Journal of Medical Ethics and History of Medicine
Original Article
Analyzing the politico-moral foundations of the Iran’s health system based
on theories of justice
Forouzan Akrami
1
, Mahmoud Abbasi
2
, Abbas Karimi
3
, Akbar Shahrivari
4
, Reza Majdzadeh
5
,
Alireza Zali
6
*
1
PhD by Research Candidate, Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences,
Tehran, Iran.
2
Associate Professor, Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
3
Professor, Faculty of Law and Political Science, University of Tehran, Tehran, Iran.
4
Pharm D, Medical Ethics and Law Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
5
Professor, Community Based Participatory Research Center and Knowledge Utilization Research Center, Tehran University of
Medical Sciences, Tehran, Iran.
6
Professor, Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence, Shahid Beheshti
University of Medical Sciences, Tehran, Iran.
Corresponding Author: Alireza Zali
Address: Tajrish, Functional Neurosurgery Research Center, Shohada Tajrish Neurosurgical Center of Excellence,
Shahid Beheshti University of Medical Sciences, Tehran, Iran.
Email: dr_alirezazali@yahoo.com
Tel/ Fax: + 98 21 22724214
Received: 09 Sep 2016
Accepted: 12 Mar 2017
Published: 08 Apr 2017
J Med Ethics Hist Med, 2017, 10:4
© 2017 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences. All rights reserved.
Abstract
Public health ethics is a field that covers both factual and ethical issues in health policy and science, and has positive obligations
to improve the well-being of populations and reduce social inequalities. It is obvious that various philosophies and moral
theories can differently shape the framework of public health ethics. For this reason, the present study reviewed theories of
justice in order to analyze and criticize Iran’s general health policies document, served in 14 Articles in 2014. Furthermore, it
explored egalitarianism as the dominant theory in the political philosophy of the country’s health care system. According to
recent theories of justice, however, health policies must address well-being and its basic dimensions such as health, reasoning,
autonomy, and the role of the involved agencies and social institutions in order to achieve social justice beyond distributive
justice. Moreover, policy-making in the field of health and biomedical sciences based on Islamic culture necessitates a theory of
social justice in the light of theological ethics. Educating people about their rights and duties, increasing their knowledge on
individual agency, autonomy, and the role of the government, and empowering them will help achieve social justice. It is
recommended to design and implement a strategic plan following each of these policies, based on the above-mentioned values
and in collaboration with other sectors, to clarify the procedures in every case.
Keywords: Politics, Moral philosophy, Public health, Justice, Iran
mailto:dr_alirezazali@yahoo.com
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 2 of 10
Introduction
Public health ethics (PHE) is a relatively new field of
applied ethics, and is linked to the ethical
implications of activities aimed at maintaining and
improving health among the population. PHE covers
both factual and ethical issues in health policy and
health sciences (1). Article 25 of the Universal
Declaration of Human Rights explicitly recognizes
the right to health. Article 12 of the International
Covenant on Civil and Political Rights emphasizes
that governments should recognize everyone’s right
to the highest degree of physical and mental health
that is possible within each society. Therefore,
protecting public health (PH) should be the most
important goal of governments. In most countries,
the health care system is organized at the national
level, which indicates the responsibility of the state.
However, these systems suffer from various
pathologies that affect their performance (2 , 3).
PH has affirmative obligations to improve public
well-being and reduce evident social inequalities.
Therefore, a PHE framework should not only protect
the citizens’ negative rights for not intervening, but
also emphasize their positive rights (4, 5). Several
functional frameworks have been provided by PH
professionals to facilitate policy- and decision-
making (6 - 8). Any ethical framework has a
background of moral theories or at least an ethical
approach to justify the selected moral norms, and
various moral philosophies and theories can
differently shape these structures. For example in
consequentialist theories, the policy or action that
delivers the best outcome is considered morally
right. In utilitarianism, which is one of the most
popular frameworks and is widely used in health
policy, the only value is to do the greatest good for
the greatest number. On the contrary, in
deontological theories, the agent’s acts must only
comply with moral duties.
PHE is connected to overlapping spheres of political,
social and moral philosophy. However, the health
care system mainly requires a “public philosophy”,
which would provide a moral foundation and set
limits on PH laws, policies and practices, as well as
on social institutions and organizations involved in
PH activities (9).
The primary moral justification in PH as an
institution is social justice, and the focal points of
moral necessities are the oppressed and subordinate
groups. These include people whose well-being
expectations including health are so limited that their
life choices differ from those of others; or children
whose prospects of welfare are so poor that they are
permanently locked in the systematic deprivations of
their early years (10). Will Kymilicka states:
“Political philosophy is a matter of moral argument,
and moral argument is a matter of appeal to our
considered convictions. In saying this, I am drawing
on what I take to be the everyday view of moral and
political argument, that is, we all have moral beliefs;
these beliefs can be right or wrong, we have reasons
for thinking they are either right or wrong, and these
reasons and beliefs can be organized into systematic
moral principles and theories of justice. A central
aim of political philosophy, therefore, is to evaluate
competing theories of justice to assess the strength
and coherence of their arguments for the rightness of
their views” (11).
