The Moral Determinants of Health: Purpose, Promise, and Propositions

Part One: Aligning Work with Purpose

Nelson Tuazon, DNP, DBA, RN, NEA-BC, CENP, CPHQ, CPPS, CPXP, FNAP, FACHE, FAAN
Vice President & Associate Chief Nursing Officer, University Health
Director, District 8, Texas Organization for Nursing Leadership

Laying the Foundation

In his groundbreaking keynote speech during the 2019 Institute for Healthcare Improvement (IHI, 2020) National Forum titled, Quality, Mercy, and the Moral Determinants of Health, Dr. Donald Berwick paid homage to two leading quality experts in quality – Avedis Donabedian and W. Deming. In paying tribute to their pioneering work, Dr. Berwick ascribed the following quotes to them: "Ultimately, the secret sauce of quality is love," and "All anyone asks for is a chance to work with pride," respectively. He concluded his remarks with a poignant revelation about his insights on quality. Profoundly, he provoked us by asserting that quality should transform from its technical essence to the essence of morality. This was the seminal thesis that brought the concept of the moral determinants of health to the forefront.

Scope, Scale, and Substance

There is paucity in the literature with regards to the concept of moral determinants of health. As nurses, the third provision of the Guide to the Code of Ethics for Nurses stipulates that the "ultimate moral duties of professional nurses involve working with people who need nursing care" (Fowler, 2010, p. 25). I have to admit that in researching this topic, I came up with more questions than answers. I initially had predictions in the working title, but I opted to explore propositions to provoke the conversation that Dr. Berwick has sparked. In this three-part series, I will examine the purpose, the promise, and the propositions on the moral determinants of health. In Part One, I will review the background and trace the development of the moral determinants of health. I will be focusing on moral theories as a framework for determining the purpose of the moral determinants of health. In Part Two, I will explore the promise of the moral determinants of health in conjunction with the social determinants of health. Specifically, I will explore whether the moral determinants of health intersect with the social determinants of health or if they are considered an evolution, Finally, in Part Three, I will outline the propositions on the moral determinants of health with a focus on the role of nursing leaders.

The Ubiquity of Moral Issues

Regardless of our role in our healthcare facility or institution, or our professional organization, moral issues constantly barrage us (Kreitler et al., 2014). The issues come from different people at different times, with varying degrees of complexity. Our day may begin with the first call about staffing needs in the early hours of the morning and end with a late call-in at night. The 20 or so patients waiting in the emergency department and the backlog in the operating room continue to preoccupy us. The looming budget cuts because of the operational losses brought about by the pandemic bring anxiety. The competing demands to improve the scores on patient experience amidst the distress that the staff faces consume our energy. Likewise, the academic environment is not spared from these moral issues. De Barros et al. (2019) have identified various causes of moral distress among nursing faculty including changes and disruptions in work processes, increased workload, competing priorities, lack of time, resources, and support, among others. Grace (2018) stated that nurse leaders and educators are ill-prepared to help in the development of the moral agency of nurses due to the lack of ethics education in academia. Students are also subjected to ethical conflicts and dilemmas that can affect their working potential and may cause physical and mental health issues. Moral distress among nursing students is a reality (Renno et al., 2018).

Physicians are not isolated from the moral issues surrounding healthcare. The competition for the allocation of resources – driven greatly by increases in new technologies and new drugs – puts the physicians in moral dilemmas. The promise of advances in technologies and pharmaceuticals is tempered by the high costs. This also comes with the recognition that the demands for healthcare care may be infinite but the resources are finite (Mallia, 2020).

Purpose of MDOH

In his book, Man's Search for Meaning, Victor Frankl (1959), asserts that humans seek meaning by committing to a cause or purpose outside of themselves. To understand the purpose of the moral determinants of health, it is important to distinguish and ascertain what constitutes or contributes to the notion of what is "right" in healthcare (Commins, 2019). Berwick submits that the following determine and influence the betterment of health (Berwick, 2020)

1. Ratifying the basic human rights treaties and conventions of the international community by the U.S.,
2. Recognizing healthcare as a human right in the U.S.,
3. Restoring U.S. leadership on climate change,
4. Reforming the criminal justice radically,
5. Implementing immigration reform,
6. Ending hunger and homelessness, and
7. Restoring order, dignity, and equity to U.S. democratic institutions and ensuring that every legal vote is counted.

