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June 12, 2020

The Moral Determinants of Health

Author Affiliations
  • 1Institute for Healthcare Improvement, Boston, Massachusetts
JAMA. 2020;324(3):225-226. doi:10.1001/jama.2020.11129

The source of what the philosopher Immanuel Kant called “the moral law within” may be mysterious, but its role in the social order is not. In any nation short of dictatorship some form of moral compact, implicit or explicit, should be the basis of a just society. Without a common sense of what is “right,” groups fracture and the fragments wander. Science and knowledge can guide action; they do not cause action.

No scientific doubt exists that, mostly, circumstances outside health care nurture or impair health. Except for a few clinical preventive services, most hospitals and physician offices are repair shops, trying to correct the damage of causes collectively denoted “social determinants of health.” Marmot1 has summarized these in 6 categories: conditions of birth and early childhood, education, work, the social circumstances of elders, a collection of elements of community resilience (such as transportation, housing, security, and a sense of community self-efficacy), and, cross-cutting all, what he calls “fairness,” which generally amounts to a sufficient redistribution of wealth and income to ensure social and economic security and basic equity. Galea2 has cataloged social determinants at a somewhat finer grain, calling out, for example, gun violence, loneliness, environmental toxins, and a dozen more causes.

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    15 Comments for this article
    EXPAND ALL
    Compassion-Driven 6 Action Items in Donald Berwick's Visionary Article are Doable
    Barry Kerzin, MD; BA | Altruism in Medicine Institute
    Once again Donald Berwick, bolstered by compassion, outlines a future for America of health and societal equity based on dignity and respect for each member of society with no one left behind. As the new Surgeon General in January 2021, Dr. Berwick will accomplish setting in motion these 6 shortlisted action items he mentions, and more. They stand on moral ground, on compassion, and equity for all. Thus, they have the power of truth, guided by our founding fathers.

    The United States needs to reassert its values in the international community by ratifying basic human rights international treaties and
    conventions. We must restore US leadership in tackling climate crisis for our children. Establishing health care as a right for all regardless of race, religion, gender, cultural background, or sexual orientation is long overdue. Radical reform of the criminal justice system free of racism, restructuring police attitudes from warriors to guardians of peace, and prisons as humane genuine rehabilitation institutions brings hope to the powerless. Compassionate immigration reform excluding no one returns us to roots of diversity as a nation built on the backs of people of different cultures from around the world. The time for ending hunger and homelessness is now. Restoring dignity and equality to all of our people in this greatest nation on earth makes us all stronger. This is where he and we will start. There is no telling how much more he and we can catalyze and accomplish in 4 or 8 years. Thank you, my friend, Donald Berwick, for your warm heart, clarity of vision, and imminent implementation. Warmly, Barry Kerzin, M.D.
    CONFLICT OF INTEREST: None Reported
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    Setting Priorities
    Richard Plotzker, MD | Retired Endocrinologist
    Big project. Like any other big project if you have 20 priorities, you really have no priorities. Amid the protests now, or in 1963 when public support mobilized around the egregious bombing of the 16th street Baptist Church, making statements abound over making a difference. LBJ clearly had priorities for legislation and attention to voting rights and some change of behavior in allowing access to public accomodations. We have no clear agenda with measurable end points or even which end points to pursue.

    Ironically, it may be medicine that has done the best in what
    is really a massive behavioral modification project. Medical care is safer because of mandated reporting, non-punitive assessment of outcomes, focused guidelines for diseases with reasonably good voluntary clinician compliance. Not perfect, but a lot better than when I graduated in 1977.