Rajabi et al. in their study aimed to explain the
principles and values of the health system to be
utilized in Iran’s health system reform plan of 2025.
While emphasizing respect for human dignity and
protection of human prosperity, they concluded that
addressing PHE challenges necessitates new
perspectives on both individuals and the society and
the relationship between them (12).
Designing an ethical framework for health policy-
making first requires an analysis of the political
philosophy of the country's health care system, since
the approach to PH depends on the political
philosophy of each country (13). Therefore, this
study aimed to explain the political philosophy of the
health care system based on theories of justice. In
this study, after an overview of these theories, we
analyzed the general health policies (GHPs), which
have been codified by the leader of the Islamic
Republic of Iran in implementing Paragraph I of
Article 110 of the constitution after consultation with
the Expediency Council.
Method
Document analysis is a systematic approach for
reviewing or evaluating texts. Like other analytical
methods in qualitative research, document analysis
requires that data be examined and interpreted in
order to extract meaning and insight, and develop
empirical knowledge (14). In this document analysis,
The GHPs document was examined to explain the
politico-moral foundations of the health care system
based on theories of justice and to explore how the
moral values were enfolded. Additionally, for critical
discussion, Web of Science (ISI), PubMed, Embase,
and Scopus databases were purposefully searched
using the following keywords: “public health/ethics”
[MeSH Terms] OR “public policy/ethics” [MeSH
Terms] NOT “research” [MeSH Terms] AND
“philosophy/ethics” [MeSH Terms].
Theories of justice
The Libertarian Justice Theory
Influenced by philosophers like John Locke and
Robert Nozick, a libertarian theory of justice focuses
on individual freedom, and thus on our duty to
respect the freedom of others, and the duty of
governments to protect the freedom of citizens – as
their right – when they are at risk. This often means
a “minimal state” to prevent or punish breaches of
personal boundaries, including individual property
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 3 of 10
rights. In this view, health care is not a right, but
people can voluntarily choose the charitable act and
contribute in some way to distribute health care in a
community. PH can be legitimate, especially if it
focuses on protecting people against infectious
diseases; a type of boundary violation, preferably to
broader concepts of health promotion that is
characteristic of contemporary public health (15).
Libertarians do not oppose to utilitarian and
egalitarian distributive patterns, provided that they
are chosen freely. Any fair distribution can be
justified in health care coverage, if and only if
people have freely chosen it in the relevant groups.
As a result, libertarians generally support those
health care systems in which health care insurance is
private and purchased voluntarily. In such systems,
the investors have the property right in the health
care of the insured, doctors have the freedom right
and the society is not morally obligated to provide
health care. The libertarian interpretation of justice is
not based on addressing the citizens’ health needs or
the general benefit, but rather on carrying out
unrestricted fair activities (16).
The Utilitarian Justice Theory
Utilitarian theories of Justice were formed by
prominent figures such as Jeremy Bentham and John
Stuart Mill. The ground conceptions of justice in the
principle of utility require policies, actions or rules
that produce the maximum benefit. Justice, which
involves the correlation of rights and duties, is not an
independent decision, but rather a derivation of
interest. Within this framework, the duties and rights
in fair health care are the presupposition of net profit
foundation. Health care and PH can be valuable at
least to the extent that they produce net social benefit
(15).
Most of the utilitarian social programs support PH
and distribute basic health care among all citizens.
Nevertheless, rights such as health care – when
based on maximizing the ultimate good – will find a
fragile basis, because the benefits may change at any
time. For example, it seems unfair that a society
itself maximizes the ultimate good by eliminating the
access of the weakest and the sickest population.
Therefore, utilitarian principles of justice seem to
have very serious problems, but if their inclusion
scope is strictly limited, they can play a major role in
health policy-making (16).
The Communitarian Justice Theory
The communitarian justice theory arises from several
philosophical views similar to utilitarian theories and
do not assign an independent importance to
individual rights such as freedom. Thus, the
perception of health care and a just health system
depends on the community perception of health in
relation to other primary goods (15).
Communitarians have a pluralistic view on the
principle of justice, believing that they are as varied
as the diverse perceptions of good in different
societies. The duty of people with respect to justice
depends on the criteria in each community.
