What Is Unfair? Depends on Where You're Standing.
Commenter Catee Lalonde levels three fundamental critiques against Dahlgren and Whitehead's definition of inequity. The third one, about the meaning of ‘unfairness', is the topic of this posting.
Catee queries whether choices that we make as a society and that lead to serious inequalities (Catee cites the way the US has organised its health care system) mean that they are self-inflicted and consequently not unfair. The obvious answer here is: that depends. ‘Unfairness' should always be regarded in its context, and to understand that context we need to ask three basic questions about any disparity that could be unfair:
- Who is the disparity inflicted upon?
- Who profits from the disparity?
- Who inflicts the disparity?
In the example of the US health system, there are two ways of answering these questions, depending on whether you look at it from an intra-societal point of view or from a global point of view.
To start with the latter: the way the US system is organised contributes to a lower health status of its population than of comparably wealthy countries. From this perspective, the disparity is inflicted upon the American people in general, nobody really profits from this disparity, and the disparity is a result of actions and choices made by American society itself. Consequently, the disparity can hardly be called unfair.
However, things suddenly look very different when we look at these same questions from a perspective that is placed within American society. It is clear that some groups, especially those who cannot afford private health insurance, are much more disadvantaged by the system than others. Higher income brackets (who can afford insurance or even can afford not to be insured and to pay costs out of pocket) are much less disadvantaged and could even profit from the system: in a system that ensures greater parity, their tax burden would probably be higher. The difficult question here is the last one: who inflicts this disparity? Different answers are possible, but one could argue that the American political system disenfranchises exactly the people who suffer from this disparity: the poor, and those who struggle just above the poverty line. (Note that I am don't know whether that this is really true, but it can be argued, and has been argued quite convincingly - see our sister blog on universal health care for the hows and whys.) If one accepts this, the conclusion that this disparity is unfair is inescapable.
Would this mean that it is also inequitable? Not immediately: remember that Dahlgren and Whitehead's three requirements are cumulative, i.e. a disparity needs to avoidable, and unnecessary, and unfair. It is clear that this disparity is avoidable: it might not be simple to change the health system, but it is not impossible. Whether it is also unnecessary can only be answered by the American people (of which I am not part): do you feel that these disparities are essential?
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