    Medicine has an advantage over public officials in bringing this about. Our leaders are respected because they deserve to be respected, and there really is no overt opposition to undermine a project. Our public officials need some of that ethical underbelly to vote for them so it is important to seize the advantage of a time of widespread public consensus which will disappear within a few months. I am also a little disturbed that no meaningful accountability is imposed on the beneficiaries of these efforts. Not engaging in crime will reduce prison populations immensely, finishing school has health benefits well established for many diseases, don't turn my nearest interstate into a NASCAR practice track requires some voluntary compliance that is yet to be achieved. Correcting this requires a partnership, not only among the people we elect or whose expert skills we depend upon, but the beneficiaries as well.
    CONFLICT OF INTEREST: None Reported
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    Paradigm Paralysis
    Paul Nelson, MS, MD | Family Health Care, P.C. retired
    The litany of problems associated with our "nation's population health and its healthcare" represent the clearest indictment for our failure to adapt to our evolving times. We have no reason to believe that the evolving character of the pandemic can be managed. The likelihood of a reliably effective vaccine in the near future is far from certain. By today's standards for immunization effectiveness, we have really never had a reliable influenza immunization. And, our history of immunization progress is far from viewable as a steadily improving and reliably available sequence.

    Furthermore, there is
    no reason to accept that our current progress for solving the cost and quality problems of our nation's healthcare industry as eventually becoming successful in the near future. The rampant issues are broadly unacceptable: worsening maternal mortality, childhood maltreatment, pre-adolescent obesity, adolescent suicide/homicide, substance abuse/mortality, homelessness, mass shootings, mid-life depression/suicide, rural mid-life preventable deaths, and stagnant longevity at birth since 2010. Given a reasonably assembled data-set, there may be more than 600 women who die annually in the USA just because they lived in the wrong nation at the time of conception (total maternal mortality is @900 deaths per year out nearly 4 million births annually).

    The knowledge, resources, and human dignity needed to resolve our nation's paradigm paralysis for honoring each resident person's human capabilities already exists. Somewhat randomly, I think of Robert Putnam, C. Northcott Parkinson, Richard Thaler, Doloris Curran, Arthur Kleinman, Stephen Covey, Peter Drucker, Carl Rogers, John Iglehart, Thomas Kuhn, Addy Pross, Tom Peters, Lawrence Weed, Baron C.P. Snow, Eric Hoffer, Leon Festinger, and Elinor Ostrom. Parenthetically, I should also cite the 1913-14 Congress that produced legislation for both the Federal Reserve and the Cooperative Extension Service. Remember, our nation's agriculture industry is the most efficient and effective among all the developed nations of the world, by a wide margin, and the dollar is still the most widely used currency for international asset exchange, also by a wide margin.

    As a parting comment, I remind everyone that the upstream SDOH occur from locally-driven ecologic and cultural traditions. These traditions are unique to each community and will no doubt require local, community-driven collaborative processes for their prevention, mitigation, and amelioration. Furthermore, this process will need to be associated with a stakeholder collaborative process to assure that advanced primary health care is equitably available to each person within each community. With advanced primary health care that offers 24/7 medical triage and is managed during office hours by RN level "innately wise" nurses, it is likely that hospital utilization rates can be reduced by 25-30%. Let's do it!
    CONFLICT OF INTEREST: None Reported
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    Health or Health Care?
    Stephen Bezruchka, MD, MPH | School of Public Health, University of Washington
    One way to begin considering health as distinct from health care relates to the choice of words. When we speak of health workers, we really mean health care workers, and universal health insurance signifies universal health care insurance. By clarifying the distinction between health and health care we can begin Berwick's moral crusade to produce health.
    CONFLICT OF INTEREST: None Reported
    A Moral Authority We Can Measure
    George Anstadt, MD | University of Rochester
    Don Berwick makes an eloquent appeal for the medical profession to refocus on a shared goal of health. He cautions that “No sufficient source of power exists to achieve the investments required”, and hopes for moral authority to drive change. He is right on with the goal. Frustrated physicians are already applying their moral authority, but without much traction because they don’t have data to back up the high value they achieve by focusing on good health. The cost accountants have numbers, and the doctors soon are out of business if they don’t focus mostly on what is being reimbursed, chronic disease treatment. Happily, the data in support of moral authority can now be extracted case-by-case by modern learning systems applied to our clinical databases.

    These neural networks can measure multi-factorial interactions of patient, physicians, and the social determinants of health, and inform the doctor, patient, and customer about what works and what does not. Millions of clinical interactions with Covid-19 cases have gone unaggregated and so produced little actionable direction. This clinical experience is branded as “anecdotal” by the doubly blinded. Absent a good measure, healthcare customers (patients, governments, and employers) buy based on price with no measure of results achieved.

