Bioethics ISSN 0269-9702 (print); 1467-8519 (online)

Volume 23 Number 2 2009 pp 7989

doi:10.1111/j.1467-8519.2008.00714.x

ARTICLES
EPIDEMIOLOGY AND SOCIAL JUSTICE IN LIGHT OF SOCIAL
DETERMINANTS OF HEALTH RESEARCH
SRIDHAR VENKATAPURAM AND MICHAEL MARMOT

Keywords
social determinants of
health,
social epidemiology,
health inequalities,
social justice,
health equity,
public health ethics,
philosophy

ABSTRACT
The present article identifies how social determinants of health raise two
categories of philosophical problems that also fall within the smaller domain
of ethics; one set pertains to the philosophy of epidemiology, and the
second set pertains to the philosophy of health and social justice. After
reviewing these two categories of ethical concerns, the limited conclusion
made is that identifying and responding to social determinants of health
requires inter-disciplinary reasoning across epidemiology and philosophy.
For the reasoning used in epidemiology to be sound, for its scope and
(moral) purpose as a science to be clarified as well as for social justice
theory to be relevant and coherent, epidemiology and philosophy need to
forge a meaningful exchange of ideas that happens in both directions.

1. INTRODUCTION
The articles in this special issue highlight some of the
diverse and complex ethical issues arising from identifying and responding to social determinants of health
(SDH). Aside from providing compelling content, this
collection of articles also marks an important milestone
because social epidemiology and ethics, and their respective broader disciplines of epidemiology and philosophy,
have so far had limited cross-disciplinary exchange.
Explicit ethical analysis in modern epidemiological
theory and practice, as well as in consequent health policy
planning and implementation, has often been in response
to contemporary events and thus, sporadic and circumscribed. The most recent coming together of ethical
analysis and epidemiology occurs in the nascent and
separate discussions on public health ethics and health
equity. The literature on public health ethics is now
extending the scope of bioethics debates beyond just individual patient issues to also considering the causes and

social responses to ill-health in populations.1 And health

equity discussions are aiming to link a moral framework
to extant epidemiological data in order to motivate social
action as well as supplement the predominance of economic analysis in health policy-making.2 Indeed, health
1

N. Daniels. Equity and Population Health: Toward a Broader Bioethics Agenda. Hastings Cent Rep 2006; 36: 22; N. Kass. An Ethics
Framework for Public Health. Am J Public Health 2001; 91: 17761782;
Public Health Ethics: from Foundations and Frameworks to Justice
and Global Public Health. J Law Med Ethics 2004; 32: 232242, 190;
D.L. Weed & R.E. McKeown. Ethics in Epidemiology and Public
Health I. Technical Terms. J Epidemiol Community Health 2001; 55:
855857: Nuffield Council on Bioethics. 2007. Public Health: Ethical
Issues. London: Nuffield Council on Bioethics.
2
P. Braveman & S. Gruskin. Defining Equity in Health. J Epidemiol
Community Health 2003; 57: 254258; J.A. Macinko & B. Starfield.
Annotated Bibliography on Equity in Health, 19802001. Int J Equity
Health 2002; 1: 1; T. Evans et al. eds. 2001. Challenging Inequities in
Health: from Ethics to Action. Oxford & New York: Oxford University
Press; S. Anand et al. 2004. Public Health, Ethics and Equity. Oxford &
New York: Oxford University Press.

Address for correspondence: Sridhar Venkatapuram, Department of Epidemiology and Public Health, University College London, 119 Torrington
Place, London WC1A 6BT. Email: s.venkatapuram(at)ucl.ac.uk
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Sridhar Venkatapuram and Michael Marmot

equity has also become a growing concern for health

economists, but such concern is largely focused on defining and applying the value of equity to the distribution of
resources while taking the theory, practice, and products
of epidemiology as given.
Discussions on the ethics of SDH will unavoidably
cut across discussions on both public health ethics and
health equity as they both draw on epidemiology to
some extent. However, some ethical concerns raised by
SDH are so deep or foundational that reasoning about
them could significantly reorient not only these two
emergent discussions, but also the broader field of epidemiology. As important, discussions on the ethics of
SDH also have significant potential to influence the
ongoing philosophical debates on the merits of competing conceptions of social justice. This article presents a
general overview of how the identification of SDH raises
two foundational categories of philosophical problems
that also fall within the smaller domain of ethics; the
first category pertains to the philosophy of epidemiology, and the second pertains to the philosophy of health
and social justice (health justice). Focusing at the level of
these two broad categories, rather than on a specific
ethical issue, is motivated by the aim to highlight the
depth of the ethical concerns raised by SDH, and to
suggest a common starting-point for future discussions.
After reviewing these two categories of ethical concerns,
the limited conclusion we make at this preliminary stage
is that identifying and ethically responding to SDH
requires inter-disciplinary reasoning across epidemiology and philosophy, and significantly more than is currently occurring. Philosophical reasoning has to become
more explicit in epidemiology and the causation and distribution of health has to become more central to social
justice philosophy. In order for the reasoning used in
epidemiology as a whole to be sound, for its scope and
(moral) purpose as a science to be clarified, and equally
as important, for philosophical theorizing on social
justice to be relevant and coherent, epidemiology and
philosophy need to set in motion a meaningful exchange
of ideas that flows in both directions.

