by the promotion of health is thus critical to the maintenance of fair opportunity, and consequently to the maintenance of the overall fairness of society.

In addressing the second question, Daniels draws on studies of the social determinants of health to argue that health inequalities are unjust if they result from “socially controllable factors affecting population health and its distribution.” These include not only public health measures, disease prevention, and education, but also income and wealth distribution as well as workplace organization. The argument is cogent, but not all readers will accept the conclusion that the promotion of health should sweep so broadly.

The third question is tied to the fact that no society can or should devote unlimited resources to health. Daniels contends that differences in values make it highly unlikely that agreement can be reached across the board on how limited resources should be allocated. He advocates as a second-best solution a set of fair procedures for making these decisions. These procedures have such features as being publicly accessible and employing reasons that are accepted as relevant by fair-minded people.

Of course, a complex work such as this book also raises its own questions. For example, defining the moral significance of health in terms of the preservation of equal opportunity may give insufficient recognition to the alleviation of suffering in health care, particularly when there is no effective treatment for a disease. Perhaps health care should be viewed as performing some functions beyond those of public and population health instead of as a subset of the single enterprise devoted to preserving equal opportunity. In addition, Daniels should have stated more explicitly how he would respond to potential disagreement by libertarians and other political conservatives.

By expanding the horizon to encompass population and public health, however, Daniels offers with this book a valuable corrective to the tendency of bioethics to focus primarily on health care. It is a major contribution to the field and is likely to prove influential in the near term and beyond.

Samuel Y. Sessions, M.D., J.D.
University of California at Los Angeles, Los Angeles, CA 90095
ssessions@mednet.ucla.edu