Brief Summary:

Giesbrecht argues that differences in social and personal factors can have significant impacts to one’s life and health, but research only tends to group people into general populations, which can cause important health data to get lost or overlooked. Other names for this are diversity based analysis, which focuses on differences between and within groups and how that affects life, and intersectionality, which is about relating two or more inequalities as they are experienced simultaneously. Sex, referring to anatomy, and gender, referring to personalities, social constructs, or behaviors, are the main categories that research typically uses, but there are also other social determinants of health like socioeconomic status, education, sexual orientation, race, ethnicity, and more. Recognizing and acknowledging the diversity of individuals can help to rectify inequity in health spheres, as treating an entire population equally is ineffective due to the unique lived experiences within smaller populations.

Hausman argues that egalitarians in regards to social policy are currently using a form of data collection about health inequalities that is ineffective, because they are unable to accurately find whether there is an injustice at hand that needs resolving. Having a health inequality can impact overall life prospects, and therefore be unjust, but not all inequalities result in injustice, and that’s where the lines get blurry. Quality adjusted life years of a certain demographic can help egalitarians pinpoint which groups of people tend to suffer more health issues, and therefore can lead to inferences about which populations have more injustices–but this system of using QALY isn’t that good because it leaves out whether the health inequality is compensable. When a health inequality is incompensable, it can be said that there is an injustice because that person is on an uneven playing field against the rest of society. Finally, Hausman gives an example for why basing injustice and general inequality on health inequality is in poor judgement: one can be poor but healthy, while another is wealthy but unhealthy. There are many inequalities between these two people, but going off of health would proclaim that there is little to none.

 

Discussion Questions:

• When would generalities about health be permissible, if at all?

• Is QALY a good way to measure inequality, and therefore injustice?

• When would an inequality constitute an injustice? 

• If a health inequality was compensable, would the person still face an overall (life prospects) inequality?

• Health inequalities differ throughout a life, so would we/how would we divide life into stages/age groups?

• Do SDH factors or sex/gender impact health more?

 

Summary of Discussion:

For question 1, the majority of the class agreed that generalities are permissible but only in certain amounts and for specific circumstances. For example, in the case of a 40 year old and an 80 year old with the same condition, it can be assumed that the 40 year old is better off because younger patients are generally healthier. Another perspective raised is that generalities are only justified when multiple ones are layered together or used as building blocks to help define the patient, rather than just using one big generality and fitting the patient in that box. Similarly, it was said that while generalities can help on a larger scale, it’s not as useful when dealing with individuals as everyone is different. A shared sentiment within the class was that generalities are permissible when not much is known about the patient, such as when first meeting them or having an unconscious patient. One person brought up the idea that generalities can be used in combination with statistics such as certain populations generally being more at risk for conditions, but the generality shouldn’t be taken as 100% certainty. On the other hand, generalities also shouldn’t be used to completely close out the possibility of a patient having a condition just because they aren’t in the population most at risk.

Question 2 opened up with people saying that the idea that someone can live a full year of perfect health is flawed, so QALY is inherently impaired. Even if someone were to not be in perfect health, it usually isn’t so bad that it would affect quality of life significantly like QALY suggests. It was brought up that a lot of health issues arise from treatable problems, so would it be correct to call something like a diabetic purposely eating sugar an injustice or just a bad choice? The class agreed that QALY is not appropriate or applicable to use because there is a diverse range of health issues while QALY is vague and incalculable. “Quality” is a generality because everyone has a different benchmark for what “good quality” means to them–according to QALY, disabled people are suffering, even when they themselves may be fully functional and happy. On a larger scale, like WHO reports, QALY is helpful, though not perfect, but when it comes down to individuals and their life choices, like a cancer patient rejecting treatment to be with family, QALY is not helpful.

The class began question 3 by defining injustice as a person having no control over their circumstances and the differences in their life cannot be rectified. Alternatively, if a person is able to do something about their situation it would be called an inequality. Inequalities and injustices are not the same, with an example being given of not having money to buy a salad vs. not being allowed to buy the salad (regardless of funds available). Injustices are systemic problems that aren’t within the scope of a physician because it involves greater social injustices, though those societal problems are a leading cause of health injustices. The conversation at this point then pivoted to talking about intersectionality and how it’s not very useful because it becomes so specific, and that intersectionality, though it intends to be less vague, it’s still susceptible to generalities about people with X and Y because multiple people can share X and Y but still be different, which just goes back to grouping people.

Response: 

Based on the discussion, I realized that a lot of reporting methods about health are very general, but that there’s no concrete way to rectify the problem. Adding onto the fact that if it was difficult for all people in our class to agree on definitions and treatments of inequalities, it would be near-impossible to find and execute a national or worldwide standard for what is acceptable in healthcare. I also noticed from the discussion that the class puts a lot of value on individual and patient-centered care, and while I also agree that it’s important to focus on each patient, I believe a paradox is at hand. The more a physician spends time giving top quality care to a patient, the busier a physician will be, leading to longer wait times before a patient will be attended to, resulting in lower care satisfaction. I bring this up to make the point that no physician and no treatment plan will ever be perfect, so instead of trying to make guidelines for what is or is not a generality, quality of life, or an injustice we should let doctors find out what works best for them and the community they serve.