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Canadian Journal of Public Health

, Volume 109, Issue 5–6, pp 633–642 | Cite as

Is ‘health equity’ bad for our health? A qualitative empirical ethics study of public health policy-makers’ perspectives

  • Maxwell J. Smith
  • Alison Thompson
  • Ross E. G. Upshur
Special Section on Qualitative Research

Abstract

Objectives

‘Social justice’ and ‘health equity’ are core values in public health. Yet, despite their normative character, the numerous normative accounts of social justice and equity are rarely acknowledged, meaning that these values are often unaccompanied by an explanation of what they require in practice. The objective of this study was to bridge this normative scholarship with information about how these ‘core values’ are integrated and interpreted by Canadian public health policy-makers.

Methods

Twenty qualitative interviews with public health policy-makers recruited from public health organizations in Canada, analyzed using an ‘empirical ethics’ methodology that combined empirical data with normative ethical analysis involving theories of justice.

Findings

Participants viewed health equity and social justice as distinct, where the former was perceived as ‘clearer’. Health equity was conceptualized as focusing attention to ‘proximal’ disparities in access to services and ‘materialistic’ determinants of health, whereas social justice was conceptualized as focusing on structural issues that lead to disadvantage. Health equity was characterized as ‘neutral’ and ‘comfortable’, whereas social justice was characterized as ‘political’ and ‘uncomfortable’.

Conclusion

These findings indicate that health equity dominates the discursive space wherein justice-based considerations are brought to bear on public health activities. As a result, ‘uncomfortable’ justice-based considerations of power imbalances and systematic disadvantage can be eschewed in practice in favour of attending to ‘proximal’ inequities. These findings reveal the problematic ways in which considerations of justice and equity are, and are not, being taken up in public health policy, which in turn may have negative implications for the public’s health.

Keywords

Health equity Social justice Health policy Bioethics Public health 

Résumé

Objectifs

« La justice sociale » et « l’équité en santé » sont des valeurs fondamentales en santé publique. Pourtant, il est rare que l’on prenne acte des nombreux exposés sur la justice sociale et l’équité, malgré leur caractère normatif; ces valeurs ne s’accompagnent souvent d’aucune explication de ce qu’elles exigent en pratique. Le but de notre étude était de combler l’écart dans la littérature spécialisée avec de l’information sur l’intégration et l’interprétation de ces « valeurs fondamentales » par les responsables des politiques de santé publique du Canada.

Méthode

Vingt entretiens en profondeur avec des responsables des politiques recrutés auprès d’organismes de santé publique du Canada ont été analysés selon une méthode « empirique éthique » combinant des données empiriques avec une analyze normative éthique incluant les théories de la justice.

Constatations

Les participants considèrent l’équité en santé et la justice sociale comme des notions distinctes, la première étant perçue comme étant « plus claire ». L’équité en santé est conceptualisée comme mettant l’accent sur les disparités « proximales » dans l’accès aux services et les déterminants « matérialistes » de la santé, tandis que la justice sociale est conceptualisée comme mettant l’accent sur les problèmes structurels qui mènent à la défavorisation. L’équité en santé est décrite comme une expression « neutre » et « confortable », et la justice sociale, comme une expression « politisée » et « inconfortable ».

Conclusion

Ces constatations montrent que l’équité en santé domine l’espace du discours où les considérations fondées sur la justice servent à guider les activités de santé publique. En conséquence, l’examen « inconfortable » des déséquilibres de pouvoir et des désavantages systémiques, fondés sur la justice, peut dans la pratique être évité en faveur d’un examen des inégalités « proximales ». Cela révèle des problèmes dans la prise en compte, ou non, de la justice et de l’équité dans les politiques de santé publique, ce qui en retour peut avoir des conséquences négatives pour la santé publique.

Mots-clés

Équité en santé Justice sociale Politique de santé Bioéthique Santé publique 

Notes

Compliance with ethical standards

This study received formal ethics approval from the Office of Research Ethics at the University of Toronto and all participants provided written consent prior to participation.

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Copyright information

© The Canadian Public Health Association 2018

Authors and Affiliations

  1. 1.School of Health Studies, Faculty of Health SciencesWestern UniversityLondonCanada
  2. 2.Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoCanada
  3. 3.Dalla Lana School of Public HealthUniversity of TorontoTorontoCanada

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