    Aggregated regional healthcare data is now widely available. Some progressive communities now even integrate some of Berwick's “subway stop” information.

    Reforming healthcare in each region around value, good health outcomes achieved per dollar, will restore joy to medical practice, improve patients' health and vitality, and contain costs. The most important benefit may be a reform that is aligned by good health outcomes, by a powerful, data-documented moral authority that we can now affordably measure in the course of daily practice and use to reform our system.
    CONFLICT OF INTEREST: None Reported
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    Moral High Ground?
    Keith Loud, MD, MSc | Geisel School of Medicine at Dartmouth
    In yet another stirring call to moral clarity, Don Berwick identifies 2 camps within healthcare: those narrowly focused on caring for illness and those who see an expanded role for physicians including advocacy. There is a third way combining both – rigorously practicing the highest value healthcare so that we can redirect wasteful expenditures away from “confiscatory” healthcare systems toward the social determinants.

    I firmly believe that most physicians consider ourselves as holistic healers, not merely practitioners of the art and science of medicine. Some of us, particularly those trained in the primary care disciplines, attempt to address the
    social determinants with individual patients, but that is not our core competency. Developing those skills may come at the expense of clinical acumen or decrease our efficiency, running the risk of burnout and/or increased waste. Others simply find the broader agenda too big, too daunting to address in clinical practice. But with over half of us now employed by health systems, most of which subscribe to a “population health” mission, we can reassure ourselves that we are on, or contributing to, the moral high ground.

    There’s the rub. Believing that we are doing good, we feel no moral force to re-engineer our practices to release the funds to reinvest in other forms of human development. Should a payer, most likely Medicare or Medicaid, suggest decreased coverage or reimbursement in order to accomplish the same goal, we would likely respond with righteous indignation.

    The initiatives that Berwick outlines – using clinical practices to connect patients to social service agencies, along with vociferous institutional, community, and political advocacy - are necessary, but may fall short of the transformation of healthcare needed to redistribute resources. Perhaps that is all that is possible within the house of medicine at this time.
    CONFLICT OF INTEREST: None Reported
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    Moral Issues
    Michael Morelock, MD | Medical Director, MediSci
    The health and economic effects of the COVID-19 virus has certainly sharpened our focus on what is important and essential in health care.

    COVID has undoubtedly been a wake up call. The societal and moral problems well described in the article are both distressing, especially for those more directly affected, as well as embarrassing on an individual, local community, and national scale.

    How health care moves forward in finding solutions to these societal problems is also a moral issue. “What would the physicians, nurses, and institutions of US health care insist on and help lead, as
    an agenda for action?” The ongoing situation brings into focus the essential balance as well as the frequent tension between personal and constitutional rights and responsibilities, and government authority. In my opinion most of the policies and principles listed are right and moral and some are debatable. All reflect some form or government intervention.

    There are insightful questions and discussions to have. It has been eye opening to experience the suddenness of both the health and economic effects of COVID as well the speed and intensity of government power used in reaction to the pandemic. Have these intensified societal and moral problems in the US and especially in the third world? I believe they have. Have government policies and political interests in some cases overridden other freedoms and just interests of society such as speech, assembly, and religion that could have been dealt with in a more selective manner? “What specific actions can individuals and organizations take toward the morally guided campaign…?”
    CONFLICT OF INTEREST: None Reported
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    Setting Highest Priorities
    Walton Francis, M.A., M.P.A., M.P.P. | Self-employed author and economist
    I share Don Berwick's fundamental perspectives about both the moral and non-medical determinants of health. I would have wished, however, for a sharper focus on actions with major effects. Missing from his not-so-short list are two of the arguably most important non-medical reforms: providing school choice to all disadvantaged American families, and providing neighborhood choice to such families through housing vouchers. We know how to do both at a relatively low cost (charter schools actually save money). Cluttering his list are international actions with arguably minor payoffs. First, the United Nations has drafted many "feel good" treaties that have been opposed by Presidents of both parties as incompatible with the United States Constitution and that are largely the law of the land already (e.g., the Americans with Disabilities Act). Second, the adverse effects of climate change on human health in this century are minor at most, and targeted remedies are already at hand. For example, the world-wide elimination of Malaria is achievable within decades, using known interventions. I'd also leave off any such list Constitutional changes, such as abolishing the Electoral College, on pragmatic as well as political grounds. That said, his focus on feasible and effective interventions that make a real difference is the right moral starting point for big health effects outside the medical system.
    CONFLICT OF INTEREST: None Reported
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    Redistribution of Public Funds
    Luz Gutierrez, MD, Master of Public Health | I work in Colombia, South America
    "Two possible sources of funds seem logically possible: either (a) raise taxes to allow governments to improve social determinants, or (b) shift some substantial fraction of health expenditures from an overbuilt, high-priced, wasteful, and frankly confiscatory system of hospitals and specialty care toward addressing social determinants instead. Either is logically possible, but neither is politically possible, at least not so far."

