Introduction

According to the protagonists of what might be termed the social determinants of health (hereafter SDH) revolution, the contribution made by social factors exclusive of health care to the overall health of individuals is greater than has traditionally been thought, perhaps as great or even greater than that made by those ingredients of health care – access to health-care professionals, pharmaceuticals, medical technologies – that have usually been viewed as central to the ‘justice-in-health’ debate (Wilkinson, 1996; Wilkinson and Marmot, 2005; Wilkinson and Pickett, 2009). From this, the conclusion is drawn that the distribution of these factors ought to be made so as to realize desirable health objectives. My intention in this article is not to reject this conclusion, but to argue that the inference ought to be drawn with care, and to provide at least in broad lines an account of how the truth of the SDH thesis should be integrated to an overall view of justice.

The outcome of this debate makes an enormous difference to the future of modern welfare states. Indeed, one of the central policy debates within such regimes has to do with priority setting. What are the health-related goods that all citizens should be insured against, independently of their ability to pay, and what should be excluded from the basket of ‘essential’ health-related services? Debates surrounding this question and other, related ones have quite naturally focused on the cost-effectiveness of different measures. In public insurance systems, for example, citizens are required to contribute to a common fund that will see to the health of all, and so they can legitimately expect that those who administer this pool of resources will do so in a manner that attempts to maximize benefit (where, again, the idea of ‘maximizing benefit’ incorporates both strict efficiency and distributive considerations).

If SDH theorists and researchers are correct, we have been misallocating these funds at least to some degree over the course of the evolution of modern welfare states. Such systems have invested massively in doctors, hospitals and pills, whereas, if SDH theories are correct, they should have in order to improve health outcomes been placing resources in the increase of people’s incomes (or in the closing of the income gap), in improving education, in providing citizens with better housing and so on. Indeed, while it would be an overstatement to claim that education, housing and the like, have fallen off the agendas of developed states, the proportion of GDP devoted to health care has been increasing.Footnote 1

My main claim in this article is that the principles that should govern the distribution of the social goods that are at the center of SDH theorists’ attention are plural, and can certainly not be reduced to what might be termed ‘health consequentialism’. These principles should instead be sensitive to the plural consequences of the goods that states distribute – consequences on health, to be sure, but also consequences on other states of affairs that ‘count’ in the evaluation of the overall justice of states. They should moreover also be sensitive to the possibility that certain goods that states distribute may have value independent of their consequences.

I will proceed in the following manner. First (I), I will identify what I take to be a pair of desiderata that all theories of justice should attempt to satisfy. According to the view that I shall defend, theories of justice should be (in senses that will be elaborated upon below) political and holistic.

Second, I will identify two ways in which the principal SDH claim – that social goods contribute causally to the health of individuals, and to the level of health inequality in a society – can be integrated into a theory of justice. ‘Monism’ about SDH, I will claim (II) satisfies the holism requirement, but only at the cost of yielding an implausible theory of the human good, and giving rise to unacceptable paternalism. I will defend what I shall refer to as a ‘pluralist’ conception of the way in which SDH should be integrated into a theory of justice about health, and will describe at least in broad lines the way in which such a conception is best integrated into a holistic theory (III).

A Political Conception of Justice

Any theory of social justice must, to begin with, be premised on an account of what the proper scope of justice is. Scope issues can be thought of in two ways. First, it will have to say something about the range of individuals that are appropriately governed by institutions of social justice. Second, it has to have something to say about the range of goods the distribution of which can properly said to be just or unjust. In this article, I bracket the former question, in order to focus on the latter.

There are two ways to think about this problem. According to an abstract conception of justice, there is no a priori limit on the kinds of goods the distribution of which can be taken to be a concern for a theorist of justice. Thus, to take an example drawn from recent work by Segall (2013, p. 23), the fact that my office is three feet closer to the coffee machine than yours, and thus, that my access to coffee is a tiny bit easier than is yours, raises issues of justice (though, in fairness, issues on Segall’s account that can be easily met).

