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

The Moral Determinants of Health: Purpose, Promise, and Propositions
Part Three: Translating Propositions into Actions

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

December is the month for reflections to take stock of what the year has brought. In Part One of this article on The Moral Determinants of Health: Purpose, Promise, and Propositions (Tuazon, 2021a), I provided the background and theoretical framework of the moral determinants of health. In Part Two, I examined the promise of the moral determinants of health as they intersected with the social determinants of health (Tuazon, 2021b). In this Third Part, I will explore the prospect of translating the propositions on the moral determinants of health into actions.

What is Past is Prologue

It has been more than a year and a half since Dr. Donald Berwick of the Institute for Healthcare Improvement (IHI) introduced the concept of the moral determinants of health. Surprisingly, his insightful albeit provocative ideas about the need to transform quality from a predominantly technical nature to the essence of morality (Berwick, 2020a) have not sparked further discussions, debate, and discourse in the healthcare arena. Except for a scholarly article by Dissanaike and Matthews (2021), there has been a paucity of published peer-reviewed articles on the topic of the moral determinants of health. A quick scan of the healthcare literature during the past several months amidst the COVID-19 pandemic revealed a modest coverage of Dr. Berwick’s call for a campaign on the moral determinants of health.

Dissemination of the Seminal Work on Moral Determinants of Health

In his presentation at an IHI CHAMP Learning Session, Berwick (2020b) quoted Sir Michael Marmot: “Inequities in power, money, and resources give rise to inequities in the conditions of daily life, which in turn lead to inequities in health” to highlight the significance of the choices we make as a part of “the new normal” after the COVID-19 pandemic. Berwick’s seminal work on the moral determinants of health has been presented at medical conferences and has been adopted by various professional associations and entities (Center for Primary Care, 2020; Trauma Research Foundation, 2020). Bloggers have scrutinized and lauded Dr. Berwick’s efforts to advance the notion of the moral determinants of health (Bailey, 2020; Dinesh, 2020; Schubbart, n.d.). I am of the conviction that more needs to be done!

Transforming the Propositions on Moral Determinants of Health into Actions

In his recent presentation, “Envisioning our Future: The Moral Determinants of Health,” Berwick (2021) reiterated the campaign for the moral determinants of health that encompasses the following actions 1) ratify the major human rights treaties, 2) make health care a human right, 3) reverse climate change, 4) reform the U.S. criminal justice system, 5) enact immigration reforms, 6) end hunger and homelessness, and 7) restore U.S. democratic institutions and assure the equal count of every person’s vote. Berwick’s advocacy for the moral determinants of health compels us to address the social determinants of health, structural racism, and healthcare inequities (Berwick 2020a; Berwick 2020b, Berwick, 2021).

The Role of Nursing in Addressing the Moral Determinants of Health

More in-depth investigation, evidence-based practice quality improvement initiatives, and research are needed to study the impact and influence of the moral determinants of health. Although the following key issues do not specifically mention moral determinants of health, they offer opportunities for nurses to play an active role in their examination, analysis, and dissemination.

Health Equity. Nurses should be acutely aware of the recommendations of The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. At every level, setting, and field of specialization, nurses should be able to articulate and explain these key recommendations. I submit that to contribute to the transformation of the propositions of the moral determinants of health, nurses should play key roles to advance health equity, improve the health of the nation, lift barriers to practice, design better payment models, strengthen nursing education, value community and public health nursing, foster nurses’ roles as leaders and advocates, prepare nurses to respond to disasters, and support the health and well-being of nurses (National Academies of Sciences, Engineering, and Medicine et al., 2021).

Structural Racism. In January 2021, the National Commission to Address Racism in Nursing was launched to examine the issue of racism nationwide. The Commission is charged with the task of describing the impact of racism on nurses, patients, communities, and the healthcare system to confront systemic racism. The American Organization for Nursing Leadership (AONL) is one of the key nursing organizations that represent a diverse and broad continuum of practice settings. The specific goals of the Commission are to 1) engage in national discussions within the nursing profession to own, amplify, understand, and change how racism negatively impacts colleagues; patients, families, and communities; and the health care system, 2) develop strategies to actively address racism within nursing education, practice, policy, and research, including addressing issues of leadership and the use of power, and 3) use the Nursing: Scope and Standards of Practice as a framework to create a roadmap for action to address racism in nursing (ANA, 2021).

Justice, Equity, Diversity, and Inclusion. Amidst the call for a renewed commitment to embrace diversity, equity, and inclusion (DEI) and social justice, a review of the nursing literature revealed a scarcity of studies on the topic on DEI (Morrison et al., 2021). The American Organization for Nursing Leadership (AONL, 2021) has established guiding principles for diversity in health care organizations through advocacy, education, and research based on performance improvement outcomes. In response to the increasing to the Texas Organization for Nursing Leadership (TONL) has established a Diversity, Equity, and Inclusion Committee charged with the strategic initiative to update appropriate TONL policies and procedures, conduct a gap analysis on DEI reporting structures, representations, and recognitions, and establish a website link on DEI. Tuazon (2020) has put out a call to action to the TONL members for developing strategies to create a leadership culture of equity beyond equality. Morrison et al. (2021) have provided recommendations for nursing leaders in assessing commitment, culture, and structural empowerment to promote and advance diversity, equity, and inclusion in organizations.