Communitarians emphasize both the duties of the
society towards individuals and the duties of the
individuals towards the community. Some
communitarians avoid using the language of justice
and use one of unity and integrity that includes both
the values related to individual obligations and the
principles of social ethics based on the common
beliefs of a group. Justice concepts do not rise from
the rational or natural principles outside the
community, but from criteria that are shaped
internally along with the political development of the
society. Communitarians believe that emphasis on
the community and the common good in health care
allocation policies is also evident (16). In this regard,
Daniel Callahan says that “we need to ask what can
best guide us towards a good society, rather than
whether it is harmful or whether it violates the
autonomy of the people” (17).
The Egalitarian Justice Theory
Egalitarian theories draw on old religious
perspectives that believe all human beings should be
treated as equals in certain respects because they are
created equal (16), and this makes the foundations of
human rights (18). No prevailing egalitarian theory
has been exclusive of a distributive principle based
on equal sharing of all primary goods by everyone. It
is characteristic of the dominant egalitarian theories
to identify basic equalities that allow for some
inequalities (16), and many of them recognize the
possible legitimacy of a two-layered system, with the
minimum decent layer of health care (set by the
deliberative democracy).
John Rawls’ Theory of Justice is the mildest, most
important egalitarian theory that has challenged
liberalism, utilitarianism and communitarianism.
Among those who have been influenced by John
Rawls, Norman Daniels argues that justice requires
the elimination or reduction of obstacles that prevent
fair equality of individuals’ opportunities, including
health as a moral importance, to allow people to
pursue a variety of objectives and programs of life
depending on their talents and skills. This includes
programs to compensate for the shortcomings of
people such as health deprivation. Daniels looks for
a comprehensive plan for fair health care and
investigates the role of social determinants of health
such as education, environmental and behavioral
factors, and the socioeconomic status of
communities (16, 19).
With the start of the 21
st
century, some innovative
ideas raised debates about justice in the field of
biomedical ethics. Although this article has been
formed in response to Rawls’s egalitarian theory, it
is not entirely the same in fundamental terms. It is
mainly influenced by the ethical theory of Aristotle,
especially the role and importance of human
flourishing states that rely mostly on fulfillment and
moral virtue. In the following section, some recent
theories of justice will be discussed.
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 4 of 10
The Capabilities Theory
This theory is based on the assumption that the
opportunity to reach states of proper functioning and
well-being is an object of value and moral
importance, and thus capability reflects an
individual’s autonomy in selecting one of several
alternative lives. People’s quality of life is
conditioned by what they are able to do, and a life
well lived is one in which people perform and
maintain their basic capabilities. This theory was
first proposed by Amartya Sen, and developed in
many ways related to biomedical ethics by Martha
Nussbaum. The latter explored the philosophical
concept of “frontiers of justice” to address equitable
inclusion for persons with disabilities, the poor, and
animals. The central idea is that the minimum level
of social justice entails the availability of 10 core
capabilities for all citizens (16), which means
everyone should be able to:
1) lead a normal life without encountering premature
death or a deteriorated state unworthy of living
2) have the benefit of physical health
3) enjoy bodily integrity, that is, the ability to live in
freedom and have security against violence, sexual
satisfaction and fertility choice
4) use the capacity of senses, imagination and
thought
5) enjoy emotional attachment to people and other
entities and experience a feeling of gratitude
6) apply practical reasoning and participate in
serious reflections bearing on one’s life
arrangements
7) feel organizational affiliation as the capability to
lead a meaningful life in cooperation with a
company or others
8) be free to exhibit concern or care for other species
9) play and enjoy creative activities
10) have control over one’s environment as an active
citizen
The Well-Being Theory
The capabilities theory focuses on abilities and
opportunities as prerequisites for well-being, but
more recent theories have focused on well-being
itself. In other words, freedom of action, capabilities,
the associated empowerment trainings and resources
are considered the well-being equipment (16).
Powers and Faden have formulated a framework for
bioethics in PH and health policy by providing a
non-distributive theory of justice that complements
distributive justice and goes beyond it. They believe
that questions about important inequalities can only
be answered by examining all the social
determinants that increasingly and mutually impact
human well-being. According to Powers and Faden,
justice is more than the principles of distribution (10,
16) and beyond the distributive share of each person,
and is identically connected to the nature of the
relationships between individuals. Some topics of
discussion in the area of justice both for individuals
and for groups include: concerns about social stigma,
disrespect, lack of organization and social functions
for adequate protection of existing capacities to
maintain social independence or autonomy (20).
From this perspective, the aim of justice is to ensure
an acceptable level of the six basic dimensions of
well-being, including health, reasoning, self-
determination, attachment, personal security and
respect for all (16, 21).
Citizens of countries that lack a comprehensive and
coherent system of health care finance and delivery
are unfortunately deprived of health services in spite
of spending high costs. It is the obligation of
governments to promote both utility and justice in
the society (16). For this reason, we will analyze the
general health policies (GHPs) of Iran served at the
national level based on the aforementioned theories.
