Healthcare need, exclusion of SEF and equity

On the assumptions of P, the principle of the social obligation to level up the health of those worst-off, we will argue that (a) and (b) are inequitable. The exclusion of SEF in the definition of need will not satisfy the social obligation to level up the worst-offs in terms of SEF. This is valid in both cases whether we consider need relative to health condition or health outcome.

Let us first consider how the exclusion of SEF in combination with focus on health condition (a) is incompatible with P. In this need concept, there is no room for considering whether the disadvantages of the socioeconomic worst-offs (for instance, lack of knowledge, bad economy, or deprived housing) may affect their capacity to benefit from care. Consequently, in cases in which SEF actually have an impact on individuals' capacity to benefit, the healthcare service will provide suboptimal care to these patients compared with those who get the same treatment without experiencing socioeconomic hindrances to benefit from treatment.

Moreover, if the doctor is unaware or ignorant of the potential impact that socioeconomic better-offs may have on the healthcare service in terms of their already acquired social advantages—say, high education—to communicate and claim their needs for health care, the socioeconomic worst-offs might end up getting comparatively less care and experience less health gain due to their lack of such relevant skills. Consequently, an ethical practice that merely focuses on health condition, and ignores SES and SEF, is likely to maintain or reinforce health inequity by the healthcare distribution itself. In cases in which SEF actually affect the outcome of treatment, patients of low SES will gain less health than better-offs with a similar health condition, ie, an assumed similar need. According to Daniels' theory on health equity2 and P—the social obligation to level up the health of those worst-off to the level of the better-offs of normal functioning over a lifespan—a distribution of care based upon this understanding of ‘healthcare need’ is not equitable.

Let us now consider the case in which SEF are ignored in conjunction with the focus on health outcome (b). In cases in which SEF, and not health conditions, are the actual hinder to benefitting from treatment, a doctor who interprets healthcare needs this way has two options: (1) she or he can claim the case is futile (as SEF should be ignored) or (2) she or he can reconsider the patient's need (without paying attention to the possible impact of SEF) at every level of suboptimal outcome the patient achieves due to SEF until the expected health outcome is obtained.

Option (1) would be absurd—and also ethically unjustified—if another effective option for care that circumvents the negative impact of SEF is available. Then, the case is indeed not futile. Option (2) is feasible, but ineffective in so far as alternative interventions that could circumvent the negative impact of SEF and bring the patients directly to the otherwise expected health level could be provided at the very start of the intervention. Let us illustrate this by an example. A woman with four children, two badly paid jobs, and an alcoholic husband is asked to start exercising in order to reduce her hypertension. This is the doctor's preferred intervention before giving her medication for her high blood pressure. In this case, the socioeconomic barriers represent a hindrance to complying with the advisory treatment. This failure may further expose her to stigma within the health system, rendering the advisory treatment even more ineffective. Ignorance of these barriers implies a longer time for recovery and poorer health over time compared with others who are not subjected to the same non-medical barriers. A more effective intervention would be to take into consideration how SEF influence the possibilities of benefitting from certain kinds of interventions.

Consequently, an avoidable step-by-step treatment procedure due to the impact of SEF reinforces health inequality. Again, reinforced health inequality would not be aligned with P and ‘healthcare need’ shaped by excluding the considerations of SEF in conjunction with either a health condition or a health outcome focus cannot be considered equitable.

Healthcare need, inclusion of SEF and equity

We proceed by exploring how healthcare distribution that takes SEF into account (c and d) may support an equitable distribution according to P.

We first consider the interpretation of ‘healthcare need’ that allows SEF to be included in conjunction with a focus on health condition (c). We assume it is irrelevant whether the health condition is caused by SEF or not; if people are sick, what counts is their health condition. The problem we face now is that a focus on the initial health condition does not offer any way to determine how SEF have a relevant influence on people's needs. A ‘healthcare need’ interpretation that is insensitive to how SEF relate to health, but at the same time confer such factors some relevance, actually allow for both pro-high-SES or pro-low-SES discrimination among patients. Consequently, this interpretation of ‘healthcare need’ is obviously not aligned with P and must then be rejected as an appropriate interpretation to basing equitable distribution of health care.