2. THE PHILOSOPHY OF EPIDEMIOLOGY

The first of the two categories of issues raised by the
identification of SDH relates to the philosophy of epidemiological theory and practice which includes concerns
such as the epistemology of causation, the ontology of
causal determinants as well as the influence of values in
epidemiological research. The ontology of human health,
as a distinct entity from its determinants, is obviously an

important and related issue worth examining. But as long

as epidemiology continues to focus on the study of illhealth impairments and mortality reasoning about
what constitutes health can plausibly be set aside when
discussing SDH. Indeed, though we use the familiar terminology social determinants of health in this article,
the focus here and in most of the SDH literature is really
on the social determinants of ill-health; the social determinants of impairments and mortality.
Furthermore, this first category may appear in the first
instance to reflect concerns about epistemology rather
than ethics. Deliberations on causation and ontology
usually fall under epistemology. Indeed, epistemology
and ethics are separate types of philosophical concerns,
but they are often inter-related and inseparable. One way
epistemology and ethics come together in epidemiology,
which is of particular relevance here, is through the influence of social and ethical contexts on epidemiological
theory and practice. It is commonplace to observe how
truths discovered by science become inputs into moral
evaluations and actions. But values and ethical reasoning
also affect scientific practice. That is, individual and
social values affect how the truth-status of a phenomenon
is established, and how much of the truth is perceived.
Moreover, in particular reference to epidemiology,
whether a particular causal relationship between exposure and impairment is true or not may be independent
to how we practise epidemiology, but the way a causal
relationship becomes recognized as being true, and the
recognition of the scope of the causal processes, are
profoundly influenced by what we think are good epidemiological theory and practice.
Sometimes, what we consider to be good epidemiological theory and practice changes a little; and at other
times, there is a call for radical changes in theory and
practice. Such calls for a paradigm shift do not change
the truth of causal relationships. Instead, such shifts are
called for in light of growing mounds of little truths that
no longer fit the existing explanatory paradigm, or when
the research methods are no longer thought to be ethically acceptable. During times of little changes or agitation for radical shifts the methodology used to identify
the causation of ill-health as well as the scope of the
explanatory framework used in epidemiology are both
influenced by what is identified as the fields moral
purpose as well as by the virtues of individual researchers.
Put more simply, social and individual values shape epidemiological theory and practice, which then also affect
what is established as truth and its scope. Our epistemological access of the truth of causal relationships is determined both by the logic of our methodology as well as its
ethics.

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Epidemiology and Social Justice in Light of Social Determinants of Health Research

The dialectical link between scientific practice and
values can be shown through the way the two categories
of concern here, (a) the philosophy of epidemiology
and (b) the philosophy of health justice are distinct but
inter-related concerns. If we assume that the ill-health of
individuals is an important moral concern from the
perspective of social justice, then it stands to reason that
following through on that moral concern is what drives
the pursuit of scientific knowledge of the causes, distribution patterns, and consequences of ill-health. Such
concern also motivates identifying and implementing
appropriate social interventions to address the three
dimensions. From this perspective, epidemiology along
with other allied health fields can be seen as having a
moral function or purpose because they spring from
moral concern about the ill-health of individuals.
Such recognition that health sciences have a moral
purpose need not affect the truth status of research findings. The evaluation of the logic of research methodology
or the validity of causal inferences made by the researchers can deal with that. Nor does it undermine or diminish
the value of pursuing epidemiological knowledge or other
scientific truths for their own sake. The pursuit of discovery and innovation can be both inherently and instrumentally valuable, as can practising the individual virtues
of intellectual curiosity and openness. However, it would
be a strange thing indeed if scientific research on aspects
of human ill-health was pursued irrespective of or devoid
of any moral concern about human ill-health. The link
between the moral concern for the health of individuals
and realizing such concern through epidemiological
theory and practice is what establishes epidemiology as
being an instrumental science with a moral purpose, and
not simply a descriptive science that is outside the domain
of values. Furthermore, when the moral concern for the
health of individuals is a constituent part of a broader
conception of social justice then the instrumental goal of
health sciences is to achieve social justice.
The growing corpus of SDH research and resulting
debates on methodology, explanatory models, purpose,
and scope of epidemiology bring forward the challenge
and opportunity to acknowledge appropriately the role
of values and virtues in scientific research while still doing
good science. A commonly held view understands scientific research and moral reasoning as belonging to two
separate spheres, and scientific research is often treated as
factual and objective inputs into the sphere of moral
reasoning. In line with such a view, some epidemiologists
see themselves as pure natural scientists discovering
natural facts about biological processes, which then
become inputs into the separate sphere of moral reasoning about which health policies to pursue in response.

