Why Socioeconomic Inequalities in Health Threaten Relational Justice: A Proposal for an Instrumental Evaluation

Socioeconomic inequalities in health in high-income countries are a well-known (and persistent) fact. When discussing the question if and why these inequalities are unjust, most scholars have focused on evaluating the causes and the distribution of the so-called ‘social determinants of health’ such as income and education level. By taking up a perspective offered by Martin O’Neill (2008), this paper asks to what extent equality in health is of instrumental value for a society of free and equals. It thereby argues that apart from evaluating the causes and the distribution of the social determinants of health, an evaluation of the consequences of health inequalities is due. We understand a society of free and equals as the ideal of relational equality and take that ideal as an evaluative framework. Considering the consequences of various health problems, we identify three ways in which inequalities in (healthy) life expectancy threaten relational equality: via unequal risks to stigmatisation, unequal risks to unemployment and the risk of unequal pension enjoyments. Risks that are especially great for those groups lower down the socioeconomic strata. And so, it is concluded that equality in health is of instrumental value to relational equality, and that socioeconomic health inequalities may not only be unjust due to their causes, but also because of their consequences. The paper continues to argue that our instrumental approach to equality in health opens a new perspective, namely to mitigate the identified injustices in health by changing society, rather than by reducing inequalities in health. That is, by differentiating pension schemes, by adjusting work conditions, and by addressing health-related stigmatisation, the inequalities resulting from socioeconomic health disparities can be decreased. This is argued to be an advantage in the light of the realistic assumption that (part) of the socioeconomic health inequalities will persist. Thus conceived, our instrumental approach is complementary to existing approaches both regarding the evaluation and the mitigation of the injustice of socioeconomic inequalities in health.