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Elena Popa, Jay Zameska: Why Specifying Causal Pathways Featuring Social Determinants of HealthMatters for Public Health Ethics
Abstract
This paper will investigate how analyses of causality can help specify social determinants of health for use in public health ethics. While important for finding effective interventions, specific pathways through which the ‘fundamental causes’ (cf., Goldberg 2023) affect health are insufficiently researched.
Regarding causal concepts, a surgical notion of intervention would not work due to the complexity of the system and because fundamental causes have multiple effects (Valles 2018). Thus, we use mechanistic and dispositional notions. The discussion of the deterioration of mental health in high-income countries due to rising inequality refers to mechanisms, one of which involves stress, disrupting cardio vascular function in a top-down manner (Wilkinson & Pickett2010: 86). The health effects of inequality are also explained through its negative effects on trust (Pickett and Wilkinson 2015).
This pathway involves the diminishing quality of human relationships where distrust is present. Here, dispositional approaches (Rocca & Anjum 2020) can help single out psychological traits associated with living in unequal societies or explain traits such as hypervigilance. At the same time, a notion of causation that connects to action in a looser sense than the interventionist one is necessary when discussing potential interventions on social determinants of health. In an ethical context, we will argue that both mechanisms and dispositional notions can provide bases for relevant interventions. By singling out properties with the potential to bring abouta specific health effect, dispositional accounts may provide a basis for more comprehensive but less certain outcomes of upstream interventions, due to complex interactions and context-dependence. Mechanistic accounts that look at lower levels may provide a basis for less comprehensive, but more certain, interventions. For instance, stress increases blood pressure through aneurophysiological mechanism that can be intervened upon through, e.g., blood pressure medication. At the same time, ‘abstract forms of interaction’ mechanisms (cf. Kuorikoski 2009,Konsman 2024) can help highlight higher level, biopsychosocial interventions, such as reducing stress by increasing access to green spaces which may reduce blood pressure while also improving mental health. Still, this is less certain due to the multiple causal pathways involved and possibly unknown connections. This indicates a trade-off between capturing certainty by more traditional mechanistic approaches and comprehensiveness by dispositional approaches and more abstractforms of mechanisms. Addressing this trade-off is an important but so far underexplored ethical question relevant to the prioritization and distribution of public health interventions.
Biographical notes:
Elena Popa is assistant professor at the Institute of Philosophy, Jagiellonian University, Krakow and PI of the project ‘Causality and Social Determinants of Health and Illness’ funded by the Polish National Science Center. She works on causality and causal reasoning and values in science, with special emphasis on cultural and social issues in medicine, particularly psychiatry and public health. Her work has been published in journals such as Synthese, Studies in History and Philosophy of Science: Part C, and Philosophy & Technology.
Jay Zameska is post-doctoral researcher at the Interdisciplinary Centre for Ethics, Jagiellonian University, Krakow and PI of the project ‘Uncertainty and Individual Justification in Public Health Ethics’ co-funded by the European Commission and the Polish National Science Center. He workson normative and applied ethics, particularly questions of fairness, distribution, and uncertainty inpublic and population health. His work has been published in journals such as Journal of Applied Philosophy, Medicine, Health Care and Philosophy, and Public Health Ethics.