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81

Contrary to such a view, which upholds a strong factvalue distinction, a science is social perspective sees
scientific research as occurring within a social context.
Whether in epidemiology or other scientific fields, social
values and intellectual virtues of individuals are recognized as influencing scientific practice, starting from
which questions are researched, how hypotheses are
framed, the scope of observations, how data and hypotheses are adjusted, how causal inferences are made, how
findings are disseminated, and so forth. The conflict
between these two perspectives on what science is and
how it should be done cannot be overstated, and it is at
the centre of the acrimonious debates presently occurring
within epidemiology.3 Those who assert that epidemiology is a purely descriptive, natural science governed only
by the logic of the scientific method, and motivated primarily by scientific curiosity deny the link between epidemiology and the background moral concern for human
health and its constitutive role in social justice.4
Social epidemiologists find themselves in the position
of having to establish their research findings as being on
par with discoveries of natural facts because they examine
social processes and openly acknowledge being motivated by a moral concern for social inequalities in health.
The truth-status of the causal relationships their research
identifies is being scrutinized, perhaps justifiably, not
only according to the principles of the scientific method
but also in light of their objects of focus, scope, and
motivations of their research. Establishing whether the
causal relationships between social determinants and
impairments are true is thus bound up in both epistemological issues in perceiving the truth about social processes as well as in the ethics of what is considered to be
good epidemiological theory and practice.
SDH research has the potential to significantly transform the theory and practice of epidemiology as a whole
through expanding its scope and possibly ushering in a
new explanatory paradigm. The focus on social factors
affecting health is not fundamentally new. There is a long
history of identifying the role of the social environment in
community and social medicine and in the epidemiological work of Louis-Ren Villerm and Rudolph Virchow
in the 19th century. However, modern SDH research
harnesses the most current epidemiological tools and
methodologies combined with sociological analysis
to explicitly identify supra-individual social phenomena
that affect both the causation and distribution of

See the collection of articles in Int. J. Epidemiol 2001; 30.

K.J. Rothman et al. Should the Mission of Epidemiology Include the
Eradication of Poverty? Lancet 1998; 352: 810813.

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Sridhar Venkatapuram and Michael Marmot

ill-health across individuals and social groups, within and

across countries.5
In philosophical terms, both the epistemology of causation of ill-health and the ontology of causal factors has
been affected. The methods used to acquire knowledge,
the causal processes we acquire knowledge about, and the
qualities of the things being observed are now more
expansive than before. On the one hand, we now know
that the number of links in the causal chain from exposures to the onset of ill-health is larger than previously
thought. We are confident of this finding even though the
specific causal links and processes are just beginning to be
more specified. On the other hand, multi-level analysis
has opened up new dimensions in the causal chain
beyond individual level exposures. Such multi-level
analysis attempts to identify the independent and interactive effects on the causal chain by determinants operating at various social levels.6 These supra-individual
levels can be that of the family, work environment, neighbourhood, state, region, country, and so forth.
Such analysis of the impact of phenomena at multiple
levels on individual biological functioning has motivated
the use of the metaphor of Chinese boxes.7 Though it
has limitations, the metaphor helps to visualize an aetiological model of ill-health where different levels of determinants are nested within each other with the individuals
biological processes in the centre. The metaphor is particularly helpful in illuminating the tension between discounting the effects of determinants at each level as it
becomes more distal from the individual while at the
same time recognizing that each distal level significantly
defines and/or constrains the determinants operating at
levels nested within. This opening up of epidemiological
analysis outward and upward to include supra-individual
social phenomena or contexts that influence individual
biological functioning has been labelled macroepidemiology.8 However, to put things into perspective,
exponentially more resources are being channelled into
research identifying determinants going in the other
direction towards the molecular level. The continued
focus on individual level factors and the more concerted
5

L.F. Berkman & I.O. Kawachi. 2000. Social Epidemiology. New

York: Oxford University Press.
6
I. Kawachi et al. A Glossary for Health Inequalities. J Epidemiol
Community Health 2002; 56: 647652; S.V. Subramanian. The Relevance of Multilevel Statistical Methods for Identifying Causal Neighborhood Effects. Soc Sci Med 2004; 58: 19611967.
7
M. Susser & E. Susser. Choosing a Future for Epidemiology: II. From
Black Box to Chinese Boxes and Eco-Epidemiology. Am J Public
Health 1996; 86: 674677.
8
I.R.H. Rockett. 1999. Population and Health: An Introduction to Epidemiology. 2nd edn. Washington, DC: Population Reference Bureau.

effort to dig deeper down into the biological make up

of the individual has been referred to as microepidemiology.9 In the face of persistent limitations to
acquiring complete knowledge of the causation of
chronic impairments, there is great optimism that genetic
risk factors are the missing pieces of the causal pie or
the hidden links in the web of causation of individual
impairments and mortality.
What is currently at play in the field of epidemiology is
whether micro-epidemiology, the dominant explanatory
paradigm during the second-half of the 20th century, can
continue to survive as a general theory of epidemiology in
the 21st century. In order for micro-epidemiology to
survive, it must at least be able to integrate macroanalysis. The robustness of SDH research compels both
intellectually and ethically the pursuit of further
research and the construction of an explanatory paradigm with less slippage. If micro-epidemiology cannot
integrate macro-analysis, a new general theory or
explanatory paradigm for epidemiology must be created
that can account for the independent and interactive
effects of determinants working at the molecular level all
the way up to the global social environment.10
As it now stands, the individual-level framework of
causation dominant in epidemiology, whether metaphorically described as the web of causation or a causal
pie, does not recognize non-natural determinants of
impairments and mortality. The model allocates relative
responsibility for the causation of ill-health across three
categories of determinants consisting of a) individual biological factors, b) individual behaviours, and c) exposures
to harmful substances. While the model does not limit the
number of different links in the web of causation or pieces
in the causal-pie, the directions of inter-actions, or time
scales, all determinants must come from within the three
categories. Such a causal-model excludes distal social
phenomena that influence the three proximate categories
of causal factors.
Social phenomena profoundly shape behaviours of
individuals and often, the exposures to harmful material
substances that eventually lead to impairments and mortality. Furthermore, individual biology, the category out
of all three that seems to be the most natural of causal
factors, can also be significantly affected by social factors.
Before an individuals birth, social phenomena can profoundly affect an individuals parents sexual behaviour,
reproduction and the quality of pregnancy, which then
directly determine an individuals biological endowments
9