 Framework for Ethical Decision-Making

The theoretical frameworks for analyzing the moral determinants of health may fall under teleological or deontological theories. Teleological theories are concerned with ends, goals, purposes, or consequences. Deontological theories, on the other hand, are concerned with duty, doing what is right because it is right. Generally, tools that are used to evaluate moral and ethical decision-making include five broad stages (Kreitler et al., 2014). These include a) defining the situation, b) generating alternatives, c) evaluating the alternatives, d) selection, and e) action.

Moral Theories: Understanding Moral Issues

The complexity of moral issues requires that the analysis of these issues begins with facts. The assertion that health is determined by moral factors necessitates an understanding of the ways that we evaluate moral issues. The five general approaches to appraise moral issues include the a) utilitarian approach, b) rights approach, c) fairness or justice approach, d) common-good approach, and e) virtue approach (Velasquez et al., 2014). When evaluating issues based on which actions provide the greatest balance of good over evil, the utilitarian approach is in use. Although the approach seems straightforward, the determination requires a series of steps. The first is to identify different available actions. This is followed by the question of who will be affected by each action, either causing benefits or harm. Finally, the action that produces the greatest benefits and the least adverse outcomes for the greatest number of affected individuals is selected. The rights approach presupposes that individuals can freely choose their actions affecting their lives and that this choice should be respected. The fairness or justice approach requires the treatment of everyone fairly, without favoritism or discrimination. The common-good approach assumes that an individual's good is inseparably tied to the good of the community and society. Finally, the virtue approach requires recognition of certain ideals for which every individual should strive, which will result in the full development of humanity (Velasquez et al., 2014).

In attempting to resolve ethical issues in healthcare, it is noteworthy to heed the advice and warning given by Upton (2011). He avers that there is currently a "lack of any generally accepted method of solving moral problems, together with the extreme improbability of philosophy achieving a plausible determinate theory" (Upton, 2011, p. 431). Because of this reason, we are directed to be open to theorizing rather than using moral theories in our attempts to solve moral issues in healthcare. On the other hand, Miller (2016) commends the efforts and contributions of authors and editors in demonstrating the critical role of theory and philosophy in the ongoing healthcare reforms, particularly with regard to national healthcare policy (p. 128).

Benchmarks for the Fairness Test

The issue of fairness or justice is at the core of the moral determinants of health. A focal point of debate and discussion is whether healthcare is a right (Commins, 2019, IHI, 2020). Amidst the massive healthcare reforms, the issue of fairness is either concealed or disregarded. The two primary reasons for the weak or absent deliberations on fairness are the difficulty in defining fairness and lack of the essential concepts and vocabulary within mainstream economics (Caplan et al., 1999). In essence, neoclassical economics "has neither the necessary moral vocabulary nor a hierarchy of moral value (Caplan et al., 1999, p. 855). In other words, moral theories may not be the sole and ultimate basis for addressing moral determinants of health.

Is the U.S. Healthcare System Fair?

The answer to this question is not easy because of the inherent complexity of the U.S. healthcare system. Caplan et al. (1999, p. 858) offered ten benchmarks upon which the fairness of the reforms in the U.S. healthcare system can be evaluated. These include:

1. Universal access – coverage and participation,
2. Universal access – minimizing nonfinancial barriers,
3. Comprehensive and uniform benefits,
4. Equitable financing – community-rated contributions,
5. Equitable financing – the ability to pay,
6. Value for money – clinical efficacy,
7. Value for money – systemic efficiency,
8. Public accountability,
9. Comparability, and
10. Degree of consumer choice.

 The readers are encouraged to read more about these benchmarks in detail to understand how these benchmarks can be applied. The authors offered a numerical system of scoring to assess for fairness. Although public input is promoted and encouraged when healthcare reforms are made in the U.S., public debate is uneven and discriminatory (Caplan et al., 1999, p. 866).

