Kristin Voigt

The Social Determinants of Health: Why Should We Care?

A growing body of empirical research examines the effects of the so-called “social determinants of health” (SDH) on health and health inequalities. Several high-profile publications have issued policy recommendations to reduce health inequalities based on a specific interpretation of this empirical research as well as a set of normative assumptions. This article questions the framework defined by these assumptions by focusing on two issues: first, the normative judgments about the (un)fairness of particular health inequalities; and second, the policy recommendations issued on this basis. We argue that the normative underpinnings of the approach are insufficiently supported and that the policy recommendations do not necessarily follow from the arguments provided. Furthermore, while many of the policies recommended—such as improving peoples living conditions and reducing inequalities in wealth and power—are justified in their own right, the way these recommendations are tied to health is problematic.

The Ethics of Not Hiring Smokers

Policies of refusing to hire smokers, which are being adopted by some U.S. employers, result in a failure to care for people, place an added burden on already-disadvantaged populations, and preempt interventions that more effectively promote smoking cessation.

Smoking Norms and the Regulation of E-Cigarettes

Electronic nicotine delivery systems (ENDS)-commonly called e-cigarettes-are at the center of a polarized debate. How should they be regulated? Central to this debate is the concern that e-cigarettes could lead to the renormalization of smoking and that the regulation of ENDS should therefore be modeled on the regulation of conventional cigarettes. I argue that arguments based on the renormalization of smoking can lend support to restrictions on marketing of ENDS, but that such arguments are problematic when used to justify restrictions on where ENDS can be used. The debate has been insufficiently sensitive to the ethical complexities of attempts to manipulate social norms to change health behaviors; these complexities must also inform the debate about ENDS and their regulation.

“If You Smoke, You Stink.” Denormalisation Strategies for the Improvement of Health-Related Behaviours: The Case of Tobacco

Denormalisation has emerged as a possible strategy to influence health-related behaviours, particularly in the context of anti-smoking initiatives. Denormalisation strategies aim to influence social norms surrounding the behaviour in question, by making the behaviour less visible and reducing its social acceptability, so as to motivate individuals to change behaviours and to strengthen public support for other public health measures and interventions. Focusing on anti-smoking efforts, this chapter assesses denormalisation strategies with respect to two concerns. First, denormalisation strategies may contribute to the stigmatisation of smokers. Second, denormalisation strategies may add to existing burdens among disadvantaged groups. These concerns point to highly problematic and potentially counterproductive effects of denormalisation strategies. However, two approaches – social norms marketing and tobacco industry denormalisation – could provide more constructive and less problematic applications of the denormalisation strategy and may therefore have a role to play in the pursuit of public health.

Childhood obesity : ethical and policy issues

Childhood obesity has become a central concern in many countries and a range of policies have been implemented or proposed to address it. This co-authored book is the first to focus on the ethical and policy questions raised by childhood obesity and its prevention. Throughout the book, authors Kristin Voigt, Stuart G. Nicholls, and Garrath Williams emphasize that childhood obesity is a multi-faceted phenomenon, and just one of many issues that parents, schools and societies face. They argue that it is important to acknowledge the resulting complexities and not to think in terms “single-issue” policies. After first reviewing some of the factual uncertainties about childhood obesity, the authors explore central ethical questions. What priority should be given to preventing obesity? To what extent are parents responsible? How should we think about questions of stigma and inequality? In the second part of the book, the authors consider key policy issues, including the concept of the ‘obesogenic environment,’ debates about taxation and marketing, and the role that schools can play in obesity prevention. The authors argue that political debate is needed to decide the importance given to childhood obesity and how to divide responsibilities for action. These debates have no simple answers. Nonetheless, the authors argue that there are reasons for hope. There are a wide range of opportunities for action. Many of these options also promise wider social benefits.

The case for banning cigarettes

Lifelong smokers lose on average a decade of life vis-à-vis non-smokers. Globally, tobacco causes about 5–6 million deaths annually. One billion tobacco-related deaths are predicted for the 21st century, with about half occurring before the age of 70. In this paper, we consider a complete ban on the sale of cigarettes and find that such a ban, if effective, would be justified. As with many policy decisions, the argument for such a ban requires a weighing of the pros and cons and how they impact on different individuals, both current and future. The weightiest factor supporting a ban, we argue, is the often substantial well-being losses many individuals suffer because of smoking. These harms, moreover, disproportionally affect the disadvantaged. The potential gains in well-being and equality, we argue, outweigh the limits a ban places on individuals’ freedom, its failure to respect some individuals’ autonomous choice and the likelihood that it may, in individual cases, reduce well-being.

Risk, harm and intervention: the case of child obesity

Abstract In this paper we aim to demonstrate the enormous ethical complexity that is prevalent in child obesity cases. This complexity, we argue, favors a cautious approach. Against those perhaps inclined to blame neglectful parents, we argue that laying the blame for child obesity at the feet of parents is simplistic once the broader context is taken into account. We also show that parents not only enjoy important relational prerogatives worth defending, but that children, too, are beneficiaries of that relationship in ways difficult to match elsewhere. Finally, against the backdrop of growing public concern and pressure to intervene earlier in the life cycle, we examine the perhaps unintended stigmatizing effects that labeling and intervention can have and consider a number of risks and potential harms occasioned by state interventions in these cases.

Too poor to say no? Health incentives for disadvantaged populations

Incentive schemes, which offer recipients benefits if they meet particular requirements, are being used across the world to encourage healthier behaviours. From the perspective of equality, an important concern about such schemes is that since people often do not have equal opportunity to fulfil the stipulated conditions, incentives create opportunity for further unfair advantage. Are incentive schemes that are available only to disadvantaged groups less susceptible to such egalitarian concerns? While targeted schemes may at first glance seem well placed to help improve outcomes among disadvantaged groups and thus reduce inequalities, I argue in this paper that they are susceptible to significant problems. At the same time, incentive schemes may be less problematic when they operate in ways that differ from the ‘standard’ incentive mechanism; I discuss three such mechanisms.

Paternalism and Equality

Paternalistic interventions restrict individuals’ liberty or autonomy so as to guide their decisions towards options that are more beneficial for them than the ones they would choose in the absence of such interventions. Although some philosophers have emphasised that there is a case for justifiable paternalism in certain circumstances, much of contemporary moral and political philosophy works from a strong presumption against paternalistic interventions. However, Richard Arneson has argued that there are egalitarian reasons that support the case for paternalism: paternalistic interventions can protect poor decision-makers from making ‘bad’ choices, thus preventing inequalities between them and those with better decision-making skills. This paper seeks to clarify and advance our understanding of the egalitarian argument for paternalism. Arneson’s argument adds an important and often neglected dimension to the debate about paternalism but also raises a number of questions about equality, paternalism and the relationship between the two.

Health and Social Justice: Which Inequalities Matter (Most)? Response to Open Peer Commentaries on "The Social Determinants of Health: Why Should We Care?".

We thank the open peer commentators for their thoughtful responses to our article, “The Social Determinants of Health: Why Should We Care?” (Preda and Voigt 2015). Since space constraints prevent us from responding in detail to all the comments raised, we focus on two areas of concern that emerged from the commentaries. The first is our claim that avoidability is neither a necessary nor a sufficient condition for defining unjust or unfair health inequalities. The second area relates to the reasons we might give for treating health inequalities as morally problematic.