Analysis and criticism of general health policies in
Iran
As the first item of the Iranian GHP, “beneficence
and service delivery based on Islamic human values,
spirituality and moral virtues and their promotion in
the community” have been emphasized. These issues
are clearly linked to social justice, and whenever
people are in the position to do good things or
impose costs, they will need justice criteria (16). In
the context of public health, justice is a core ethical
consideration, but unfortunately a theory of Islamic
justice is presently lacking.
In recent decades, significant advances have been
made in the field of primary health care, academic
education and research in Iran. Progress in
biomedical research has been accompanied by
significant activities in legislation, education and
research in the field of bioethics (22). However, the
first paragraph of the first policy highlights
“evolution” in academic environments in accordance
with Islamic values, medical ethics and professional
practice. This implies the poor desirability of the
current situation in service provision and the need to
reform the health care system based on Islamic
moral values. Moreover, the second paragraph of this
policy emphasizes the importance of educating
people about their rights and social responsibilities,
and utilization of the full capacity of health care
environments for the promotion of Islamic ethics and
spirituality in the society.
The second, fifth, and sixth policies of the GHPs
directly point to egalitarianism, equitable access and
fair distribution of health care services based on
people’s needs. These sections highlight access to
health as a social right, the responsibility of the state
to make it happen, and egalitarianism as the
dominant theory in the political philosophy of the
national health care system. For the purposes of
accountability, realization of justice, and provision
of desirable medical services, the seventh and eighth
policies specify that health resources be managed
through the health insurance system, and that
services be delivered by both public and private
sector service providers in accordance with the legal
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 5 of 10
provisions. The eighth policy further emphasizes the
significance of the principle of justice and the
importance of accountability, transparent informing,
effectiveness, efficiency and productivity in the
health care system in keeping with evidence-based
ranking and the referral system. The third paragraph
of the eighth policy concerns the protection and care
of veterans and the disabled community as
vulnerable members of the society, and concentrates
on empowerment and the promotion of health among
them.
The third policy focuses on the importance of a
healthy lifestyle, and the twelfth policy pertains to
healthy nutrition based on traditional Iranian
medicine, while the fourth policy is dedicated
exclusively to the quality and efficiency of services.
The eleventh policy is related to “raising awareness,
responsibility, empowerment, and active and
structured participation of the individual, family and
community to provide, maintain and improve health
by using the capacity of institutions and cultural,
educational and media organizations under the
supervision of the Ministry of Health and Medical
Education”. It is obvious that this is a move aimed at
achieving social justice, and therefore cannot be
placed under the supervision of the Ministry of
Health and Medical education alone.
The ninth policy discusses measures including: fair
distribution through qualitative and quantitative
development of health insurance and its delivery to
the public; complete coverage of the basic treatment
needs of the people by providing insurance to the
whole of the society and reducing the share of the
insured in medical costs; and providing services
beyond basic insurance through complementary
private coverage within the framework of legal and
transparent stipulations with an emphasis on high
quality basic health services. Moreover, paragraph 7
of the ninth policy proposes a number of
supplemental mechanisms to ensure public health,
for instance reforming the performance-based
payment system, raising efficiency, creating fair
income and positive motives for service providers,
and special attention to health promotion and
preventive activities in deprived areas. One problem
associated with health related goods and services
concerns determination of the precise limits of the
right to health. An approach in this respect is equal
access to health resources. From a minimalistic
standpoint, this means public access to health care,
which is in accordance with the idea of some
libertarians regarding the right to public resources,
although this view is untenable by the justice
theories previously mentioned. For this reason,
current prominent liberal societies have created
significant progress in solving the challenges facing
their health care system in connection with the
access, affordability and quality of care. As an
instance, the United States approved the Act of
Affordable Care (ACA), and since its adoption, the
total rate of the uninsured has decreased by 43%,
from 16% in 2010 to 9.1% in 2015 (23). Therefore,
the aim of moderate egalitarianism may be defined
as the right to minimum, decent health care, that is,
public access to basic health care and related
resources. The standard concept, however, requires a
two-layered system as follows (16):
1. Compulsory social coverage for basic health
needs and common mishaps
2. Voluntary private coverage for other health needs
and demands
The first layer addresses health needs through public
access to basic services. This model of a pure
protection to all indicates that social requirements
can be limited, which necessitates the definition of
basic and secondary health needs based on the social
norms in each society (19).
The tenth policy pertains to “sustainable financing in
the health sector” and indicates the prioritization of
public health by the state. The third paragraph of this
policy discusses “imposing taxes on products and
materials, as well as punishments on harmful health
services”, which refers to the important role of PH
law in its implementation and continuation.