Ibid.
D. March & E. Susser. The Eco- in Eco-Epidemiology. Int J Epidemiol 2006; 35: 13791383.
10

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Epidemiology and Social Justice in Light of Social Determinants of Health Research

and functioning. Thus, all three categories are influenced
by social factors.
The inability of micro-epidemiologys explanatory
framework or paradigm to recognize the influences of
social phenomena on the three individual-level natural
and proximate causal categories produces incomplete
explanations. By excluding social determinants, the explanatory model provides truncated causal explanations
and is fully robust in relation to only specific kinds of
causal determinants and pathways. Furthermore, only
when the causal links that precede the three individuallevel factors the causes of causes are allowed into the
frame are we able to perceive certain types of other
natural and social causes as well as social distribution
patterns.11
The criticism that micro-epidemiology has a limited
theoretical paradigm or offers incomplete explanations
can seem to be too far-reaching as the social environment
is often included within the hazardous exposures category. Just as the physical environment influences vectors
and causal agents such as infectious microorganisms, the
social environment is often conceptualized as also producing exposures to material causal agents. For example,
social policies that affect air pollution or the availability
of food directly shape the exposures to harmful causal
agents. Therefore, it seems reasonable to consider aspects
of the social environment as distal factors similar to
physical environment factors within the harmful exposures category. However, there is an important distinction to be made between the physical and social
environment as distal factors influencing proximate
determinants of ill-health. Though the physical environment can determine exposures to harmful agents, it does
not pervasively determine an individuals biology and
behaviour within the short-term of an individual life
span. The direct influence of the physical environment
(nature) on human biological and mental functioning
occurs either in the very short term (e.g. hypothermia) or
over millennia. In contrast, the social environment (i.e.
human made institutions) has the potential directly to
dominate the physical environment as well as pervasively
to determine the biology and behaviour of an individual
throughout a life-span.
Importantly, social phenomena cannot simply be channelled into the third category of harmful material exposures because the notion of social determinants captures
both distal social factors which causally precede all three
types of proximate causal factors as well as direct or
proximate social factors. Part of the insight of SDH
11

G. Rose. Sick Individuals and Sick Populations. Int J Epidemiol

1985; 14: 3238.

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83

research is that it has identified social processes as direct

determinants of ill-health. For example, the capability to
have control over ones activities in the workplace has
been identified as one socially determined factor that
directly affects biological functioning through the individuals neuroendocrine pathways. The persistent lack
of control in the workplace leads to various biological
responses indicating chronic stress which eventually leads
to impairments and premature mortality.12 In such a case,
there is no intervening, proximate, material factor. So far,
a range of psycho-social determinants affecting health
have been hypothesized including the presence or absence
of autonomy, dignity, respect, agency, trust, and reciprocity. While the research so far is compelling, the ontology of these types of social determinants requires more
concerted theorizing. However, what has been sufficiently
established up to this point is that phenomena that are
not natural or material can directly influence biological
pathways leading to impairments and mortality. There
is no dispute that biology, individual behaviour, and
harmful substances are distinctly identifiable from each
other and from the social structures that influence them.
But it is unclear why infectious microorganisms and
hazardous chemicals are proximate causal agents while
non-material social phenomena that directly affect
psycho-biological pathways should be classified as distal
causes. Therefore, the explanatory framework of microepidemiology seems incomplete and of limited scope
because it is unable easily to integrate social determinants
into one of the existing categories of causal factors or
easily to treat them as part of a wholly distinct fourth
category.
Some epidemiologists may argue that even if social
institutions and processes have a causal role in producing
ill-health, it is still defensible to limit epidemiologys
scope to the realm of natural science and focus only on
natural/material causes of individual impairments and
mortality. However direct the influence of social causes
may be, the study of social phenomena is seen as being
better suited to other disciplines, not the natural science
that is epidemiology. Such a perspective sees little reason
why epidemiologys scope has to include the entire causal
chain, particularly when it requires crossing disciplinary
boundaries. In fact, it may be argued that striving for a
comprehensive analysis or looking for ultimate causes of
impairments and mortality would mean that epidemiologists would also have to study the Big Bang theory. The
scope of the chain of causation for any event has to be
12
M.G. Marmot. 2004. The Status Syndrome: How Social Standing
Affects our Health and Longevity. 1st American edn. New York: Times
Books.

