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

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
 
In Part One of this article on The moral determinants of health: Purpose, promise, and propositions (Tuazon, 2021), the focus of the discussion was on aligning the work of healthcare professionals and providers with purpose. I presented the background and traced the development of the moral determinants of health. I focused on moral theories as a framework for determining the purpose of the moral determinants of health. In this 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.

Health Gap: Creating the Social Movement

As I have stated in Part One, I came up with more questions, rather than specific answers to the question of "What's new about the moral determinants of health." The complexity surrounding moral issues leads to more questions. Similar to the experience of the World Health Organization’s (WHO) Commission on the Social Determinants of Health (CSDH), there is a need for more research to gain an understanding of the moral determinants of health. However, in his commentary on the social determinants and the health gap, Marmot (2017) emphasizes the need for action amidst the pressing normative and empirical questions on the social determinants of health. I submit that we can take the same approach as we examine and explore the promise of the moral determinants of health. Similar to the social movement that Marmot (2017) has advanced, social responsibility is critical to addressing the health gap and the social and moral determinants of health. With regards to health and healthcare, social justice can be applied at the individual, community, national or regional, and international levels (Bhugra, 2017).

The Moral Determinants of Health: Shared Endeavor

The primary premise of the moral determinants of health is based on the assumption that “the moral law within commands shared endeavor for securing the health of communities” (Berwick, 2020, p. 225). As the harbingers and champions of the promise for the betterment of health, physicians, nurses, other healthcare professionals, and healthcare institutions must advocate for and lead a series of actions. The list could be long but the immediate priorities encompass the following (Berwick, 2020; Commins, 2019):

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.

Claiming the Moral Determinants of Health into the Healthcare Lane

This initial list that comprises the moral determinants of health, albeit short, is daunting and overwhelming. Berwick (2020) opines that some may say that the agenda for the moral determinants of health is outside the realm of traditional healthcare – that is, to care for those who are ill. However, the long-standing issues of inequities and disparities in our healthcare delivery system should compel healthcare professionals to act on these moral determinants of health. In 2005, the WHO established the CSDH to turn public-health knowledge into political action (Marmot, 2005). While the focus of this Commission is neither new nor surprising, poverty remains a critical and complex issue when it comes to inequalities in healthcare. The time has come that the moral determinants of health that impact the health of vulnerable populations fall within the healthcare lane (Berwick, 2020).

The Promise for the Betterment of Health: The Moral Determinants of Health

Any discussion on the relationship between healthcare and efforts to improve social conditions, counteract inequity and disparities, and fight against structural racism evokes emotional, mental, and psychological responses. Because of their political nature, there is disagreement on these issues even among honest and compassionate people. The traditional belief that healthcare should be confined to treating and caring for illness is still espoused by some (Berwick, 2020). Exploring the promise of the moral determinants of health merits our attention. Below is a brief exploration on the promise of the moral determinants of health.

Basic Human Rights Treaties and Conventions. The U.S. was a leader in shaping the United States Charter and the Universal Declaration of Human Rights (UDHR) (Simcox, 2018). The UDHR has become the “basis for health and human rights thinking, advocacy, scholarship, and actions” (Beyrer, 2020, p. 359). However, the U.S. has not fully ratified or advanced all of the nine core human rights conventions that have been adopted by the UN General Assembly. These unratified conventions involve economic, social, and cultural rights; all forms of discrimination against women, the rights of the child, the migrant workers, and their families, and persons with disabilities (Berwick, 2020). Three U.S. administrations have viewed economic, social, and cultural rights as desirable social goals, rather than rights. Additionally, only three of the treaties have been ratified including the 1966 UN Convention on Civil and Political Rights, the 1966 Convention on the Elimination of Racial Discrimination, and the Convention against Torture. Since the founding of the UN International Labor Organization (ILO), the U.S. has ratified only 14 of the 189 ILO conventions (Simcox, 2018).

Healthcare as a Human Right. Khosla (2020) chronicles three significant events that marked the serious attention that has been given to human rights in health at the global level. These include the establishment of the Francois-Xavier Bagnoud Centre on Health and Human Rights at the Harvard School of Public Health in 1993; the call for the universality, indivisibility, and interdependence of all human rights during the World Conference on Human Rights held in Vienna in 1993; and the appointment of the first UN Special Rapporteur on Right to Health in 2020 (Khosla, 2020, p. 335). Berwick (2020) laments that the staggering number of uninsured individuals – approximately 30 million – compels us to push for the recognition of healthcare as a human right.