According to what I shall term a ‘political’ conception of justice, justice has not to do with all inequalities or all distributions of goods. Justice, on this construal, is not just about measuring equalities and inequalities, whatever they may be, and attempting to justify them (or not). It is also about the use of the coercive power of the state. More precisely, it is about using the various coercive powers that are at the disposal of the state to disallow certain inequalities, and to rectify them or compensate for them through the setting up of institutions charged with governing the distribution of certain goods. This will require, at a minimum, the coercive levying of taxes, the setting up of institutions charged with delivering the goods in question and the training of officials charged with gathering data as to the distribution of these goods, with the enforcement of patterns of justice deemed to be just, and so on.

A first claim I wish to defend is that political conceptions of justice are preferable to abstract ones. Political conceptions enjoin us to consider the full range of ethical questions that are relevant to the administration of justice. They ask not only whether there are inequalities relevant to good x, nor whether x is a good that matters sufficiently to individuals to be an appropriate object of concern for theories of justice, but also whether it is ethically appropriate to wield the coercive power of the state in order to enforce the just distribution of goods that are seen to matter. Thus, (to use an example that has been widely discussed in the philosophical literature), while there are (abstract) reasons to view the fact that children differ in the extent to which they are read bedtime stories by their parents, a state that would enforce a just distribution would be ethically unattractive.Footnote 2

The bedtime story example shows, moreover, that abstract and political conceptions of justice are not simply complementary. That is, abstract theorists cannot claim that what I have described is simply a matter of the division of intellectual labor, between the determination of unjust inequalities on the one hand, and the way in which to institutionalize the rectification of these injustices, on the other. If the distinction I have drawn between abstract and political theories is correct, the very determination of the inequalities that are to count as unjust can only be made within a political framework.

Luck egalitarianism is a paradigm case of an abstract theory as I have defined it here. It views any inequality that reflects the operation of brute bad luck as one that at the very least calls for justification, and in the absence of justification, for rectification or compensation. Luck egalitarianism is abstract in that it focuses on the causes of inequality, rather than on its objects.Footnote 3

In fairness, however, many luck egalitarians (and again I will use Segall’s recent work as a paradigm case) realize that they must introduce some limiting consideration in order to avoid absurd implications. Reverting to the ‘distance to the coffee machine’ example I have borrowed from Segall, the concession is made that inequalities in the distribution of particular goods only register at the bar of justice if these (apparently trivial) goods somehow realize more important goods.

The problem for luck egalitarians in particular, and for abstract theorists in general, is that this concession typically gives rise to a slide to another unhelpful form of abstraction. According to abstract theorists, apparently homely goods like access to coffee matter, if they do, because they allow for the realization of that which is of ultimate interest (for example, Segall, 2013, p. 35), which is typically taken to be ‘well-being’, ‘opportunities for welfare’ (Arneson, 1989) or some similar reference to people’s overall welfare.

This slide to abstraction is made necessary because there are no resources available to abstract theorists of justice that allow them to block the slide between directly observable inequalities of all kinds (for example, with respect to the number of feet to the coffee machine) and an abstract consideration of well-being, which is viewed as justifying the concern with specific observable inequalities. The problem with this approach (putting aside philosophical and real-world controversies about exactly what well-being consists of) is, to put the point baldly, that the state cannot distribute well-being. Assuming that it can come up with a metric that allows it to measure well-being, it can at most see differences in well-being as evidence of the degree to which the goods that conduce to well-being are or are not being distributed fairly. And we are thus sent back to a consideration of different observable inequalities. Given abstract theorists’ neglect of the political and institutional dimensions of justice, they have no way in which to prioritize specific inequalities as more or less deserving of attention by state institutions.

What we need is a mid-level theory, one that satisfies two constraints. First, such a theory would block the regress from the observation of ground-level inequalities to an unhelpfully abstract consideration of ‘welfare’. Second, it would be part of a theory that took seriously the political and institutional dimensions of justice. In other words, it would be bound up with an answer to the question of what goods the state appropriately and effectively takes up the distribution of.

