By Charlene Galarneau
To the extent that communities are the principal contexts for the social relations and institutions most central to health and health care, then communities should be critical moral actors in determining what constitutes health justice.
I propose that the health justice framework may be fruitfully developed in conversation with community justice, a social justice framework for health and health care that centers communities and their notions of health justice within national standards of justice. As Michael Walzer has observed, “Justice is a human construction, and it is doubtful that it can be made in only one way.”
As I have argued, community justice “insists on respect for the meanings and values that diverse communities create and hold dear.” As such, “[c]ommunity justice does not describe in a fine-grained way what just [health and] health care would look like; rather it articulates standards or norms required for reaching agreed-to understandings of health and health care that are needed for the provision of just health care services” and community health. Defining the boundaries of just health care communities and creating the institutional structures necessary for inclusive community participation are surely formidable but not unattainable undertakings.
This community-oriented approach runs counter to some discussions of health justice, which, like the philosophical theories of justice they draw on, assume society or the nation to be the sole governing moral collectivity. In these discussions, justice is understood as justice for the nation: an aggregate of individuals with moral responsibilities to one another by virtue of their national identity. Importantly Makhlouf interrogates the boundaries of the health justice “community,” understood as the nation, with regard to immigrants.
But health and health care are social at multiple levels of collectivity, including global, national, community, and family levels. As such, health and health care are community goods as well as familial, national, and global goods. Here, I propose an understanding of communities as roughly subnational social groups, typically larger than families, that, to varying degrees, share identity, participation, and mutual responsibility.
Within a nation, say, the United States, multiple and diverse communities — local, religious, racial/ethnic, for example— play vital roles in health and health care in at least four ways. First, communities are sites of meaning making; in other words, it is in communities that we learn and create particular meanings and values regarding health, illness, and health care. Second, communities influence the health of their individual members. Third, health care, both institutional and “informal,” often happens in communities. Finally, communities benefit — or not — from the health and health care of their members, making health a community good.
To understand what a community justice approach to health justice might look like, imagine the United States divided into defined geographic health communities, each comprised of multiple (sub)communities that inevitably hold both different and often overlapping understandings of health as well as different priorities for public health and health care.
Community justice requires that these each of these defined geographic health communities respect the diverse health understandings and priorities found among its community members. Through inclusive deliberative processes, they must come to sufficient agreement on relevant understandings and priorities so as to be able to organize just health care and public health activities.
Three ethical norms mark the allowable boundaries of community, care, and participation for all communities nation-wide.
First, the just community in community justice is inclusive of all residents in a defined geographic area. Second, just care is care for whole persons both sick and well, including measures addressing the social determinants of health. Third, just participation entails the effective voice of community members such that they are enabled to express their perspectives and engage with others to create “the social meanings, institutions, and conditions necessary for just (whole person)… care.”
Importantly, community justice is not a utopian ideal; various expressions of its elements are found in current health policies, programs, and activities. Community governing boards of community health centers embody just participation as effective voice; efforts targeting just whole person care are present in hospital community health needs assessments; and the promotion of inclusive communities is the central work of many community health advocacy groups.
Community justice invites health justice to deepen its embrace of community by asking, for example, how might health justice engage health as a community good, and how might communities participate in creating the meanings of health justice? In this way, health justice expands its embrace of the social and specifically community nature of health and health care.
Charlene Galarneau, PhD, MAR, is Senior Lecturer in the Department of Global Health and Social Medicine and Faculty Member for the Center for Bioethics at Harvard Medical School; and Associate Professor Emerita in the Women’s and Gender Studies Department at Wellesley College.