Climate Change. The effects of climate change on health systems include a) costs, which are estimated to be in the order of trillions of dollars; b) utilization of healthcare services depending on climate change exposure; c) disruption of care caused by extreme weather; and d) undermining of public health infrastructure and global health achievements (Salas & Solomon, 2019).  The recent winter storm in Texas significantly affected healthcare delivery due to the disruptions in electricity, water supply, food distribution, equipment and supplies, transportation, and other essential services and resources in the community. Ryan et al. (2018) have explored the application of systems thinking for health promotion and climate change adaptation. Their preliminary evidence demonstrates the benefits of joined-up action on climate and health, exploring the negative health impacts of climate change, particularly in rural areas (Ryan et al., 2018, p. 569). The recent developments have indicated that the U.S. is taking a leadership role in addressing climate change. Both proponents and skeptics to the greater involvement of the U.S. in leading the climate change agenda have expressed their concerns. I submit that healthcare providers and nurses will remain steadfast in addressing the impact of climate change on health and healthcare. Belkin (2020) posits that social and emotional resilience will determine our ability to adapt to or mitigate, endure, and enact policies related to climate and ecologic change.    

Criminal Justice Reform. Miah (2020) provides compelling arguments for the abolishment and replacement of the U.S. criminal legal system. He posits that the U.S. has two de facto criminal legal systems – one for African Americans and people of color and the other for whites (Miah, 2020, p. 4). Rappaport (2020) provides an equally compelling description of the ills of the U.S. criminal justice system including unprecedented levels of incarceration, disproportionate numbers of incarceration across racial groups, and police that hurt people whom they have a duty to serve and protect. He warns though that the democratization of the criminal justice system, although appealing, will not truly fix what ails us (Rappaport, 2020, p. 711). With regards to health and healthcare delivery, Harzke and Pruitt (2018) provided a comprehensive summary of the prevalence of medical conditions in U.S. prisons and jails. They examined the determinants and progression of these medical conditions and made recommendations to improve a) measurement of the burden of chronic medical conditions, b) healthcare delivery in correctional settings; and c) continuity of care post-release and re-entry into the community.

Immigration Reform. The topic of immigration continues to be a controversial U.S. public policy issue. Any discussion on immigration will likely involve issues on the burdens that immigration places on the U.S. population, public assistance, health, and educational systems. Regardless of one's position on the immigration debate, the issues center around the protection of the interests of U.S. citizens on the one hand, and the addition of new labor and innovative thinking that benefit the U.S. economy and all Americans, on the other hand (Bean, 2020). Immigration policies should be more incremental, specific, and pragmatic. They should be visibly and directly connected to economic benefits to the middle class (Peri, 2020).

Ending Hunger and Homelessness. Hunger in America, one of the richest countries in the world, persists. It has been projected that more than 50 million Americans faced hunger in 2020, exacerbated by COVID-19. This was up from 35 million before the pandemic. This means that 1 in 6 individuals, including 1 in 4 children suffered from hunger (Villareal, 2020). The National Healthcare for the Homeless Council (2019) provides alarming statistics on homelessness in the U.S. It has been estimated that 1.5 million people experience homelessness annually; some believe that these numbers may be doubled. Individuals who are homeless experience higher rates of illness and have a shorter lifespan of 12 years compared to the general U.S. population. Unfortunately, as a part of a vicious cycle, poor health is a major cause of homelessness. The solution to this problem may seem obvious but is complex – stable housing. The Center for Disease Control and Prevention (CDC, 2020) provides resources on homelessness as a public health issue. Hunger and homeless are completely addressable issues (Berwick, 2020, p. 225).

Election Reforms. Not unlike the first six issues that have been presented, any discussion on election reforms evokes powerful sentiments and provokes heated debates. Berwick (2020, p. 226) posits that restoring order, dignity, and equity to U.S. democratic institutions is critical and ensuring the right of every individual’s vote to count equally is crucial. The American Organization for Nursing Leadership (2021) advocates for empowering nurses to vote and for the voices of nurses to be heard in local, state, and federal elections.

What Lies Ahead

The promise of the moral determinants of health may not be in sight soon enough. Due to the nature of the moral determinants of health and the present environment in which we live, “there is a visible decline in the willingness to take on issues that are now viewed to be too controversial or even radical” (Gruskin, 2020). We can only heed the advice from the WHO Review of the social determinants and the health divide: Do something, do more, do better! (Marmot, 2014). Is the impetus for advocating for moral justice to eliminate the health gap resonating to all of the healing professions? While the empirical evidence for the moral determinants of health is developing, we must take action at the individual and structural levels. Gruskin (2020) reminds us to be strategic and not just reactive to be able to address the crisis of the moment. For nurses, Maykut (2020) asserts that moral habitability – defined as the “intersect between the socio-political location of nurses and the ideologies and structure of workplace environments” – is necessary to ensure humanistic caring (p. 491). As healthcare administrators, nurse executives, and leaders, it is our responsibility to promote work climates that foster moral habitability among nurses at all levels.

Note: In the upcoming final section, Part Three, I will outline the propositions on the moral determinants of health with a focus on the role of nursing leaders.

References

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