Moreover, the fourth paragraph covers “paying
subsidies to the health sector, targeting health
subsidies and treatments aiming at justice and the
promotion of health particularly in deprived areas,
and providing dedicated help to poor people and
lower income groups”. This latter point clearly
emphasizes the fairness of needs-based distribution
and fair financial contribution.
The thirteenth and fourteenth policies imply the
importance of the educational aspect of medical
sciences in providing efficient local and national
human resources in order to improve the overall
health of the population (24). These policies also
stress the strategic development of medical research
with an innovation and planning system approach to
achieve excellence in science, technology, and
provision of medical services in the region and
throughout the Islamic world, in accordance with the
country’s 20-year vision document and to
complement the previous policies.
Discussion
To a large extent, the principles of egalitarian justice,
respect for everyone and treating all people as equals
comply with the fair procedures doctrine in the
distribution of primary goods and not only health
care. In the second policy, reference to “realization
of a comprehensive approach to health and a healthy
society in all legislation and executive policies” is
consistent with the approach to health in all polices.
The implementation of this approach enables the
state to establish an integrated act in response to the
health needs and well-being of the people. This,
together with the ultimate goal of reducing health
inequalities, considers the effects of other policies
and laws on health through the social determinants
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 6 of 10
of health (25), and will be realized when health-
based laws and policies are designed, planned and
implemented in all areas (26).
No dominant egalitarian theory that consists of a
distributive principle has been based on equal
sharing of all primary goods by everyone. According
to Daniels, allocation of health care resources should
provide justice through fair equality of opportunities.
This inspiring theory of Rawls has broad
implications in national policies of health care.
Based on this theory, each member of the society
should have enough access – not necessarily
maximum access – to a level of health care
regardless of their assets and positions. The exact
level of access depends on the available social
resources and public processes for decision-making.
Daniels believes that the social institutions
influencing the distribution of health care should be
coordinated so as to allow each person to receive a
fair share of the normal range of the opportunities
available in the community to pursue the objectives
and plans of his or her life (16, 19).
According to the theories of “Moral Desert”, people
get what they deserve: good people are rewarded and
bad people are penalized (27). From the perspective
of defenders of luck egalitarianism, paying higher
premiums or taxes by people who have healthier
choices is not fair when others may have had morally
irresponsible behaviors (28, 29). They believe that
discussions on social factors affecting health are
untenable. Such reasoning is applied to health
services in relation to crimes or bans on the access of
individuals or groups who choose unhealthy
lifestyles. Nevertheless, there are reasons for
unhealthy behavior that are not mere choices (30).
Differences in choices and lifestyles can be caused
by social conditions and inequalities (31). Some
characteristics are the consequence of the natural and
social lottery, and many people do not have a fair
chance to obtain or change them; hence, they cannot
be a morally acceptable basis for discrimination in
allocation of social resources. Accordingly, people
with disabilities should receive a higher level of
health care to have a fair chance in life. They may
not be entitled to health care services if they are
responsible for their disability, but if they are not, the
principle of fair opportunity requires that they
receive services that help them to compensate for the
negative effects of lotteries (16).
In proposing such an approach, Sen has presented an
explicit critique of Rawls’ “fair equality of
opportunity”, arguing that such opportunities are
brutal stories, since many options are the outcome of
poverty, low literacy, racism, and other similar
events that are determined at birth. He argues that
the primary and main concern of justice must be
something that people are really able to achieve, a
situation that Amartya Sen calls “substantive
freedom”. In the view of Sen, this includes “the
ability of a person to do good actions and reach
valuable states of being” (32). If people’s abilities
are restricted by the circumstances or a range of
limited conditions, the society cannot be considered
a just one (33). In this view, injustice can be
evaluated by the current practices and policies of
major social institutions within the community. Such
practices enable certain social groups to develop
capabilities necessary to obtain a decent and
reasonable life, find work or other living
arrangements to support their family, and be
employed in projects, activities and valuable social
relationships.
There are occasional conflicts between public
interests and autonomy in policy debates of public
health that can be resolved by concentrating on the
difference between freedom and autonomy. The
debates on the potential violation of the principle of
autonomy need to refocus on the issue of whether
people can make meaningful choices about what
they can do in their lives. People may be free to buy
a large bottle of carbonated drink, but we cannot be
dragged into talking about this deviated way of
respecting autonomy, nor should we think that
making the purchase of extra-large harmful products
difficult is an important step in improving the lives
of people and creating a just society (34).
Although there is not a single theory of justice that is
unanimously accepted, “social justice” is a common
term in the field of public health these days (35). The
recent theories of justice state that having freedom to
choose healthy behavior is not enough, and the
ability of individuals to reason and their autonomy to
make healthy choices must be developed (16, 21).
David R. Buchanan argues that improving public
health is better achievable by expanding people’s
autonomy through promoting the concept of justice,
which is the definition of human progress.
