INEQUALITY, EQUITY * EQUALITY *

ECONOMICS
Factors Affecting Social Inequalities in Health
1. Social Status
2. Geographical Factors
3. Income and economic resources
4. living and working conditions
5. Attitudes and behaviour
SC I : Professional Occupations ( University
Academic Staff, Physicians, Lawyers)
SC II : Managerial and Technical Occupation
SC III : Non Manual Skilled Occupation (Clerks and
shop assistants)
SCIII : Manual Skilled Occupation ( Coal Miners)
SC IV : Partly Skilled Occupation ( Bus Conductors
and postmen)
SC V : Unskilled Occupation ( laborers)
Classification of Social Class
Geographical Factors
Education
Diet
Income
Working Conditions
Living Environments
Lifestyle
Ethics, equity and economics
Ethics - theories of justice
- medical versus economic polarisation
Equity - definitions
- health, need and access vs. use
- micro versus macro
Economics - equity and efficiency
Why ethics?
Philosophy determines objectives of health care
system e.g.
-maximise social well-being based on
(consequentialist) utilitarianism
Different philosophical concepts have different
implications, esp. for efficiency
Main practical manifestation = equity

Categorising ethical theories (1)
Distributive justice - political or social
philosophy - concerned with outcome

Procedural justice - moral philosophy -
concerned with process used in achieving the
outcome
Categorising ethical theories (2)
Political philosophy - societal focus e.g. Rawls
Moral philosophy - individual focus e.g Kantian
Imperative
Interaction e.g. utilitarianism - social utility
maximised by each individual maximising own
utility
Categorising ethical theories (3)
Individual Society
Process Entitlement
Deontological
Virtue
Outcome Utilitarianism
Rawlsian
Egalitarian
Rights
Ethical theories
Utilitarianism
Rawlsian
Entitlement/libertarian
Egalitarian
Deontological
Virtue
Rights
Utilitarianism
Jeremy Bentham (classic) and John Stuart Mill
(adapted)
Maximising greatest utility for greatest number
Underlies efficiency
Issues - domain (whose utility)
- malevolence (utility from suffering)
Utilitarianism
Utilitarianism was described by
Bentham as "the greatest
happiness or greatest
felicity principle".
[
Utility, the
good to be maximized, has been
defined by various thinkers
as happiness or pleasure(versus
suffering or pain),
although preference
utilitarians define it as the
satisfaction of preferences. It
may be described as a life
stance, with happiness or
pleasure being of ultimate
importance.

Act utilitarianism states that,
when faced with a choice, we
must first consider the likely
consequences of potential
actions and, from that, choose
to do what we believe will
generate the most pleasure.
The rule utilitarian, on the
other hand, begins by looking
at potential rules of action.
Rawlsian maximin
John Rawls 1971
Allocation
conducted under
veil of ignorance
- leads to position
of less well off in
society being
maximised
Theory of Justice
Each person is to have
an equal right to the
most extensive scheme of
equal basic liberties
compatible with a
similar scheme of
liberties for others

Social and economic
inequalities are to be
arranged so that (Rawls,
1971, p.303):
a) they are to be of the
greatest benefit to the
least-advantaged members
of society (the difference
principle).
b) offices and positions
must be open to everyone
under conditions of fair
equality of opportunity

Entitlement/libertarian
Robert Nozick 1974
Individuals entitled to what they have acquired
justly i.e. within a market situation
Stresses freedom of choice and property rights -
minimal state involvement
Similar to utilitarianism
Egalitarian
Equal shares in the distribution of a commodity

Issues - of what? health, services?
- according to what criteria?
need, age?
Deontological (deon (Gk) = duty)
Immanuel Kant
Moral rules of how to live which should not be
broken (ie absolute moral code)
Do to others as you would have done to you
Humans as end, not means
Virtue theory
Not what should I do but what kind of person
should I be

Similar to deontological - absolute moral rules
Medical vs. economic ethic (1)
Medical - individual (deontological) ethic
- Hippocratic oath, Nightingale
Pledge
- Agency and professional codes
conduct
- best interests of patient
- opportunity cost ignored (?)

