Module Components

• Overview

Topics

• Definitions
• Social Determinants of Health
• Health Disparities
• Social Justice and Ethics
• Role of the Public Health Nurse

Nurs 467 - Community / Public Health Nursing

Module 2: Foundational Concepts: Social Determinants, Social Justice and Ethics

Social Justice and Ethics

Basic Concepts

Social Justice is defined by the ANA in Public Health Nursing: Scope and Standards of Practice as:

“The principle that all persons are entitled to have their basic human needs met, regardless of differences in economic status, class, gender, race, ethnicity, citizenship, religion, age, sexual orientation, disability or health. This includes the eradication of poverty and illiteracy, the establishment of sound environmental policy and equality of opportunity for health personal and social development” (ANA, 2013, p. 68).

In accordance with this statement, public health nurses have an ethical and professional responsibility to the clients we serve. This responsibility includes respect of human rights and application of the principles of social justice. Patricia Schoon (2011) describes what she terms a “social contract” between nurses and their clients.

“Professional nurses have a social contract with their clients and the public to ensure that the health care needs of individual, families, populations and communities are met in a caring, nonjudgmental, just and equitable manner. Nurses as professionals and as private citizens are guided by the role of law that protects basic human rights and by ethical principles that provides the foundation and rational for what is done in public health services (Schoon, 2011, pp. 218).

Ethical dilemmas present a quandary as nurses make difficult decisions. For example, do individual rights outweigh the rights of the public? Are resources distributed according to need or equally to everyone? Careful consideration of resources, client needs/priorities, and your obligation as a health professional is needed to arrive at the best decision.

Two disparate perspectives exist regarding health care: the social justice perspective and the market justice perspective. Market justice means that people are entitled only to those valued ends such as status, income and happiness that they acquire by individual efforts, actions or abilities. Social justice means that people in society receive benefits by belonging to a community, and the burdens and benefits of society should be fairly and equitably distributed. Public health nurses abide by the social justice perspective which posits that health care is a basic human right and the government should ensure access to health care to the citizenry. Alternatively, the market justice perspective dictates that health care is a commodity and should be available to only those who can purchase it. The following Comparison of Value Structure table compares the two perspectives.

Market Justice	Social Justice
Human Rights
Individual rights Individualism Autonomy Personal freedom and responsibility	Common good Member of community Collective Responsibility to community
Approach
Short-term thinking and actions Science-based Treatment Local perspective	Global perspective
Goals and Priorities
Profit motive Bottom line Cost effective	Quality of life Stewardship of the future Recognition of hidden costs
Rights of Ownership and Allocation of Resources
People deserve what they earn Private business has the right to earn money	People have rights by belonging to the community Private business has an obligation to the community at large
Role of Government
Mistrust in government, especially big government Individuals are responsible for themselves Government infringes on individual rights Local control of plans and actions Government is inefficient	Trust in governemnt to do the right thing Government is responsible to and for its citizens Government has an obligation to protect citizens Federal control of overall plans and some actions Government can be efficient

Examples of Social Justice

Social justice is based on the premise that societal resources will be distributed in a manner so that all of its members are protected from harm. Harm includes, but is not limited to, disease and illness. When some members of society are exposed to preventable, avoidable conditions while other members are not, this is considered unjust. Consider the recent news stories related to lack of air conditioning in Baltimore City Public Schools. Were these schools in the more affluent areas of the city, like Roland Park? Can you imagine this scenario in a wealthy county, like Howard or Montgomery? It certainly does not seem that societal resources are being fairly distributed to students in many Baltimore City public schools.

Below are two maps showing a visual example of the linkages between social determinants and health. The green map shows the distribution of income in Baltimore City by neighborhood. The lighter color depicts areas where annual income is low and conversely, the darker colors indicate a higher annual income. The purple map depicts the life expectancy in Baltimore City neighborhoods, with darker colors indicating higher life expectancy.

It is interesting to see how the darker areas in both maps overlap. Areas where the income is low have the lower life expectancy. The areas with higher incomes have higher life expectancies. Based on our knowledge of the characteristics of healthy neighborhoods, we can surmise that neighborhoods with low income and poor health are also likely to have lower quality schools, poor access to health and social services, inadequate transportation services, less access to nutritional food, violence and safety issues and are segregated by race, class and/or income.

Social justice is not only a matter of equitable distribution of resources but is also related to imbalances in power. There are examples of this imbalance across the globe, where a few people use power and influence to exploit and control the majority of people. A key strategy used to control the majority is oppression and dependency. Sometimes people (the majority) become empowered and confront the powerful. Examples of this include the Arab Spring where several governments have been overthrown by the people. Here in the United States, the Occupy Wall Street and Black Lives Matter protests are another example of the people rejecting the powerful establishment that is preventing social justice. As you can imagine, these kinds of protests are done at great expense to the people involved and those impacted, and therefore understandably rarely done. As a country, we are capable of improving the quality of life for the underserved, our failure to do so is unjust.