CDE Appendix 1 Literature Review - Central East Local Health ...

The Culture, Diversity and Equity Project: Literature Review
3.1), and take Canadian policy-makers to task for failing to sufficiently elaborate clearer ethical foundations for
health equity policies. 16
Table 3.1: Different interpretations of the same ethical ideal: “Equity”
(a) “Equity: access to health services should be based on need and need alone, not on other factors such as wealth, origin,
the region where people live, their gender or age” (Commission on the Future of Health Care in Canada, 2002, p. 48).
(b) “Equity: all Canadians are equally entitled to access our health system based on health needs, not ability to pay” (ibid., p.
50).
(c) “Equity: no one should face financial hardship because of illness, disease or disability. Wealth should not be able to buy
better treatment, higher-quality care or a better chance at a cure” (British Columbia Ministry of Health Planning, 2002,
p. 15).
(d) “Equity: every person has a fair opportunity to attain his/her full health potential. Policies and services are developed to
reduce the differences in health status that are associated with factors such as socio-economic status, gender, age,
ability, and culture” (Department of Health and Community Services, 2002, p.10)
(e) “Equity: no one should face excessive financial hardship or possible bankruptcy because of illness, disease or disability.
Access to timely and medically necessary health services should be available to all, regardless of income. These two
access issues are fundamental to Canadian health care and are tenets almost all British Columbians would agree with.
This does not mean, however, that British Columbians should not bear some responsibility to keep healthy or to
contribute to the future sustainability of the health care system, which will be discussed in more detail further in the
report. Rather, it means that any funding mechanism or financial involvement should be equitable and fairly distributed.
No one disease profile, demographic or sector of society should bear a disproportionate burden of the health care
costs” (Legislative Assembly of British Columbia, 2001, p.13).
(f) “Equity: participation, access, and the sharing of benefits and risks, taking into account the characteristics of each
population” (Reseau de Medecine Genetique Appliquee du Quebec 2002, p. 2).
Source: Giacomini et al., 2009
Anthony Culyer (2007) similarly encourages Canadian policymakers to be more explicit about their ethics in order
to better manage and translate ethical positions “into policy action in reasonable and doable ways”. Failing to do
this, by leaving ethics largely implicit, he argues,
means that the huge differences between us that might otherwise remain submerged could become
underwater reefs with the potential to rip the bottoms out of well-meaning policies for equity in practice -
as soon as it becomes clear that one person's notion of equity is not also another's. We need to be clearer
about what we mean and where we might differ in what we mean (p.12).
Mackenbach et al. (2002b) likewise stress the importance of “explicitly justify[ing] policies to reduce
socioeconomic inequalities in health, not only because it is important to convince policy-makers of different
political convictions that something needs to be done, but also because one's choice of justification will partly
determine which policies should receive priority” (see Mackenbach et al., 2002b for examples of the implications of
different policy justifications).
16 Surveying a bewildering array of definitions and interpretations of ‘equity’ as a value in healthcare policies (see Table 3.1 above), Giacomini
et al. (2009) for instance argue:
[t]he instrumental role of the ethics framework should be made clear, particularly its relationship to the development,
interpretation, and implementation of the policy it accompanies. Currently, many ethics frameworks seem detached from policies,
floating alongside in special text boxes or appendices. They are also set apart by vague, platitudinous language; imperatives are
typically expressed in terms that are inspirational, positive, nonspecific, and non-operational. The language offers vast license in
interpretation and discretion in response. Some degree of flexibility is appropriate and necessary in ethical analysis. However, expansive
ethical terms with little definition or operationalization become weak rhetoric, and apparent agreements (e.g., to include
“accountability” among guiding principles) may mask fundamentally different aims (e.g., involving public participation vs.
transparent reporting).
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