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Sridhar Venkatapuram and Michael Marmot

confined somewhere, and for epidemiologists committed

to practising natural science, it seems reasonable to
confine epidemiologys scope to proximate, natural
factors influencing individual biology starting from the
point of conception till death.
Such a view, seeking to uphold disciplinary boundaries
even at the possible cost of only seeing part of the causal
picture, expresses a particularly narrow conception of
natural sciences; and it ignores the ethical background
and moral purpose of epidemiology. Even though the Big
Bang may be the initial historical cause of everything, the
instrumental purpose of epidemiology shapes the parameters of the field. The moral concern for the health of
individuals that are presently alive and those of future
generations should motivate epidemiologys theoretical
framework to encompass the chain of causation to
include social determinants. And because social determinants influencing present individuals will affect the
biology of future generations, the scope of analysis must
begin at least a generation before an individuals conception. At the same time, intellectual virtues such as curiosity and openness should militate against disciplinary
boundaries and motivate the expansion of epidemiologys scope to include social determinants as they show
promise of contributing to more complete explanations
of causation and distribution of impairments and mortality. There needs to be a far more convincing justification to limit the scope of epidemiological research to only
proximate natural and material factors in order to maintain its status as a natural science in light of the moral
purpose of epidemiology and intellectual virtues.
Aside from excluding social phenomena, microepidemiologys model has limited abilities to produce
information on the distribution of impairments and
mortality across social groups. Epidemiological analysis
aggregates individuals into particular groups in order to
make causal inferences between the grouping feature and
onset/alleviation of impairments and mortality. Because
micro-epidemiology recognizes only individual biological
features, behaviours, and exposures to hazardous materials, it can only stratify and evaluate individuals according to those kinds of characteristics. Features of
individuals outside these three categories are considered
to be irrelevant to the aetiology of impairments and
mortality and are, therefore, excluded from analysis.
Nevertheless, there may be good reasons to identify
the distribution of impairments and mortality across a
diverse range of individual and social features aside from
their possible role in the causal chain. From the perspective of social justice distribution patterns of ill-health
across particular kinds of social groups as well as the
breadth and distribution of consequences flowing from

impairments may be valuable information in determining

an appropriate social response. For example, information on the distribution of ill-health across historically
oppressed groups or those who have fought in wars, or
information on the overlap between those who are ill and
those who are unemployed, may be valuable for determining a right and just social response. Yet, microepidemiology does not allow identifying the distribution
of ill-health across individuals by features aside from
those linked to aetiology.
Of course, if it is thought to be important to do, there
is no conceptual difficulty in co-joining epidemiological
information with other demographic information in
order to analyse the social distribution or inequalities of
levels and consequences of ill-health. But why should
concern for the social distribution of ill-health be outside
the scope of epidemiology? Why should epidemiology be
interested only in the causation of ill-health and not also
in the social distribution of ill-health? Epidemiology and
demography, the initial place to turn to for supplementary information on social distribution, both have
common roots in the initial creation of mortality tables.
Yet, as modern epidemiological analysis increasingly
excluded social determinants in explanatory models, the
concern for the social distribution of ill-health also came
to be seen as being outside epidemiologys scope.
However, if epidemiologys moral function flows from
moral concern for the health of individuals, then both
causation and distribution of ill-health across human
beings must come within its scope.
Social epidemiologists are indeed very interested in the
distribution of ill-health, but their research confounds
this issue by making any features of social differentiation
into potential aetiological factors. In SDH research, it is
often the case that an observable pattern of unequal
social distribution of impairments and mortality is the
impetus for researching possible social features that
produce that pattern. For example, distribution patterns
of health indicators across genders, socio-economic
classes, or marital status spur research on the causation
of impairments in individuals. In the back-and-forth
between recognizing social distribution patterns and
identifying distal and proximate social causes of illhealth, explanations of causation of ill-health get crossed
with explanations of the causation of distribution. For
example, the gradient in health achievements across
socio-economic classes is often interpreted to mean the
cause of ill-health is differences of income. The causal
inference is that the less money an individual possesses in
the distribution, the more ill-health the individual experiences. Or conversely, the more money one possesses the
better ones health outcomes. Looking more closely at the

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Epidemiology and Social Justice in Light of Social Determinants of Health Research

income-inequality research produces the more likely
explanation that it is what individuals are able to be and
do at each level of the social hierarchy that produces the
gradient in ill-health rather than the simple fact of being
in possession of different amounts of income.13 If the
social gradient in health showed that those who had more
income fared worse, it is more likely that the focus would
be on how income affects individuals rather than concluding simply that the possession of different amounts of
income directly causes ill-health.
The high risk of confusing the causes of any social
distribution patterns for the social causes of ill-health in
individuals reflects the newness of the field of social determinants research. One only needs to look at the types of
errors made when epidemiology as field began in the
mid-18th century. The difficulty in making warranted
causal inferences is not unique to social determinants
research, but a problem that is pervasive throughout epidemiology. It is just that the expansion of scope to
include social phenomena in addition to individual level
factors exponentially complicates the process of making
causal inferences. Because the ontology of social determinants is still being identified, social epidemiologists need
to be especially diligent about making causal inferences
between social distribution patterns and social features.
Indeed, this need for social epidemiologists to give more
attention to the logic of the reasoning used to infer causation provides an opportunity for epidemiology as a
whole to undertake a thoroughgoing analysis of the reasoning used in making causal inferences.14

3. SOCIAL JUSTICE THEORY

The second set of ethical issues raised by SDH pertains to
social justice. Any practical policy deliberations striving
to identify the right social response to ill-health in individuals or groups unavoidably confront ethical questions. Health policies are profoundly political because
they distribute significant and diverse benefits and
burdens across individuals and groups. They are ethical
in so far as justification is provided for why particular
interventions should be implemented or indeed, should
not be implemented.15 It is too simplistic to maintain that
health policies are or should be simply a matter of scien13

Ibid.
D. Weed. 1996. Epistemology and Ethics in Epidemiology. In Ethics
and Epidemiology. S.S. Coughlin & T.L. Beauchamp, eds. New York:
Oxford University Press.
15
S. Alkire & L. Chen. Global Health and Moral Values. Lancet 2004;
364: 10691074; M. Roberts & M. Reich. Ethical Analysis in Public
Health. The Lancet 2002; 359: 10551059.
14