    I think another source is possible: to reduce funds for war, the investment in guns, and use it in welfare.
    CONFLICT OF INTEREST: None Reported
    Going Deeper Than Kant's moral law
    Daniel Benz, MD | Medical Director Health Insurance
    Dr. Berwick is on the right track noting that we need to take moral inventory of ourselves as a health care community and a nation in addressing injustices to the structure of our health care and social systems. Too many of our neighbors and fellow countrymen suffer as I remain comfortable. A deepening sense of solidarity will go a long way in lessening these inequities. But I think the personal sense of civil duty which could be manifest in elections ,financial systems or politics will be inadequate. I think I at least, and probably many others, need a kind of "change of heart", an interior change which will bear more fruit than any externally enforced mandates. Deep down I have found, and I hope many of my medical colleagues agree, that being unconditionally loved by God is what can give the impetus to value the "love of neighbor" as the moral imperative that we need to reach the marginalized and change social structures. We need to value each person universally from the in utero child with Down's, to the black person trapped in the crowded, inner city to the senior with dementia in a nursing home . When we have that love that values the dignity of each person then we will have the peaceful force to bring about real change - beginning with me.
    CONFLICT OF INTEREST: None Reported
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    The US Has Lacked the Will to Change Structural Racism
    Anthony Young - CDHS, Psy.D. Forensic & Clinical | Colorado Dept. of Human Services-Performance and Strategic Outcomes, Direct Care Facilities Quality Assurance / Quality Improvement Analyst
    The US has tremendous human, technological, intellectual, and financial resources, but heretofore has fundamentally lacked the moral will to eradicate the structural racism that results in health inequities, poverty, homelessness, etc. Adequate moral will would certainly require a reckoning of contradictions and also require an authentic national discussion on American slavery, the genocide of indigenous people, and predatory capitalism. As evidenced by the current state of our national health and out political and moral crises, the majority of medical, political, religious, economic, educational leaders, scholars, and average citizens have engaged in centuries of denial, distortion, and avoidance of these issues. The forces that maintain the status quo have an insidious talent for resisting change by publicly (and superficially) embracing "change" while morphing into policies, practices, and programs that appear to be "change" while fundamentally continuing business as usually. Thus the stage is set for future frustration, conflict, and confrontation once it becomes clear again to the masses that absolutely nothing has changed as they continue to experience the same social and medical ills.