Medical vs. economic ethic (2)
Economic - population based ethic
- principally utilitarian
- based on opportunity cost

Overlap of considerations in both professions
Medical dilemma (1)
I recall a patient who bled massively from his inoperable
cancer of the stomach, I was the houseman and I had a strong
sense that I must do my utmost for my patient, I ordered large
quantities of blood to be cross matched and set up an infusion
to replace the blood the patient had lost. It was not that I
believed that the blood would cure him, but it would very
probably save his life for a while longer, whereas without the
blood transfusion he would have probably died there and then.
A few days later the patient had another massive bleed and I
again ordered more blood and set up a transfusion, again the
patient survived what would almost certainly have been a fatal
blood loss. The patient himself, knowing the situation, was
keen to fight it as hard as possible.
Medical dilemma (2)
After the second massive bleed and equally massive blood
transfusion, my chief gently pointed out that there was no
point in pouring in the blood as I had been, the patient had
widespread cancer secondaries, his stomach was riddled with
cancer and likely to bleed whenever the cancer eroded a blood
vessel; blood transfusions could do no more than prolong the
patients life by a very short time. If I went on ordering blood
at the predigious rate I had been, I would literally break the
bank, the blood bank, causing enormous expense whilst
seriously jeopardising the chances of other patients for whom
a blood transfusion could really be lifesaving, rather than
merely death prolonging.
Medical dilemma (3)
I wanted to discuss all this with the patient, but he died the
same day from a further massive bleed and that time I simply
was not called. My superior had decided that there was
nothing beneficial that could be done. More precisely,
however, his analysis was surely based on a different
assessment, notably that the benefit to the patient of repeated
blood transfusions each time his stomach cancer bled, even if
he himself wanted to fight to the last second, was insufficient
to justify the enormous cost (to others) of providing the
blood.

Tavistock Group - BMJ, Jan 23, 1999
- healthcare is a human rightprovide
accessregardless of their ability to pay
- care of individuals is at centre of health care but
must be viewed within context of [generating]
greatest possible health gains for groups and
populations
CONCEPTS OF EQUITY IN THE
DISTRIBUTION OF HEALTH CARE
Utilitarianism
Equality of Health
Equality of Expenditure
Equality of Use for equal
need
Equality of access for
equal need
Rawlsian Maximin
Definitions of equity (2)

Equal access (opportunity to use) for equal need e.g
equal waiting time per condition
Equal utilisation (use) for equal need e.g. equal
length of stay per condition
Equal treatment for equal need
Equal health
Why equity? (1)
Health = fundamental commodity necessary for
enjoyment of all else
Health care important determinant, but often
expensive/unpredictable
Insurance = imperfect/expensive
Why equity? (2)
Healthcare should not be allocated/distributed
according to income/wealth
Equity main reason government involvement in
health care world-wide
Issues - concern with existing distribution
income/wealth then why not change
this directly?
- trade off with efficiency?
Why equity in health care?
The social conscience is more offended by severe
inequality in nutrition and basic shelter, or in
access to medical care, than by the inequality in
automobiles, books, furniture or boats

Tobin 1970
Equal health?
Definition e.g. QALYS, LYs?
Influence of non-health care factors e.g.
housing, diet
Choice versus coercion e.g.smoking, diet
Implies reducing overall health not
increasing - only truly equal state = dead
Maximising versus minimum standards
Equity and need (1)
Need = ambiguous and confusing
Who determines need - producer
- individual
- elite
Supply driven - what is available determines
what is needed
Need versus capacity to benefit - treat worse off
even if health improvement less than treating
better off
Equity and need (2)
need versus preference
objective versus subjective need
maximising - quantity of resources required to
ensure individual becomes /maintained as healthy
as possible = bottomless pit
Minimising - standard of care which ensures
individual not fall below adequate level of health

Measuring equity
Finance - Kakwai Index
- Suits Index
Health - Gini coeff - see McGuire p.59
Data - see Folland, Goodman & Stano
book p.487
- see Donaldson & Gerard
Equity not necessarily = equality
Equity concerned with fairness' justice (i.e.ethical
theories)
May not necessarily entail equality. e.g.minimum
standards of care, postitive discrimination etc.
However, equity usually synonymous with equality
of something.