Grace Wang

With my aspiration to pursue a career in medicine motivated largely by my passion for helping
those who are the most vulnerable both physically and emotionally, it seems fundamentally contradictory
for medical practice to passively turn a blind eye towards the ways in which our current healthcare system
exacerbates the impacts of the non-medical determinants of health. However, the difficulty of translating
theoretical moral inclinations into actionable approaches poses a practical dilemma, especially as I
consider how attending to these social determinants of health may jeopardize my commitment as a
physician to providing the best care possible to each patient, regardless of individual identity.
When reflecting on this issue, I am particularly drawn to Iris Young’s social connection model of
responsibility, which shifts away from the binary thinking of liability models that retroactively juxtapose
right and punishable wrong, towards a more forward-thinking conception of responsibility that is tied to a
continuum of possibilities for collective action. Young’s model views inequities in health and healthcare
as structural injustices—ones that cannot be attributed to the actions of a single individual or the impact
of a specific institution or policy (Young 2011). To me, questioning how conventions within healthcare
that are accepted as the norm may be affirming structural injustices seems like a reasonable responsibility
for physicians as part of the burden naturally associated with their position of authority, which requires
that physicians base responsible medical practice on nuanced, evolving, and interdependent relationships
between themselves, their patients, and society. By employing the perspective of both care and justice-
based ethical frameworks, I would argue that physicians do have a responsibility to provide patient care
that is cognizant of an individual’s health-impacting social background, although this should be
secondary to a primary responsibility to embrace their collective ability to catalyze transformative
organizational changes in healthcare systems to actively attend to the non-medical determinants of health.
At the level of individual patient care, I strongly believe that any actions aimed at addressing the
non-medical determinants of health must be approached cautiously in order to avoid patient alienation or
the jeopardization of physician-patient bonds of trust. In daily medical practice, urgent questions of
distributional justice arise when physicians make decisions on how to allocate the limited resources of
time and medical supplies; distributional justice questions whether or not there exists a basic minimum of
material goods, opportunities, or outcomes to which all persons are entitled, and seeks to address issues of
maldistribution. Whenever one patient’s care may be directly compromised to favor another’s, I do not
think it is appropriate for physicians to act in disregard of race-blind approaches, as doing so has the
potential to inadvertently reaffirm existing implicit biases, exacerbate feelings of alienation, increase
chronic health-deteriorating stress, and increase inequality by benefitting whites more quickly and
disproportionately (Kindig 2017). As Axel Honneth has posited, suffering itself is an injustice regardless
of the causal structural processes (Dotolo 2018), and I furthermore do not believe that there exists a
completely objective evaluation of who is the most disadvantaged, since all individuals have complex,
intersecting socioeconomic backgrounds and cultural identities. I find notions of equality of outcome to
be wrongfully idealized in the context of individual patient care when prioritized above the equality of
treatment, and thus do not believe that it is a responsibility of physicians to adopt behavior that seeks to
actively compensate for the health effects of non-medical determinants at the point of care.
However, I would not argue that this exempts physicians from diligently acting in full
consciousness of these factors to avoid exacerbating their effects. In light of the shift in the 20 th century
from a paternalistic to a shared-decision making model of the physician-patient relationship, this notion of
responsibility can be derived from a care ethic framework, which shifts the unit of moral analysis to
interpersonal relationships, asking questions of how to respond to moral problems of detachment,
abandonment, and neglect (Baier 1995, Gilligan 1995). For example, when a patient misses an
appointment, a physician should not assume that the patient bears the guilt of negligence towards their
health, but rather consider factors such as the limitations of public transport, the grievances mid-day
appointments may pose to unsalaried, minimum-wage workers, and language barriers of ethnic minorities
in determining how to best empower patients to engage in in-home self-care when possible. In a care
ethic approach, physicians should demonstrate full understanding that comprehensive measurements of
health must look beyond numerical statistics that describe physical health to encompass the emotional
health of patients and their interpersonal relationships, especially those involving patients’ care teams.
These changes in mentality have the capacity to make real impacts on health outcomes, and I believe they
lie within a physician’s reasonable professional duties, informed by the fundamental bioethical principles
of beneficence and nonmaleficience.
I also believe that physicians have a responsibility to embrace their capacity to exert more
sustainable influence on structural trends in medical education, institutional organization, and social
norms through advocacy and leadership by example, albeit these contributions may take time to
accumulate into tangible outcomes. This analysis appeals to the concept of recognitional justice, which
seeks to combat social exclusion and champions the idea that all persons deserve a secure foundation of
self-esteem and publicly acknowledged social value regardless of their ethnicity, socioeconomic status,
sexual orientation, or other identity. In her work on recognition theory, Dotolo cites a mixed methods
study on the experience of LGBTQ individuals caring for seriously ill or dying partners in inpatient
hospital settings. After being forbidden to lay in bed with Tom who had lost decision-making capacity,
Tom’s long-time partner Charles reflected on his feelings of helplessness when he was unsure if hospital
policy was being enforced, or if this was yet another manifestation of heteronormative bias (Dotolo
2018). I think that this case presents a powerful example that illuminates how inaction on the part of
physicians can equate to exacerbation of recognitional injustices and thus an increase in the potency of
non-medical determinants of health. Physician may easily address similar situations by insuring
transparency, but more notably, such actions at the point of care should also be translated into giving
pushback to institutional policies which prioritize efficiency—for example, the heteronormative policy
that one’s legal spouse is the assumed surrogate decision-maker—to ones which more responsibly
promote and sustain recognitional justice, when anticipating the impact on future patients. This may
initially only propel changes at the level of hospital administration, but it has the potential to catalyze
conversation for macrosocial changes in the long-term.
Moreover, physician-mediated restructuring of medical education at an institutional level may be
motivated by the need for increased structural competency to complement the previous discussion of
cultural competency. Structural competency trains physicians to better identify cross-cultural expressions
of health and illness (Metzl 2014); it can be employed to address the moral wrongs of structural injustices
that systematically make large groups of people subject to deprivation and domination—in terms of
material goods, or more abstract forms of Nancy Fraser’s concept of participatory parity (Young 2011,
Fraser 1995). Thus, I believe structural competency appeals to transformational approaches which are
grounded on both distributional and recognitional justice, and do not benefit some at the cost of others.
To this end, physicians may help medical students develop an attunement to structures that shape clinical
interactions. Physicians can also collaborate with arts and science colleagues to develop a richer
vocabulary of structural stigmas to make marginalization more visible, propose programs that combine
clinical research with grass-roots advocacy, and empower the next generation of physicians to combat a
learned helplessness in medicine to the social determinants of health (Metzl 2014). The importance of
interdisciplinary approaches here mirrors the complex nature of the non-medical determinants of health,
which impact multiple disease outcomes through a plethora of risk factors and are reproduced over time
due to their dependence on universally useful resources (Phelan 2010). Given their traditional position at
the pinnacle of health care teams, physicians furthermore have the power to deconstruct sterile hierarchies
amongst healthcare professionals by engaging in and facilitating interprofessional education, which has a
demonstrated ability to curate improved health outcomes aligned with the notion of proportionate
universalism, where both intrinsic burden and relative rates of health adversity can be combated
(Gergerich 2018, Kindig 2017); hierarchies on health care teams are proven sources of unresolved
tensions that jeopardize the quality of all patient care, and the inclusion of more diverse voices on patient
care teams can undoubtably improve the efficacy and accessibility of care provided to marginalized
minorities in particular.
With the recent developments in personalized medicine, it is a crucial responsibility of physicians
to not lose site of the robust and enduring inverse stepwise relationship that exists in our society between
social position and health, which has a very real potential to be exacerbated when certain patients remain
predisposed to reap the benefits of the personalized attention conferred by “precision” medicine.
However, as expressed by Iris Young, this responsibility is one that can only be collectively discharged,
and the pressing issue at hand becomes how healthcare professionals can each be inspired—and
empowered—to tackle a piece of this shared responsibility.
References