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85

tifically identifying the appropriate interventions and

using economic analysis to distribute resources across
such interventions. In contemporary health policy
debates, ethical ideas are often used to justify how limited
resources are distributed across individuals or for constraining individual rights. But just beyond these familiar
and immediate policy questions about distribution of
resources or individual liberties, there exist far deeper
questions regarding how and why there should be social
interventions to address ill-health in the first place. What
is it about health or ill-health that compels a social
response or makes it a concern for social justice? Is it the
types of causes of ill-health, the absolute levels of health
achievements, their relative inequalities, or the consequences of ill-health that must be addressed as a matter of
social justice? There are good reasons to believe that all of
these multiple dimensions of health should matter for
realizing social equity and justice.16 Even so, how do we
then morally evaluate the different dimensions of the
types of causes, levels of ill-health, and consequences of
ill-health in relation to each other? Which dimension
should social action address first, second, and so forth.
Furthermore, how does the understanding of what
matters about these different dimensions change when
the moral concern for individuals is supplemented by
concern for groups? These various questions show that,
although we can accept that the moral function of health
sciences and services flows out of the moral concern for
health, that concern is indeed multi-dimensional.
SDH research complicates these numerous and difficult ethical questions even further by elucidating how
improving absolute and/or relative health inequalities
requires making changes to a range of basic social practices and institutions. The scope of social intervention to
address health concerns has now become much larger
than just providing health care or addressing individuallevel material causal factors. In fact, SDH research
explodes the scope of social intervention to encompass all
social environments as it strives to identify and address
any and all possible social determinants of impairments
and mortality. While some social determinants are such
things as the social bases of autonomy, freedom, dignity,
or respect, interventions to transform such determinants
could mean redistributing economic resources and
opportunities, material goods as well as choices and
duties of individuals and institutions. What this means is
that addressing inequalities in the realm of individual or
group health achievements will have to manipulate or,
indeed, create inequalities in the other realms of individual lives and societal functioning.
16

A. Sen. Why Health Equity? Health Econ 2002; 11: 659666.

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In the language of distributive justice debates, mitigating or manipulating social determinants of ill-health and
mortality means that there must be a redistribution of
some valued goods or things in different social spheres.
While SDH research, or social epidemiology, has provided information on some social bases of causal pathways to impairments and mortality, the literature has
given little attention to the possible consequences in other
non-health social spheres that would follow from transforming such causal pathways. It is always implicit in the
SDH literature that the logical social response to the
identification of social determinants of ill-health is to
transform them. Ideally, transforming or redistributing a
particular social determinant will improve health achievements which, in turn, will create even more positive social
determinants. For example, engendering the social bases
of dignity through creating opportunities for income and
wealth could improve health achievements. Individuals
who take advantage of those opportunities could in turn
create more opportunities for income and wealth and
thus, also, more social bases of dignity for themselves and
others. Where such a virtuous circle does not exist,
however, what sort of criteria shall we use to evaluate if,
when, and how trade-offs are made between improving
absolute levels and relative inequalities in health functioning, and how things function or are distributed in
other social realms?
In conjunction with evaluating the multiple dimensions
of causes, distribution, and consequences of ill-health, the
identification of SDH means that reasoning about the
right social response to health concerns must occur across
multiple disciplines. Multi-disciplinary reasoning is necessary in order to both identify the variety of social bases
of the causal factors of ill-health as well as to identify the
potential non-health consequences in other social realms
of possible interventions addressing SDH. It is important
to identify how addressing various kinds of SDH will
affect their respective social spheres because avoiding illhealth is only one among other ends valued by individuals and societies. When standing within the health sector,
it seems self-evident that the primary goals of health
interventions are to transform the causes, levels, and consequences of health. All things being equal, it may be a
good thing to lessen health inequalities. Yet, as is now
made more obvious by SDH research, health policies
must also be seen as cross-sector social policies. Thus,
determining the right social response will require reasoning about how the moral concern for the multiple dimensions of health of individuals and groups relates to the
right and just functioning of a variety of social spheres.
Ideally, a general theory of social justice would provide a
clear framework which would help guide social action by

identifying why and how to address health concerns in

relation to pursuing other social goals. However, without
a readily available general theory of social justice that is
coherent or commonly accepted, we are presently left
with relying on a casuistic approach to ethical analysis of
health concerns and their relation to the just functioning
of other social spheres.
While only a handful of contemporary philosophers
have begun to examine the implications of SDH literature on ethical reasoning about health and justice,
outside academic philosophy, an ethical framework that
tries to account for SDH has already been gaining much
attention. The idea of health equity has been around
for many decades, but has recently gathered momentum
alongside SDH research and related health policy discussions. The World Health Organizations conception
of health equity identifies a moral social obligation to
prevent or mitigate impairments and mortality that are
avoidable, unnecessary, and unfair/unjust.17 This threetiered ethical framework has been valuable in bridging
the science of epidemiology with ethical principles in
order to identify a moral motivation for a social
response.
Health equity, as the term implies, is a notion that
is concerned with the inequalities in health functioning
of individuals, social groups, and national populations.
There is great affinity with such a concern over inequalities in health and SDH research because social determinants are believed to explain both the causation of
ill-health in individuals and the social distribution
patterns of ill-health. Thus, for those whom social distribution is the primary concern rather than causation,
addressing any inequalities in health between individuals or social groups will ultimately entail addressing
distal or proximate social determinants of ill-health in
individuals. That is, even where health inequalities can
be improved just through the provision of medicines,
the availability and distribution of such medicines is
determined by social factors. Because social determinants are conceptualized as causes of causes the social
environment behind micro-epidemiologys three causal
categories any health inequalities can be traced back
to the social environment. Therefore, the moral concern
for the social inequalities in health achievements and the
evolving hypotheses that social determinants are responsible for such patterns creates overlap between health
equity and SDH literature.
17