It is important to note that the two adverbs in the foregoing sentence encompass distinct requirements. The question whether it is appropriate for the state to take up the distribution of a good has to do, for example, with the question of whether ascribing this responsibility to it would yield an unattractively intrusive set of institutions (one that, for example, checked in with parents every evening to make sure that they were spending just the right amount of time reading bedtime stories to their children). The question whether it would be effective to place this responsibility on the state has to do with whether the state, rather than, say, the market, is best situated in order to deliver the good in question, that is, to deliver it in sufficient quantity and quality, and with sensitivity to the relevant distributive norms.

Rawls’ theory is one that tries to satisfy at least one of these constraints. His limitation of his theory of ‘justice as fairness’ to the ‘basic structure’ of society reflects his view that justice is principally about what the state does. His theory of ‘primary goods’ attempts to identify, among all of the goods that the state presumably could distribute, those that most reliably conduce to citizens being able to lead good lives. This, I take it, is the sense that should be ascribed to Rawls (1971) well-known dictum according to which primary goods are those goods that it is rational for an individual to want, whatever her conception of the good.

Though Rawls is the right kind of theory, I would argue that, focused as it is on basic primary goods such as rights, opportunities and income, it still suffers from an unhelpful abstraction. A more promising starting point for a political conception of justice would begin not just from an abstract consideration of the kinds of goods that it is rational for agents to want, no matter what else they want, but from a theory of the state which asks what concrete goods the state can appropriately and effectively regulate the distribution of. The selection of these goods should be empirically grounded. A theory of the kind I am thinking of would look both at the goods that the state already distributes, and ask whether it is appropriate for the state to distribute them, whether it can do so effectively, and what import these goods have for citizens.Footnote 4 In order to avoid an unattractive conservatism, it would also look at goods that are distributed by institutions other than the state (for example, by the market), and ask whether these goods are more appropriately and effectively delivered by the state, for example, because they are subject to market failures when they are left to the operation of the market. Health is an obvious case in this context, because of the predictable tendency of human agents to underinvest in the periods of their lives during which they earn the most income in a good that most of them will only require in later life. But I would argue that transportation and housing are also examples (the former because of the state’s appropriate role in solving collective action problems, the latter because of the market’s failure to correct the rent-seeking behavior of property owners).

How do we figure out what the appropriate principles are for the distribution of all of these goods? One answer to this question would be piecemeal.Footnote 5 The approach would identify a distributive principle that was most attractive for each good, taken in isolation. Thus, for example, it might be argued that all inequalities in health are suspect from the point of view of justice, and ought to be addressed either by being eliminated or compensated. Or, it might be argued that every citizen has a right to the level of health that will allow her to enjoy fair equality of opportunity. This process would be repeated for each of the goods specified in the earlier phase of theory construction.

Such a piecemeal approach would face the problem of trade-offs. This problem is, again, rooted in an ineradicable fact about modern societies, which has to do with limitations on the amount of resources available for collective provision of goods the distribution of which is to be organized by the state. Concretely, the principles that might emanate from a piecemeal approach are likely not to be compossible. We cannot have all of the health-related resources, all of the educational resources, all of the resources related to housing and so on, that principles elaborated on the basis of a piecemeal approach would seem to indicate that we ought to be able to provide collectively. And the piecemeal approach does not provide us with any guidance as to how to make the trade-offs that will be required in order to make the provision of all of these goods compatible with predictable constraints on the public purse.

I want to claim that the question of how to make these tradeoffs is itself a problem of justice, rather than a purely administrative or technical one. In other words, citizens have a right that the way in which resources are distributed as between these different goods be responsive to appropriate norms of justice. If this claim is correct, it would seem to suggest that the question of how to distribute goods should be conceived of holistically.

Now, the defender of a piecemeal approach might defend the view that her approach is entirely compatible with the holism that I am defending at the level of trade-offs. According to this view, the piecemeal approach yields just principles, and then higher-order principles of justice are adduced in order to determine what compromises are defensible with respect to these first-order principles. Against this, I want to defend the view that whole bundles of goods are the appropriate objects of ethical evaluation. In other words, it only makes sense to exercise first-order moral judgment as to how public investments in social goods should be distributed as between different goods when one considers what I refer to in other work as a ‘platform’ – that is an organized proposal as to how different kinds of goods are to coexist within an overall scheme of public provision.Footnote 6