According to recent theories of justice, the most
important issue in PH is not limiting the autonomy of
individuals, for example by restricting the access of
minorities and the poor to fast food or sugary,
carbonated drinks in the hope of their weight loss,
but rather the promotion of autonomy among
community members. In other words, autonomy is a
core value in a just society in which conditions for
fostering the abilities of reasoning and decision-
making are provided (34). Schröder-Bäck et al.
analyzed the health strategy of European Union (EU)
via its ethical scope and considered implications for
future health policy-making. Their study showed that
the health strategy of European Union is barely
documented and discussed in scientific literature,
and that no specific attention has been given to its
value base. Their analysis showed that the mentioned
values are particularly focused on health care in
general rather than on PH in particular. They also
concluded a theory of well-being is needed on a
more general level for effective policy-making.
Therefore, a moral theory is required to explain this
and the place of health values in a comprehensive
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 7 of 10
and coherent policy approach (36).
Although the capabilities theory highlights the
important considerations in the analysis of the
relationship between agency and structure, according
to the theory of well-being, the aim of justice should
be to ensure an adequate level of basic welfare,
including health, reasoning and autonomy for every
person, and not only the capabilities and means to
achieve it. In this doctrine the origin of value or
obligation is not merely individual choices or
exercising one’s intellectual capacity for choosing,
but the process of “creativity through choosing”
which is integrated in autonomy is considered a part
of well-being. PH professionals need to pay attention
to much stronger fields, both moral and practical, in
advocating for health policies and programs rather
than creating bans (34).
A healthy lifestyle is influenced by both individual
agency and social determinants of health, including
structural factors and living conditions (31).
Recently, personalism has been proposed firstly in
regard to human dignity and secondly because of the
agency of individuals as social beings who construct
the collective good through solidarity, and as the
philosophical core of the health care system (2). The
concept of lifestyle-related diseases and individual
responsibilities for/toward health plays an important
role in discussions about fair allocation of scarce
health resources. Looking into this issue from the
perspective of solidarity emerged as a value in the
context of a Solidarity Project in Bioethics by
Nuffield Council in 2011. Barbara Prainsack has
analyzed the most important arguments in favor of
using lifestyle choices as a benchmark in solidarity-
based health policy-making to prioritize and classify
access to health care services (30, 37, 38). Still,
arguments about crimes or prohibitions on the access
of individuals or groups that choose unhealthy
lifestyles are provided in treatment services.
Nevertheless, there are different unhealthy behaviors
that might not be restricted to “mere choice”, so
access to PH based on lifestyle choices is not an
exclusively moral issue, and despite the arguments
presented to this effect, unhealthy behavior is not a
breach of solidarity in itself (30).
Recent studies have explained the role of moral
virtues in PH (39 - 41). They demonstrate that for the
past several decades, the concept of “structure” in
moral theology has almost exclusively focused on
the structure of the society with regard to the need to
change. The structures that have continued unfair
positions and created systematic barriers for human
development are classified as “structures of sin” and
have therefore been the object of social and
theological criticism. PH professionals and health
policy-makers are attempting to create new
structures (i.e. law, policy and environment) that
have a positive impact on the lives of individuals and
communities. Such social structures are formed by
individual characteristics and virtues as units of
fundamental value that form each person’s habits
and behaviors. According to Michael D. Rozier,
“structure is only one part of a larger system of our
behavior” (40). We have the disposition rooted in
our personality and we want to cultivate it. We
identify the habitual behaviors that are
transformative, and adopt social norms that
encourage the behavior. Therefore, we build the
social structures that promote social norms and
virtues. In this manner, the internalized virtues of
moral agents continue to spread across the
community and finally to structures that shape the
society and agents (40).
The constitution determines the special powers of the
federal government and limits its authority to protect
freedom (42). In other words, the constitution of a
country provides a framework for the localization of
global treaties including the International
Declaration of Human Rights. Although the state has
the authority to act for the common good, it should
also apply the internal power of the limits imposed
by the constitution (21). The Charter of Fundamental
Rights of the European Union has been developed in
accordance with the common commitments between
international and national laws of the European
Union in line with the citizen’s rights of member
states, including the right to health care (43). In Iran,
the constitution, the 20-year vision document, and
the comprehensive scientific map of health are
among the reference documents that have presented
the guidelines for involved institutions.
The first step towards awareness of a law that can
change people’s lives is legal literacy. Legal literacy
programs educate community members, patients and
health care providers about their national and local
laws and their rights, and this knowledge enables
them to utilize these rights and seek support for
specific health needs. Some objectives of such
programs include: increasing awareness and capacity
building, training educators, education and
community empowerment, and encouraging law
students to work for social justice and solidarity (44).
These goals are all considered as moral norms in PH
and health policy-making (45).