Role of Nurses

Amidst the considerable reforms in the U.S. healthcare system that are taking place – and more is necessary and essential – nurses will continue to play a vital role in addressing the persistence of healthcare disparities and the rapidly increasing healthcare costs. Nurses at all levels have the moral imperative to help shape health and social policies (Mason, 2016). Nurses are also caught between economic priorities and their ability to ensure the delivery of equitable care to their clients. Nurse leaders must continue to take part in the decision-making process and to have their voices heard with regard to health policies that foster quality. Ultimately, they must forge and sustain an environment for moral agency (Maykut, 2020, p. 491).

In my own pragmatic way, here are my thoughts on Dr. Berwick's shortlist of agenda for action on the moral determinants of health. As I have mentioned, I had more questions than answers when I was researching this topic. My questions are by no means exhaustive.

As nurse executives, administrators, and practice leaders:

1. Do we have an institutional mission/vision/value statement, and do we operate according to those values?
2. What are our policies and procedures in ensuring that the rights of our patients are enforced?
3. How do we ensure that the rights of homeless, non-citizens or those from jail that come to our ER and hospitals receive the care they need?
4. How do we assess food insecurity, among others, as part of our discharge planning?
5. How have we collaborated with community leaders to address the needs of the homeless?

 As faculty, academicians, and researchers: 

1. How do we educate our students on the moral determinants of health?
2. How have we integrated ethical decision-making into our curriculum?
3. Have we encouraged students, especially doctoral students, to consider these topics as part of their capstone or dissertation?
4. Have we published or written an op-ed on any of the moral determinants of health?

As leaders and members of our professional associations:

1. How have we incorporated these moral determinants of health in our mission and vision statements?
2. What programs, activities, or initiatives have we taken to address climate change, hunger, and homelessness, or any of the 17 Sustainable Development Goals by the United Nations (UN, n.d.)?
3. How have we advocated for healthcare as a human right or immigration reform?
4. How have we promoted that each of our members exercises their right to participate in elections and vote?

 Parting Words

As I mentioned earlier in this paper, I had more questions than answers as I was preparing for this article. The concept of the moral determinants of health is relatively new and there has not been a lot of information that has been published on this topic. I would like to open the dialog and pose the following questions. Please send me your thoughts to Nelson.Tuazon@uhs-sa.com. With your permission, I would like to include your ideas in Parts Two and Three of this article in the next couple of issues of TONL Monthly.

1. What are your thoughts on the moral determinants of health?
2. Are there other moral issues that you would like to see added to Dr. Berwick's list?
3. What is the role of nursing – practice, academia, research, and nursing leadership – with regards to the moral determinants of health?

Author's Notes:

Part Two: The Social and Moral Determinants of Health: Intersection or Evolution?

The next part of this article will explore whether the moral determinants of health intersect with the social determinants of health or if they are an evolution of the social determinants of health. The focus of the discussion will be on the promise of the moral determinants of health.

References

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Commins, J. (December 12, 2019). Berwick outlines sweeping 7-step campaign for quality movement. HealthLeaders, Retrieved from https://www.healthleadersmedia.com/innovation/berwick-outlines-sweeping-7-step-campaign-quality-movement

de Barros, A. M., Ramos, F. R. S., Barth, P. O., Brito, M. J. M., Rennó, H. M. S., & Rocha, J. M. (2019). The moral deliberation process of college nursing professors in view of moral distress. Nurse Education Today, 73, 71–76. https://doi.org/10.1016/j.nedt.2018.11.014

Frankl, V. (1959). Man's search of meaning. Beacon Press.

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Mallia, P. (2020). Allocation of resources in medicine – a moral imperative for doctors as well. Medicine, 48(10), 671–674. https://doi.org/10.1016/j.mpmed.2020.07.002

Mason, D. J. (2016). Promoting the health of families and communities: A moral imperative. Hastings Center Report, 46, S48–S51. https://doi.org/10.1002/hast.633

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