M. Whitehead. 1990. The Concepts and Principles of Equity in Health.

Copenhagen: World Health Organization Regional Office for Europe:
29; M. Whitehead. The Concepts And Principles Of Equity And Health.
Int J Health Serv 1992; 22: 429445.

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Epidemiology and Social Justice in Light of Social Determinants of Health Research

As is generally done in bringing together science and
ethics, the health equity criteria exemplifies how ethical
values are brought to bear on separately produced scientific data. Upon initially looking at the three health equity
criteria, it seems clear they are meant to be applied to
existing epidemiological data. The question of whether
something is avoidable, we must assume, is in regard to
scientific knowledge about causes and available treatment rather than about practicality or what popular
opinion says. In effect, the first criterion looks to science
for what is and is not possible, or the scope of ethical
action. The ethical analysis of when, why, and how to
respond to the concern for health equity begins after
science has already determined what is an impairment, its
cause, and whether it is avoidable or not. Fortunately or
unfortunately, the debates over the epistemology of causation, ontology of causal factors, or the robustness of
the explanatory paradigm in light of SDH research are
out of view and left to be internal issues in the field
epidemiology. In any case, once a set of impairments/
mortality cases are determined to be avoidable, the next
step entails identifying which of those are unnecessary.
And after that, the last criterion determines which of the
remaining impairments/mortality are unfair/unjust. In
purpose and effect, the health equity criteria function as
ethical principles or rules to filter what is believed to be
objective scientific data on extant types of impairments/
mortality in a given society.
There is much attraction in making use of the health
equity criteria to motivate addressing SDH. These three
criteria do seem correctly to reflect moral intuitions
about where and when to act. However, while identifying moral motivation to address social inequalities in
health is incredibly valuable and necessary, SDH raise
deep ethical questions which require a much richer
ethical framework than these three criteria. For
example, SDH research identifies that how basic social
institutions are structured and function go on to affect
both causation and distribution of ill-health across individuals and social groups. Therefore, identifying the
right social response to ill-health that is caused by basic
social institutions requires ethical reasoning that evaluates what is acceptable and unacceptable functioning of
basic social institutions. In turn, to determine what is a
fair or just functioning of basic social institutions
requires complex ethical reasoning about first principles,
the functions of basic social institutions, and value of
health for individuals. The three criteria do not give sufficient guidance to be able to undertake such reasoning.
The criteria may be more amenable to evaluating
impairments/mortality that largely have proximate,
individual-level material causes as identified by micro-

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87

epidemiology. Yet, even then, it is unclear as to why the

unfair/unjust criteria would be the last criterion, since a
conception of fairness or justice is what produces the
moral concern for health in the first place. That is,
defining a health inequity as something that is unfair
and unjust can be seen to be tautological.
So, what is social justice?
Repeated references to social justice, and arguments
that it should come prior to or serve as the background
for addressing health concerns, may understandably lead
to the question, so what is social justice anyway? Such a
question may have received a simple and probably unsatisfactory answer five or more decades ago. Now, just as
there is great theoretical activity in the field of epidemiology, there is a diverse range of conceptions or theories
of social justice being advocated in the field of philosophy. Throughout the 19th and most of 20th centuries, the
dominant conception of social justice in liberal societies
followed utilitarianism. Simplifying greatly, an action or
society was considered to be just if it produced the greatest happiness or welfare for the greatest number of individuals. Since the last quarter of the 20th century, due to
the profound critiques of utilitarianism and a meaningful
alternative proposed by John Rawls, debates on alternative conceptions of social and indeed, global justice are
flourishing again.18 Nevertheless, despite the profound
critiques of utilitarianism, for a range of historical and
sociological reasons, utilitarian thought continues profoundly to shape public policy making around the world,
particularly public health policy.
All liberal theories of social justice begin from the
premise of the individual as the primary unit of analysis
or moral agent, and that every individual has equal moral
worth. The equal moral worth of individuals is seen to
arise from the capacity of human beings to reason and
thereby, conceive and purse a plan of life. Equal moral
worth and the freedom to conceive and pursue ones
life plans are seen as inter-related concepts. From this
common starting point, different theories go on to articulate what that means for how society must treat the individual. This central question of how individuals should
be treated by society has been transformed into the question of what should be distributed to individuals. The
reason why treatment has turned into distribution is
because social contract theories have had profound influence on liberal conceptions of social justice, of which
John Rawlss theory is the most recent. Such influence
has meant that liberal social justice, or how society

18
W. Kymlicka. 2002. Contemporary Political Philosophy: an Introduction. 2nd edn. Oxford & New York: Oxford University Press.