Conclusion
Given the centrality of the principle of justice in
public health, in this study we analyzed GHPs issued
at the national level in terms of the theory of justice.
The findings point to egalitarianism as the dominant
theory in political philosophy in the country’s health
care system.
The first policy on the list focuses on beneficence
and providing health services based on
humanistic/Islamic culture and values and their
institutionalization in the community without
mentioning the fair procedures. Although decision-
and policy-making in the field of bioethics has no
justification in Muslim societies without paying
attention to the Islamic culture, justice principles are
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 8 of 10
required in providing goods. The second, fifth, and
sixth policies of the 14-item list of GHPs directly
point to egalitarianism, equitable access of people
and fair distribution of health care services based on
need. Nevertheless, since “social justice” adequately
supplies well-being dimensions including health
beyond distributive justice, the distinct areas of
justice are rejected. It is possible, however, to talk
about justice in the PH and health policy-making
without referring to the construction of other public
policies and social structures. These policies must
therefore address something beyond well-being and
its basic dimensions such as health, reasoning and
autonomy, or the role of agencies and involved
social institutions in order to achieve social justice.
Making people aware about their rights and
responsibilities, as well as increasing their
knowledge and empowerment, implies the role of
individuals’ agency and autonomy in choosing their
lifestyle, in addition to the role of governments in
achieving social justice. Finally, for the
institutionalization of humanistic/Islamic values in
the community, public health structures should aim
to promote healthy behaviors. Moreover, for the
purpose of policy-making in the field of health and
biomedical sciences in Islamic communities based
on Islamic culture, a theory of social justice in the
light of theological ethics is essential.
Community participation requires transparency,
commitment and responsiveness of health care
providers, and solidarity is a core value based on
moral responsibility and virtues that support and
sustain PH policies, programs and interventions.
Therefore, it is recommended to design and
implement a strategic “how to” plan following each
of these policies based on the above-mentioned
values and in collaboration with other sectors.
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 9 of 10
References
1. Dawson A. Public Health Ethics. USA: Cambridge University Press; 2011.
2. Bielecki A, Nieszporska S. The proposal of philosophical basis of the health care system. Med Health Care Philos. 2017;
20(1):1-13.
3. Bielecki A, Stocki R. Systems theory approach to the health care organization on national level. Cybern Syst
2010;41(7):489-507.
4. Jonsen A, Seigler M, WinsladeWJ. Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine. New
York: Macmillan; 1982.
5. McCullough LB, Ashton CM. A methodology for teaching ethics in the clinical setting: a clinical handbook for medical
ethics. Theor Med. 1994;15(1):39-52.
6. Kass NE. An ethics framework for public health. Am J Public Health. 2001;91(11):1776-82.
7. Marckmann G, Schmidt H, Sofaer N, Strech D. Putting public health ethics into practice: a systematic framework. Front
Public Health. 2015;3:23.
8. Ten Have M, van der Heide A, Mackenbach JP, de Beaufort ID. An ethical framework for the prevention of overweight
and obesity: a tool for thinking through a programme’s ethical aspects. Eur J Public Health. 2013;23(2):299-305.
9. Childress J, Bernheim R. Introduction: a framework for public health ethics. In: Bernheim R, Childress J, Melnick A,
Bonnie R, eds. Essentials of Public Health Ethics. USA: Jones & Bartlett Publishers; 2015, p. 1-20.
10. Powers M, Faden R, Saghai Y. Liberty, Mill and the framework of public health ethics. Public Health Ethics.
2012;5(1):6-15.
11. Kymlicka W. Contemporary Political Philosophy: An Introduction. USA: Oxford University Press; 2002.
12. Rajabi F, Esmailzadeh H, Rostamigooran N, Majdzadeh R. What must be the pillars of Iran's health system in 2025?
Values and principles of health system reform plan. Iran J Public Health. 2013;42(2):197-205.
13. Huster S, Schramme T. Expanding the normative framework of public health ethics: Some results from an
interdisciplinary research group. Public Health Ethics. 2014;8(1):4-6.
14. Strauss A, Corbin JM. Basics of Qualitative Research: Techniques and procedures for developing grounded theory.
California:Sage publications;1998.
15. Childress JF. Moral considerations: bases and limits for public health interventions. In: Bernheim R, Childress JF,
Melnick A, Bonnie R, eds. Essentials of Public Health Ethics. USA: Jones & Bartlett Learning, LLC, an Ascend
Learning Company; 2015, p. 21-43.