Consider the way in which the piecemeal theorist might go about the need to engage in trade-offs between different distributive principles. Imagine we view equality of opportunity as the most appropriate way to govern the distribution of health-relevant resources, whether health care narrowly construed, or other SDH (Daniels, 2008). Given the impossibility of realizing this principle fully, in the context of resource constraints, the obvious way for the piecemeal theorist to respond is to water down the principle of equal opportunity, and to attempt to minimize to the greatest degree possible the departure from the principle that such constraints will make necessary. But if equality of opportunity is really what matters to us, then it could be that there will be other goods, the distribution of which, in connection with health, will best realize fair equality of opportunity. It could be the case that the best way in which the full complement of goods that will serve the cause of equality of opportunity will require adverting to some different principle for the distribution of health-relevant resources, and that insisting on minimizing the departure from (local) fair equality of opportunity will detract from our ability to achieve (global) fair equality of opportunity. This is a version of what has been referred to in public policy theory as the ‘fallacy of the second best’ (Goodin, 1995). Thus, it seems that serving the values that piecemeal theorists invoke in the distribution of particular goods requires moving to the ‘platform’, rather than to particular goods, as the primary object of evaluation for theories of distributive justice.

Again, this point is not particularly original. In fact, it points back to an underappreciated position developed by Rawls (1977). That position is that, when considering the justice of the basic structure, one should adopt a holistic approach, and remain sensitive to the possibility that local defeats of what seems an appropriate principle can be made good by the way in which the basic structure as a whole deals with the distribution of goods. The difference between Rawls’ view and the one that is being sketched here is that the basic structure of goods that in my view constitute a ‘platform’ are situated at a lesser level of abstraction than are Rawls’ primary goods.

Against Monism

If I have made the claim that theories of justice should be political and holistic plausible, then the question arises as to how we should think about justice in health in the context of such a theory. More specifically, in the context of the present article, we should think about the way in which SDH theorists fit into such a theory.

The specific question I want to address has to do with the normative pressures that bear on the distribution of social goods. To be more precise, SDH theorists claim that social goods such as education, housing, transportation, income and the like, all contribute to health, and that differentials in the distribution of these goods positively correlate with distributions of health. The question, therefore, is to what degree should the distribution of these other goods be sensitive to their impact on health, and on health distributions?

I will call a first possible answer to this question ‘monist’. MonismFootnote 7 holds that the distribution of all social goods should be such as to maximize their positive impact upon health (either aggregate health outcomes over a whole society, or the maximal possible decrease in health inequalities, or whatever).Footnote 8 Monism is a permanent temptation of much of the SDH literature. Having identified causal mechanisms through which positive outcomes with respect to health might be achieved, the thought is that there can be no objection to activating these mechanisms through appropriately designed social policies. As Venkatapuram and Marmot (2009, p. 86) put it, ‘it is always implicit in the SDH literature that the logical social response to the identification of social determinants of ill-health is to transform them’.

SDH theories, whether monistic or not, satisfy one of the structural desiderata that I have imposed upon theories of justice. They are political, in that they focus their attention on goods the distribution of which positively correlates with health, and that are, on the face of it, appropriate objects of effective state action. Typically, SDH accounts focus on such things as education, housing, income, transportation and the like, and there is no real question that states should have at least a hand in regulating the distribution of these goods. SDH theories are thus ‘political’ in the sense of the term relevant to my purposes.

In their monist variants, SDH theories are, moreover, holistic in the sense that they provide an answer to the problem of trade-offs. To the extent that social investment in the various goods that are appropriate objects of effective state action are according to this view to be organized to maximize the realization of some objective related to health, monism addresses the problem of trade-offs in essence by eliminating it. Whenever a conflict arises between two goods that are potential objects of state funding, the conflict is to be resolved in the way that maximizes the realization of some health-related goal.

Though monism structurally satisfies the conditions defended earlier in this article on theories of justice, its monism renders it implausible. Health is clearly a very important good, but other things matter as well. A life devoted solely to the maximal extension of healthy life would be a very dreary one indeed. It would involve avoidance of risky activities that give life much of its flavor, and it would also involve devoting oneself rather obsessively to a rather narrow band of activities. A life devoted to nothing but health would be a humanly impoverished life, and a society whose institutions were single-mindedly devoted to health would be a correspondingly impoverished society.