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Sridhar Venkatapuram and Michael Marmot

should justly treat its members, is predominantly understood as being a conception of how to distribute the
benefits and burdens of social cooperation fairly across
individuals.
In reviewing a the range of alternative theories,
Amartya Sen has argued that the various modern conceptions of liberal social justice can be understood to
differ most fundamentally according to the thing that is
valued and how the theory distributes that thing across
individuals.19 Among the range of different theories of
social justice, the things to be distributed include welfare
(preferences, objective welfare), resources (income, primary goods, personal and impersonal resources, negative
liberties) or capabilities (basic capabilities, ten central
human capabilities). Underlying both the identification
of the things and the distribution schemes is the profound
concern for inequality. Each of the different theories provides reasoning as to how the equal moral worth of individuals allows or disallows inequalities in different
aspects of lives of individuals thought to be relevant to
social justice. Importantly, what has come to be accepted
is that equal respect and concern for every individual
does not necessarily mean the equal distribution of things
to individuals.20
Despite the resurgence of ethical reasoning about
social justice taking place over the past five decades, only
very recently have inequalities in biological and mental
functioning across individuals been put forward as something that should be a central concern for social justice.
Previously, the concern for individuals with severe mental
and biological impairments was either considered to be
outside the scope of justice where values such as beneficence or charity could apply. That is, health functionings
were thought to be largely a natural good which has no
social bases. Or, reflecting micro-epidemiologys causal
framework, the moral concern for health was thought to
be sufficiently addressed by a just distribution of healthcare and/or self-regulation. Health concerns have
recently been gaining more attention in mainstream
social justice debates in relation to the needs of individuals with severe impairments and their care-givers.21
However, with a few exceptions, such discussions are
19
A. Sen. 1992. Inequality Reexamined. Cambridge: Harvard University Press.
20
Ibid; N. Daniels. 1996. Equality of What: Welfare, Resources, or
Capabilities? In Justice and Justification: Reflective Equilibrium in
Theory and Practice. Cambridge & New York: Cambridge University
Press; M. Clayton & A. Williams. 2002. The Ideal of Equality. Basingstoke: Palgrave.
21
M.C. Nussbaum. 2006. Frontiers of Justice: Disability, Nationality,
Species Membership. Cambridge, Mass. & London: The Belknap Press
of Harvard University Press.

largely unaware of the growing body and significance of

social determinants of health research. Why health concerns have largely been considered peripheral to discussions on social justice may be due more to historical and
sociological reasons rather than the convincing power of
reasoning that sees health as being a natural good or
subject to self-mastery. Nevertheless, it is clear that the
marginal status of health concerns should not continue.
This is because philosophical reasoning on social justice
would be vulnerable to being criticized as irrelevant to the
majority of humanity and for not giving full respect to
human beings whose daily lives are pervasively shaped by
ill-health, or those individuals who must care for those
who are ill.22 At the same time, it seem as incumbent
on social epidemiologists to be cognisant about the
emergent philosophical discussions on justice and social
determinants.

4. CONCLUSION
The often acrimonious debates about methodology and
scope of epidemiology that have resulted from the greater
recognition of SDH are fundamentally about the stability
and justification of the dominant explanatory paradigm.
If an explanatory framework in science has to be significantly altered in order to fit the observable facts, a completely new framework, or a paradigm shift, is necessary.
Social determinants research confronts the individuallevel micro-epidemiology model with observations that it
cannot easily fit. Epidemiology needs a robust general
theory of the causation and distribution of ill-health in
order to do better science, and to provide richer information for determining the ethical social response to the
causes, distribution patterns, and consequences of illhealth. At the same time, the exchange between epidemiology and philosophy has to become more vigorous and
mutual because social justice theorizing would be significantly incomplete if it did not take into account the
empirical knowledge of the social bases of health
inequalities and their consequences.
This article has outlined two basic types of ethical
issues raised by SDH, one set relating to philosophy of
epidemiology and the other relating to health and social
justice. Instead of focusing more directly on a specific
ethical issue, the article aimed to highlight the depth and
inter-related nature of these two types of foundational
ethical issues arising from SDH research. The overarching argument has been that to do good epidemiology,
social or otherwise, and to do social justice, requires
22

Ibid.

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Epidemiology and Social Justice in Light of Social Determinants of Health Research

placing the scientific and moral concern for human health
at the centre of social justice theory and practice. Epidemiology as a field is inescapably linked to the moral
concern for the health of people, and no conception of
social justice can be considered complete if it does not
account for the social bases of impairments and mortality. It is only from combined ethical and scientific reasoning that it becomes possible to imagine the construction
of a general theory of health that can account for all the
causes, levels and consequences of ill-health, and what
the right social responses should be. Epidemiologists and
philosophers need to create a meaningful exchange of
ideas to ensure that the reasoning used in epidemiology is
defensible, both for the instrumental moral purpose of

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89

epidemiology to be clarified, and for conceptions of social

justice to be more relevant and coherent.
Acknowledgements
The authors would like to thank the editors, Alex Broadbent, and two
anonymous reviewers for their valuable assistance. Research for this
article was made possible by the Joint ESRC-DFID Scheme for
research on international poverty reduction (RES-167-25-0369).
Sridhar Venkatapuram is a research fellow at the Department of Epidemiology and Public health, University College London.
Michael Marmot is Chair of the Department of Epidemiology and
Public Health, University College London, and Chair of the World
Health Organizations Commission on Social Determinants of Health.