The Moral Determinants of Health: Global Implications

Regrettably, in spite of the enormous need for heightened awareness on health equity, Amri et al. (2021, p. 1) lament that the leading health care organization – the World Health Organization (WHO) – continues to hold ambiguous, inadequate, and contradictory views of equity that are rooted in different theories of social justice. The propositions that I offer to advance the campaign for the moral determinants of health have global healthcare implications. Global issues such as emerging infectious diseases, human trafficking, maternal-newborn health, health inequities, and maldistribution of health workers intersect with the moral determinants of health. The role of the nurse leader has to expand beyond the walls of hospitals and other health care settings if we are to successfully impact the fight against emerging global health issues (Edmonson et al., 2018).

Paving the Way from Propositions to Actions

The members of AHRQ's National Advisory Council have put out A Call for Action to Achieve Health Equity (AHRQ, 2021). They emphasized that “we must understand and agree that there is no healthcare quality without healthcare equity.” It is imperative that we enhance collaborations, improve integrations, and coordinate efforts in fulfilling our moral obligation to address systemic racism and healthcare inequities. To paraphrase Dr. Berwick, the effectiveness and success of our actions in advancing the transformation of the propositions of the moral determinants of health will not be based on predictions, projections, or prognostications. Rather, our triumph will be based on the choices that we make and on the actions that we take. The time has come to chart the path and pave the way toward the full consideration of the moral determinants of health.

References

Agency for Healthcare Quality and Research (QHRQ). (2021). A call to action to achieve health equity. A Call for Action to Achieve Health Equity | Agency for Healthcare Research and Quality (ahrq.gov)

American Nurses Association (ANA). (2021). Leading nursing organizations launch the National Commission to Address Racism in Nursing. Leading Nursing Organizations Launch the National Commission to Address Racism in Nursing (nursingworld.org)

American Organization for Nursing Leadership (AONL). (2021). Guiding principles for diversity in healthcare organizations. Guiding Principles for Diversity in Health Care Organizations | AONL

Amri, M. M., Jessiman-Perreault, G., Siddiqi, A., O’Campo, P., Enright, T., & Di Ruggiero, E. (2021). Scoping review of the World Health Organization’s underlying equity discourses: Apparent ambiguities, inadequacy, and contradictions. International Journal for Equity in Health, 20(1), 1–16. https://doi.org/10.1186/s12939-021-01400-x

Bailey, F. A. (2020). Moral determinants of health. Palliative Care Blog. Moral Determinants of Health (cuanschutz.edu)

Berwick, D. M. (2020a). The moral determinants of health. JAMA, 324(3), 225–226. https://doi.org/10.1001/jama.2020.11129

Berwick, D. (2020b, October). The moral determinants of health. CHAMP Learning Session. COVID-19: The Other Side of the Curve (uvm.edu)

Berwick, D. (2021). The moral determinants of health. Envisioning our future. The Moral Determinants of Health — Envisioning Our Future For Children

Center for Primary Care. (2020). Don Berwick’s moral determinants of health. Don Berwick's Moral Determinants of Health (harvard.edu)

Dinesh, A. (2020). Moral determinants of health? How is it different from social determinants of health? Moral Determinants of Health? How is it Different from Social Determinants of Health? (mbbshacker.blogspot.com)

Dissanaike, S., & Matthews, J. (2021). The moral determinants of health: An overview of disparities in healthcare. Journal of Vascular Surgery, 74(2), 2S-5S.

Edmonson, C., McCarthy C., Trent-Adams, S., McCain, C., & Marshall, J. (2018). Emerging global health issues: A nurse’s role. OJIN, 22(1), manuscript 2. DOI: 10.3912/OJIN.Vol22No01Man02

Morrison, V., Hauch, R. R., Perez, E., Bates, M., Sepe, P., & Dans, M. (2021). Diversity, equity, and inclusion in nursing: The pathway to excellence framework Alignment. Nursing Administration Quarterly, 45(4), 311–323. https://doi.org/10.1097/NAQ.0000000000000494

National Academies of Sciences, Engineering, and Medicine; National Academy of Medicine; Committee on the Future of Nursing 2020–2030, Flaubert, J. L., Le Menestrel, S., Williams, D. R., & Wakefield, M. K. (Eds.). (2021).The Future of Nursing 2020-2030: Charting a Path to Achieve Health Equity. National Academies Press (US).

Schubbart, B. (n.d.). The moral determinants of healthcare. Health Care. "The Moral Determinants of Healthcare" - Bill Schubart

Trauma Research Foundation. (2020). The moral determinants of health. The Moral Determinants of Health - Trauma Research Foundation

Tuazon, N. (2020, September). Equity: Creating a leadership culture beyond equality. TONL Monthly. Equity: Creating a Leadership Culture Beyond Equality (naylornetwork.com)

Tuazon, N. (2021a, January). The moral determinants of health: Purpose, promise, and propositions. Part One: Aligning Work with Purpose. TONL Monthly (naylornetwork.com)

Tuazon, N. (2021b, March). The moral determinants of health: Purpose, promise, and propositions. Part two: The promise for the betterment of health. TONL Monthly. TONL Monthly (naylornetwork.com)