Nor (to advert to another possible health-related goal) are health inequalities the only inequalities that matter. Imagine a (misguided) benevolent autocracy informing its citizens that it will arrange policy in such a way that, though all other inequalities remain in place – for example, inequalities to do with fulfilling jobs and with educational opportunities – health outcomes will be equalized to the maximal degree possible. Though it is impossible to demonstrate this solely through philosophical argument, it seems plausible to speculate that the citizens of this health equality-crazed state would gladly trade some degree of health equality for the reduction of other forms of inequality in access to important goods.

There are two ways in which the monist can respond to these prima facie arguments against her position. The first response would be a paternalist one. Her argument would be that regardless of what people think, health is in fact the most important good. According to this view, it is valued both intrinsically, but also as an outcome that determines the distribution of all other goods, to the point that, to quote Marmot (2008), ‘health and the distribution of health can be used to tell us how well a society is functioning and distributing its benefits’.

A further distinction might be introduced at this point. The paternalist position can be formulated either in weak or in strong form. The weak version would concede that though health is not the only thing that matters, a certain minimal threshold of health is a component of any plausible conception of the good (or, to advert to the goal of health equality, a just society is one that has reduced health inequalities to at least a certain level).Footnote 9 The strong version of the paternalist position would deny this, and claim that health-related goals trump all others.

The weak version of the paternalist claim is entirely compatible with the argument of this article. For the weak version abandons monism. It concedes that social policy must achieve a balance between different goods, and that the justification for the pursuit of certain goods cannot be reduced to the contribution that they make to the achievement of health-related outcomes. It merely adds as a rider to this pluralist position that any satisfactory bundling of goods must include a level of health that satisfies the threshold requirement.

The strong version of the paternalist claim is to be rejected, I would argue, at least within the context of a broadly liberal-democratic political ethics. To the prima facie implausibility of the claim according to which health is the only thing that ultimately matters must be added the fact that a state that acted on its basis is one that would constantly find itself interfering with the negative liberty of its citizens.

A resolute perfectionist with respect to health (or with respect to any other good, for that matter) need not be deterred by the foregoing considerations. If liberal democracy does not allow us to pursue goods of ultimate importance as efficiently as might be the case outside of the liberal democratic framework, so much the worse, the argument would claim, for liberal democracy!

Now, there is no way to refute the position of the resolutely illiberal perfectionist. The most that can be done is to point to the normative costs of her position. I will simply assume, without further argument, in the context of the present article, that the abandonment of a broadly liberal democratic political ethics, represents a significant cost, one that will not be happily taken on by most readers.

The second way in which a monist about health might respond to the prima facie implausibility of her theory is to adopt a more capacious conception of health. The response to the claim of prima facie implausibility would be that this claim rests upon too narrow a conception of health. Health monism, according to this view, only seems implausible when the conception of health that is assumed is a strictly physiological conception of health. While it may seem implausible to claim that all of the resources of the state should be monomaniacally trained upon the operation of hearts, lungs, livers, brains and so on, that implausibility disappears when one accepts that health involves more than just the normal functioning of organs. To be healthy, according to this view, means to function well physically and mentally, to be sure, but also socially and spiritually. Health is on this view a total state of well-being.

Once one accepts this new, enlarged conception of health, the aura of implausibility that surrounds the monist view begins to dissipate. Of course, the monist can be taken to see, the resources of the state should be devoted to the achievement of people’s health, and/or to the reduction of health inequalities within the population. What other goal could there be, once it is seen that health in a sense encompasses all the goods that matter to people living well?Footnote 10

This strategy, despite its initial plausibility, comes at a price, however. Indeed, as is tacitly conceded, it involves stretching the concept of health so as to make it co-extensive with that of well-being, or of flourishing. Now, there may very well be nothing wrong with states being devoted to achieving the well-being of their citizens, but that was not the initial claim of the monist. The monist claimed that health was more important than any other good. The revised monism involved in the broadening of the concept of health being considered here involves the claim that health encompasses all other goods.

