From Healthcare to Health: An Update of Norman Daniels’s Approach to Justice

Here is a health policy riddle: despite the fact that we are not always clear as to what we are trying to achieve, even on the most basic level, we must make policy anyway. Odder still: this is as we might expect it to be, and perhaps even as it should be. After all, part of what makes health policy important is precisely the fact that it raises critical questions about our most basic human values and social commitments. The conversation should be fluid. Norman Daniels has long been an important participant in these conversations. Just Health: Meeting Health Needs Fairly—a titular play on his 1985 book, Just Health Care (1)—is Daniels’s attempt to wrestle with contemporary challenges that have forced him to rethink his positions. At its most basic level, then, Just Health can be read as a reminder of the tentativeness of scholarly positions on the core questions of health as well as the importance of being willing to revise both the questions we ask and the positions we take.   In Just Health care, Daniels identified six important areas of concern: 1. Adequate nutrition, 2. Sanitary, safe, unpolluted living and working conditions, 3. Exercise, rest, and such important lifestyle features as avoiding substance abuse and practicing safe sex, 4. Preventive, curative, rehabilitative, and compensatory personal medical services (and devices), and 5. Nonmedical personal and social support services (pp. 42–3). Just Health adds a sixth critical component: other social determinants of health. To get to this level, Daniels uses early chapters to establish the “special moral importance of health” as an object of inquiry (Chapter 2), and to look beyond healthcare to a more-inclusive and socially-expansive view of health (Chapter 3). As Daniels notes, “bioethics has not looked ‘upstream’ from the point of delivery of medical services to the role of the healthcare system in improving population health.” As a result, it tends to miss “the distribution of social goods that determine the health of societies”. The point is clear since—in the 21st century—health can no longer be served a la carte; we must think systemically. Hence Daniels’s larger point is that “social justice in general is good for population health and its fair distribution” (p. 82).