Baier A. (1995) The need for more than justice. Justice and Care: Essential Readings in Feminist Ethics.
Westview Press, pp. 47-58.

Dotolo D, Lindhorst T, Kemp SP, Engelberg RA. (2018) Expanding conceptualizations of social justice
across all levels of social work practice: recognition theory and its contributions. Social Service Review
143-170.

Fraser N. (1995) From redistribution to recognition? Dilemmas of justice in a ‘post socialist’ age. The
New Left, 68-83.

Gilligan C. (1995) Moral orientation and moral development, in Justice and Care: Essential Readings in
Feminist Ethics Westview Press, pp. 31-46.

Gergerich E, Boland D, Scott MA. (2018) Hierarchies in interprofessional training. Journal of

Interprofessional Care.

Kindig DA. (2017) Population health equity: Rate and burden, race and class. JAMA 317; 5:467-468.

Metzl JM, Hansen H. (2014) Structural competency: theorizing a new medical engagement with stigma
and inequality. Social Science & Medicine, 103:126-133.

Phelan JC, Link BG, Tehranifar P. (2010) Social conditions as fundamental causes of health inequalities.
Journal of Health and Social Behavior, 51(S):S28-S40.

Young IM. (2011) “Structure as the Subject of Justice” (Ch 2) Responsibility for Justice (New York, NY:
Oxford University Press 2011), pp. 43-52.