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The Moral Determinants of Health

Educational Objective
To understand the moral challenges and prerogatives when serving in the medical profession
1 Credit CME

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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Article Information

Corresponding Author: Donald M. Berwick, MD, MPP, Institute for Healthcare Improvement, 53 State St, 19th Floor, Boston, MA 02109 (donberwick@gmail.com).

Published Online: June 12, 2020. doi:10.1001/jama.2020.11129

Conflict of Interest Disclosures: None reported.

References
1.
Marmot  M.   The Health Gap: The Challenge of an Unequal World. Bloomsbury; 2015.
2.
Galea  S.   Well: What We Need to Talk About When We Talk About Health. Oxford University Press; 2019.
3.
Wegman  J.   Let the People Pick the President: The Case for Abolishing the Electoral College. St Martin’s Press; 2020.
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