The problem is not merely a verbal one. Remember that one of the desiderata I have imposed upon plausible theories of justice in health is that they address the problem of trade-offs. A monist about health operating with a narrower conception of health addressed this problem by claiming that all apparent conflicts among goods be resolved so as to favor health. Now, if the foregoing arguments were convincing, she did so at the cost of implausibility. The incorporation of all goods that matter into health leads the (revised) monist to not addressing the problem at all. If all goods that matter, and the distribution of which are effectively and appropriately taken up by the state, are incorporated into a conception of health, it follows that we have no account of how to deal with the conflicts now construed as internal to health that will unavoidably arise, for exactly the same reason that they arose when we construed these goods as ‘external’ to health (though as contributing causally to the achievement of health).

One way in which to respond to this problem for the monist is to establish hierarchies within the expanded conception of health that we have been considering. It could be claimed, for example, that though all components of health matter, biophysical health matters more (for example, because it is a condition for the achievement of other components of health).

This move would bring us back to the dilemma that we posed for the monist above. Either this hierarchy is construed in a weak manner, such that all that is being claimed is that a certain level of biophysical health should be given priority over other goods, or it is construed more strongly, such that all potential conflicts are resolved in favor of health. The first position in effect abandons monism, and so need not be argued against here, while the second raises the two unattractive features of monism that were discussed above, namely those of intuitive implausibility and of unbridled monism.

If this is the case, then it follows that we must provide a pluralist rather than a monist answer to the question of how to deal with the fact that SDH claims to occupy some of the same terrain as do other social policy domains. While acknowledging that policy in the areas of education, housing, transportation and the like have an impact on health, their value cannot be entirely expressed in terms of their impact upon health. How can this more complex way of reckoning with the impact of social goods upon health be integrated into a political and holistic theory of justice? It is to this question that I now turn.

The Importance of Platforms

If monism is to be rejected, how are SDH to be integrated into a holistic and political theory of justice?

SDH theories, pluralistically conceived, claims that the distribution of social goods such as housing, education, income and the like, has an impact on the distribution of health states. Unlike monism, it acknowledges however that impact on health should not be the only factor relevant to the distribution of these social goods. This pluralism possesses at least two dimensions.

First, social goods can be seen from two different perspectives, which I will label ‘intrinsic’ and ‘instrumental’. SDH theorists have focused on the instrumental dimension of social goods. They have concentrated on the way in which the distribution of social goods impacts the distribution of health states across a population. But some social goods embody important values, values that exercise an influence on the way in which they should be distributed that is independent of the empirical outcomes to which they are causally connected.

Consider a famous (or infamous) argument made by Mill. Mill ([1861] 2010) argued that though it was important that all citizens (including women) of a democracy be allowed to vote, the fact that certain classes of people, in Mill’s view the educated classes, have better political judgment than other justifies a system of weighted votes. According to this argument, everyone does better when the votes of the well educated are weighted more heavily, because, again on Mill’s hypotheses, the vote of the educated class gives rise to better social policy.

Assuming (for the sake of argument) that Mill is right about the degree to which the vote of the better educated better tracks political truth, why not simply disenfranchise the uneducated? After all, on Mill’s assumptions, the policies that would be selected by the intellectual elite would make everyone better off, including those who are disallowed in virtue of their lesser level of educational attainment from voting.

The answer of course, is that, even if we grant for the sake of argument that Mill’s empirical assumption is correct, voting should not be viewed as a purely instrumental good, the distribution of which is solely to be determined by its impact on the realization of other social goods, even of important social goods such as health. Voting is one of the most important dimensions of citizenship, and so there is a strong normative pull toward the equal distribution of the right to vote. The condemnation that Mill’s position now universally draws shows just how strong the importance of the equal distribution of the right to vote is, independently of the impact that that distribution might have on social policy objectives.

The pull toward equality might be more moderate in the case of other social goods. Take the case of housing. Equality in housing may not be a requirement of citizens being able to regard themselves as equal to the same degree as equal voting rights is. Nonetheless, independently of the very great instrumental values served by housing, it is arguable that equality of status within a society is incompatible with inequalities in the material conditions in which people live rising beyond a certain level (Hohmann, 2013).