As we now have rejected the three previous alternatives of ‘healthcare need’ to be counted as equitable, we are left with the fourth alternative, (d). Will the inclusion of SEF in the definition of ‘need’ when we focus on health outcome accord better with how equity is protected by P?

This fourth alternative defines the relevance of SEF in healthcare need considerations according to outcome. Compared with the outcome of the treatment of similar medical cases in which SEF do not constitute barriers, SEF emerge as relevant concerns in a healthcare need concept if they have a negative impact on the otherwise expected outcome of an intervention. That is, if SEF reduce the benefit from a treatment in order to reach the otherwise expected health outcome, health care that circumvents or counterworks this effect of SEF should be considered to meet the needs.

In an empirical setting, this interpretation of how SEF affects need may avoid the reinforcement of health inequity by the healthcare service. When efforts are made to ensure that the potential health outcome is obtained effectively in terms of interventions that avoid socioeconomic obstacles and unnecessary delays (as in a step-by-step procedure), the health status of the patient will be levelled up for a longer period of time than the standard treatment would otherwise allow for. The distribution of health care on the basis of this fourth interpretation of ‘healthcare need’ may contribute to improving the health status of the socioeconomic worst-off relative to the better-off and, thus, reduce health inequity. Therefore, the inclusion of SEF in this meaning is on a par with P.

Towards a SEF and outcome-sensitive conceptualisation of ‘healthcare need’

A conceptualisation of healthcare needs to base a fair distribution on would have to specify the ‘conditions’ that can be involved. Our analysis suggests one such condition (among others we have not considered here) that should be included, namely the category ‘SEF which affect the capacity to benefit from treatment and reach the outcome otherwise expected’. This element in a ‘healthcare need’ concept is consistent with the social obligation to level up the health of the socioeconomic worst-off to the better-offs' level of normal functioning over a lifespan. Consequently, in non-ideal circumstances in which social health inequalities persist, an equitable distribution of health care according to need (as suggested by Hurst and Daniels)3 13 must consider SEF in this respect.

Implications for clinical and political priority settings

It follows from the above that doctors would be obligated to search actively for socioeconomic barriers to effective treatment. In this sense, complete neutrality with regard to SEF and, thereby, SES cannot be required to promote a fair distribution of care. A patient's SES should trigger extra awareness and prompt efforts to discover whether there are relevant barriers in terms of SEF and how these should be circumvented in order to obtain effective treatment. Examples of such efforts could be alternative interventions, more detailed explications, information and advice about health-related issues, or welfare benefits. Allocating more time in order to determine the patient's needs with respect to SEF may also be considered. More research into barriers people experience with respect to SEF when it comes to benefitting from treatment is necessary to avoid inequity based on SES. Clearly, these suggestions indicate that priority setting with regard to SEF on a clinical and political level is required when care is distributed according to equitable needs.

Revising the claim on neutrality in ‘ordinary medical fairness’

Hurst's defence of SES neutrality is based on the view that prioritising patients in clinical care on the basis of their SES,13 other things equal, is not justified. She discusses cases in which patients with different SES have identical needs for treatment, but limited resources exclude the possibility that all can get the indivisible good (such as the operating room). Using SES as a criterion for choosing between patients is hard to justify for several reasons: First, as pointed out by Hurst,13 we lack knowledge about the effects of such levelling-up health strategies. Therefore, prioritising patients with low SES resembles more retribution for social injustice in how basic institutions shape social determinants of health rather than purposive redistribution of care. Moreover, the effects of such a policy would occur as nothing but yet another version of discrimination, rationing care to the socioeconomic better-offs simply because of their status. To let arbitrary individuals in need carry the burden of social injustice cannot be justified, neither in terms of high nor low SES. In this respect, we agree with Hurst13 and Daniels2 that neutrality towards SES is required. What our discussion suggests, however, is that the inclusion of SEF in need considerations, when this has an impact on beneficial gains, is on a par with an equitable clinical healthcare distribution. In this respect, neutrality towards SEF (and, implicitly, SES) is not justified. An adequate normative understanding of ‘ordinary medical fairness’ should distinguish between situations in which SEF represent necessary information to realise the intended outcome, and situations in which SEF-based priority represents discrimination for morally unacceptable reasons.