Collective responsibility for health: The promise of a social connection model

Renewed interest in the social determinants of health shifts attention from personal health behaviors to the social structures and processes that shape the distribution of health outcomes. This shift in focus raises questions about the justice or injustice of social conditions that influence where people grow up, live and work, and the opportunities and power they come to have or lack—questions that increasingly have been the subject of systematic ethical analyses. A closely related and urgent question, however, has received little attention. How should we as individuals—agents of public health or average citizens (sick or healthy)—think about our responsibility in relation to social injustice? And, what is the nature of that responsibility? The prominent model of responsibility in legal and much moral discourse is a “liability” model that seeks to identify a culpable agent that causes harm and absolve others and background conditions in the process. Such a model is inadequate to this task. Drawing on the work of political philosopher Iris Marion Young, I explore the strengths and weaknesses of a “social connection” model of responsibility that attends to human interdependence and foregrounds structural inequalities. It holds people responsible but not blameworthy for institutional processes that produce harm and urges collective action, not guilt. This alternative model of responsibility has promise as an ethical construct for public health, but leaves unanswered basic questions that relate to group membership, intergenerational justice, and the diffusion of responsibility. Are all men and/or all privileged women responsible for the health deficits that disadvantaged women experience? Are all white people responsible for the health deficits blacks suffer? Are we responsible for health harming institutional processes that we benefit from even if we actively advocate against them? Do those who experience health disparities have any responsibility? These are not merely academic questions. How they are answered will influence how people understand their relationship to structural inequalities and injustice and whether they understand themselves as agents of social change or mere bystanders to social forces.