16. Beauchamp T, Childress J. Principles of Biomedical Ethics. USA: Oxford University Press; 2013.
17. Callahan D. Autonomy: a moral good, not a moral obsession. Hastings Cent Rep. 1984;14(5):40-2.
18. Annas GJ, Mariner WK. (Public) health and human rights in practice. J Health Polit Policy Law. 2016;41(1):129-39.
19. Daniels N. Just Health: Meeting Health Needs Fairly. USA: Cambridge University Press; 2008.
20. Faden R, Kass NE, Powers M. AIDS, Women and the Next Generation: Towards a Morally Acceptable Public Policy for
HIV Testing of Pregnant Women and Newborns. New York: Oxford University Press; 1991.
21. Powers M, Faden RR. Social Justice: the moral foundations of public health and health policy. USA: Oxford University
Press; 2006.
22. Larijani B, Zahedi F. Health promotion, Islamic ethics and law in Iran. JMed Ethics Hist Med. 2006(Suppl. 1):7-9.
23. Cohen RA, Martinez ME. Health Insurance Coverage, Early Release of Estimates from the National Health Interview
Survey, 2011. www.cdc.gov/nchs/data/nhis/earlyrelease/insur201112.pdf (accessed on: 2011)
24. Research and Development Committee. Packages of Revoluton and Innovation in Medical Education. Iran: Deputy of
Medical Education, MOHME; 2016. [in Persian]
25. Ollila E, Ståhl T, Wismar M, Lahtinen E, Melkas T, Leppo K. Health in All Policies in the European Union and its
Member States. http://ec.europa.eu/health/ph_projects/2005/action1/docs/2005_1_18_frep_a4_en.pdf. (accessed on:
2006)
26. Maruzzi M. Environment and Health: perspectives from the intersectoral experience in euroup. Health in All Policies:
Prospects and Potentials. Helsinki, Finland: Ministry of Social Affairs and Health.
https://extranet.who.int/isacs/case/1102. (accessed on: 2006)
27. Kekes J. Justice: A conservative view. Soc Phil Pol. 2006;23(2):88.
28. Buchanan DR. Should people with unhealthy lifestyles pay higher health insurance premiums? J prim prev.
2011;32(1):17-21.
29. Wikler D. Personal and social responsibility for health. Ethics int affairs. 2002;16(02):47-55.
30. Prainsack B. Justice & Solidarity in Priority Setting in Health care: Taking solidarity seriously – can it help? Brussels
joint initiative of the King Baudouin Foundation and the Belgian Advisory Committee on Bioethics. https://www.kbs-
frb.be/.../Justice-and-solidarity-in-priority-setting-in-health. (accessed on: 2013)
31. Cockerham WC. Health lifestyle theory and the convergence of agency and structure. J Health Soc Behav.
2005;46(1):51-67.
32. Sen AK. The Idea of Justice. USA: Harvard University Press; 2009.
33. Sen Ak. Inequality Reexamined. MA: Harvard University Press; 1992.
34. Buchanan DR. Promoting justice and autonomy in public policies to reduce the health consequences of obesity. Kennedy
Inst Ethics J. 2015;25(4):395-417.
35. Hofrichter R. Health and Social Justice: Politics, Ideology, and Inequity in the Distribution of Disease. San Francisco:
Wiley; 2003.
J Med Ethics Hist Med 10: 4, April, 2017 jmehm.tums.ac.ir Forouzan Akrami et al.
Page 10 of 10
36. Schröder-Bäck P, Clemens T, Michelsen K, Sørensen K, Borrett G, Brand H. Public health ethical perspectives on the
values of the European Commission's White Paper:" Together for Health". Cent Eur J Public Health. 2012;20(2):95.
37. Have HAT, Gordijn B. Bioethics in a European Perspective. Netherlands: Springer; 2013.
38. Hoedemaekers R, Dekkers W. Justice and solidarity in priority setting in health care. Health Care Anal. 2003;11(4):325-
43.
39. Rogers WA. Virtue ethics and public health: a practice-based analysis. Monash bioeth rev. 2004;23(1):10-21.
40. Rozier MD. Structures of virtue as a framework for public health ethics. Public Health Ethics. 2016;9(1):37-45.
41. Karen M, Meagher B. Considering virtue: public health and clinical ethics. J Eval Clin Pract. 2011;17(5):888-93.
42. Gostin LO. Mapping the Issues: Public Health, Law and Ethics. http://scholarship.law.georgetown.edu/facpub/374.
(accessed on: 2010)
43. Den Exter A. International Health Law and Ethics: Basic Documents. Netherlands: Maklu Pub; 2015.
44. The Joint United Nations Programme on HIV/AIDS(UNAIDS). Key programmes to reduce stigma and discrimination
and increase access to justice in national HIV responses.
http://www.unaids.org/sites/default/files/media_asset/Key_Human_Rights_Programmes_en_May2012_0.pdf. (accessed
on: 2012)
45. Den Exter A. International Health Law: Solidarity and Justice in Health Care. Netherlands: Maklu Pub; 2008.