Thus, the values and meanings attached to various social goods must be taken into account when determining how to distribute a good, alongside the causal consequences that different distributions might yield. What’s more, these values and meanings are themselves plural. While I have discussed a well-known illustrative example in which equality is the operative value, other goods engage quite different values. To advert once again to the example of housing: while the way in which people are housed can have an impact on the attainment of certain kinds of desirable outcomes (for example, many urban theorists have argued that ‘densification’ of the kind that is to be found in urban centers such as Manhattan is much more efficient from the point of view of resource efficiency than is the sprawl that has come to characterize many North American urban regions), housing has also come to be associated in a very deep way with self-expression. Attending to the legitimacy of people’s desire to express part of their ‘conceptions of the good’ through their homes imposes a limit on the degree to which the regulation of housing can be governed exclusively by a concern with resource efficiency.

A second way in which the health-centered consequentialism of SDH is tempered within a pluralistic theory of justice becomes apparent when we focus on the instrumental dimensions of social goods. The central claim made by SDH theorists, which is that health outcomes are powerfully influenced by the way in which a multiplicity of such goods are distributed, can indeed be made on behalf of other kinds of outcomes as well.

Take the case of education. A case very similar to that made by SDH theorists can be made with respect to the kinds of states that educational institutions aim at. Schools, daycares and universities all aim to provide citizens with a certain range of cognitive contents, but beyond that, they also aim to instill a number of cognitive skills. The argument might be made that explicitly educational institutions only contribute a part of these contents and skills. Other institutions – families, a thriving, free press, bookstores and libraries, public broadcasting, publicly funded arts and so on) – all contribute to the attainment of these educational objectives. There are, in other words, social determinants of education (where education is construed as the state of being educated, rather than as being limited to specifically educational institutions).Footnote 11 Similar analyses could doubtless be provided for outcomes related to security, to subjective well-being and the like.

If something like this is true, not only must we attend in figuring out how to distribute various goods to the values that they embody, but also to the plurality of kinds of outcomes that are causally connected to them.

Conclusion

The limited purpose of this article was to show that the (at times) excessive claims of SDH theorists must be disciplined by being integrated pluralistically into a holistic theory of justice. I have, given these limited aims, said nothing about the way in which the holistic requirement is to be achieved by such a pluralistic theory. I will conclude with a few necessarily programmatic remarks on this large issue.

Taking seriously the pluralism that I have argued for means giving up the hope that any meta-value will allow us to adjudicate between different ways of integrating the various values that are relevant to the elaboration of a complete theory of distributive justice. In the absence of such a purely theoretical tool to effect the reconciliation among the various relevant normative considerations, the option is, as it were, to ‘go procedural’, that is, to define appropriate deliberative and decision-making institutions to choose between various ways of effecting the required holistic integration (Daniels et al, 2004, pp. 82–83; Powers and Faden, 2006, pp. 182–184).

I have argued elsewhere that theories of democratic proceduralism must take a political turn similar to the one I have argued for in the case of theories of distributive justice. That is, they must to the greatest degree possible attempt to define ways in which actually existing democratic institutions might be made to instantiate relevant political values. Indeed, abstraction of the kind that I have identified in the case of theories of distributive justice also bedevils contemporary democratic theories. If a Martian were to attempt to understand the democratic life of humans on the basis of the writings of modern democratic theorists, he would not find anything out about elections, and electoral systems, political parties, political platforms and the like.

In other work,Footnote 12 I have argued that we should think of political platforms as different ways of articulating the distribution of the full range of social goods, in the light of the relevant normative considerations. Deliberation that takes place within political parties in the formation of policy platforms, and among political parties during electoral campaigns, should focus on the advantages and disadvantages of these platforms. Democratic theory should focus on ways of organizing the electoral system, the conduct of policy conventions and of electoral campaigns and on broader aspects of social organization (such as the regulation of media) so as to embody the relevant procedural values. It should ask what the best way of organizing and regulating these institutions so as to ensure that all relevant voices are heard and given proper weight in the elaboration and selection of platforms, as understood here. But that, as the saying goes, is a topic that must be taken up elsewhere.