    Dr. Berwick provides very actionable solutions to several challenging, controversial issues. The article is a "must read" for anyone truly committed to action, rather than simply talking about meaningful social change.
    CONFLICT OF INTEREST: None Reported
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    The True Role of a Physician
    Adam Skrzynski, MD | ChristianaCare William J. Holloway Community HIV Program
    Dr. Berwick’s article is an excellent summary of the upcoming tasks at hand for the profession of medicine. Perhaps it is this very moral imperative that will not only make our society a more just and equitable place, but will also rescue medicine from the malaise of physician burnout and loss of physician autonomy. Perhaps it is no coincidence that as the profession of medicine has been subsumed by the “healthcare industry,“ dominated by those in the legal and business fields, that societal health has continued to degenerate. The physician as healer, a historically sacred and profound role, has become almost an anachronism. In many ways we as physicians have been reduced to the role of mechanic, without the time or space to re-expand our rightful role as leaders in all aspects of society, both humanistic and scientific. We seem to have relinquished our political impetus and left decision making at the governmental and society level to those who have no idea what it actually means to be a physician, let alone a human being. Fortunately, it seems that the tide has begun to turn, on both the personal and corporate level. To behold the suffering of vast swaths of society is a call that we can certainly continue to ignore, but at great personal and professional costs. Those costs are now evident. There is a moment of decision at hand and who else but members of our profession are better equipped to make the necessary changes, with our intense knowledge of both the scientific and the humanistic? Who else on a daily basis sees first-hand, through the self-narrations of our patients, the struggle and inner workings of systemic racism and overall injustice? It is my hypothesis that the ongoing malaise in medicine can be traced back to these exact factors, witnessing firsthand the quantity and quality of suffering and poor health, and at the same time being largely unable to do much about it, as competing business, political and legal interests continue to siphon off our resources and exploit the hard work of all health care workers. Could it be, through the greater societal program prescribed here by Dr. Berwick, that we physicians can ultimately find our way again, and restore our collective passion? I believe so. And it will require all of us to wake up to this fact and mobilize on all fronts, with the same courage that we approach the care of our patients, even in the worst of times. Bearing witness to the actual and ongoing “American carnage,” as eloquently laid out by Dr. Berwick, invites nothing less than a total moral inventory of our personal and professional lives. I for one will be taking this inventory for some time to come, and I hope to someday be involved in the healing that needs to occur.
    CONFLICT OF INTEREST: None Reported
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    "Moral Compact" or "Moral Compass"?
    Mar R. | Freelancer
    I am wondering if the start of the third line should read "moral compass", rather than "moral compact". Notwithstanding, I found the article illuminating and something to think about. I will re-read it and take some notes.

    I remember some time ago a meta-analysis declared that money was the best indicator of health, quality of life, and number of years lived. I guess the moral compass has been slightly skewed and it needs to be re-calibrated.

    Thank you for making me think.
    CONFLICT OF INTEREST: None Reported
    Religion
    Henry Wei, M.D. | Self (Physician in New York)
    Curious what the author thinks of religion in morality. In the U.S., about 2/3 of people are moderately to highly religious. Patients, from birth until their dying moments, often have religious needs.

    Immanuel Kant appears to assert if morality exists, then God exists (Critique of Pure Reason; unclear how to cite Kant in a modern citation format).

    If we are to heal a divided nation, physicians may not be able to take a purely secular approach to morality without offending the sensibilities of their patients.

    It might be refreshing to hear sincere discussion
    about religious values in the context of moral determinants of health, by a diverse set of perspectives.

    Often it is tempting as well-learned professionals to appeal to rationality and scientific explanation — pure reason — with our patients and policy-makers alike. Vaccine hesitancy, politics, and a host of other issues illustrate that pure reason may not be as compelling as an appeal to values.

    And the practical reality of not just the U.S. but of many regions in the world is that an appeal to values may need to necessarily invoke religion, not as an afterthought, but as Kant notes, a basis of morality for many patients, and most likely many physicians as well.
    CONFLICT OF INTEREST: Employment and academic affiliation; this comment does not reflect the views of the employer nor the academic institution
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    An Article With an Opposing Viewpoint
    James Springate | Retired MD
    I bring your attention to "A Tyranny of Health?" by Theodore Dalrymple:

    "According to the figures provided by JAMA, over 100,000 people have read the article on-line. I would imagine, though I don’t know, that most of them are doctors. In the comments, there is not a single dissent from the premises of the article. Whether dissent would be censored, I do not know, but I very much doubt it.
    I think, then, that it is possible that a dictatorship of virtue would not be abhorrent to at least a large section of the population" (1)

    REFERENCE
    /> 1. https://lawliberty.org/tyranny-of-health/
    CONFLICT OF INTEREST: None Reported
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