When I saw this article and title I was intrigued. This could be very political, and this is in JAMA? Well, it is political, but isn’t everything? Don Berwick is the author; I met him over 20 years ago. He started the organization Institute for Healthcare Improvement (IHI). He popularized Continuous Quality Improvement and the omnipresent PDSA (Plan Do Study Act) programs. He has been sounding the alarm on the plague of iatrogenic harm and death patients experience from the health system, which is now estimated to be several 100,000 deaths a year. Now he is turning his attention to not just what we do within the healthcare system but what we are and are not doing out in our community.

“The source of what the philosopher Immanuel Kant called “the moral law within” may be mysterious, but its role in the social order is not.”

We talk about Social Determinants of Health a lot now. Calling them a nebulous term like “Social” diffuses responsibility. But Moral Determinants. That makes me sit up and take notice. Let’s take, for example, inadequate and unsafe housing. It is crowded, there is poor ventilation, or perhaps no protection from the cold or oppressive heat, for those who live in a hot climate. One would not choose to live there if there was an alternative. One knows that many children raised in these homes will develop asthma, and inadequate housing is a likely contributor to the increased risk of COVID-19 infection and morbidity in our less affluent communities. It is impossible to self-isolate and quarantine safely in such conditions.

As a society, we have made a moral decision to pay a minimum wage of less than $10, and housing options are limited because of discrimination based on race and ethnicity. No one chooses to live in a slum but “slumlords” like Jared Kushner benefit from this arrangement.

John Rawls is the most important Moral Philosopher of the 20th century. He was interested in Justice and ultimately defined Justice of Fairness. His famous thought experiment was the “Veil of Ignorance” All of the citizens gathered to decide the rules of the society. They did not know what their gender, race, intellectual and emotional capacity, or wealth would be. They knew that most will be OK, but many, through no fault of their own, would at some time during their lives need to call on fellows’ citizens and society for help and support. Would citizens choose for some in their society to be desperately poor, abused and discriminated against because of their race or gender, or murdered knowing that they, when entering society themselves, may be black, poor, undocumented, a woman, or George Floyd?

We would not design an unfair society that is unfair to us and our family.

I grew up in a poor family that made ends meet with substance farming supplemented with hunting and fishing. I now have all the privileges of being a white, male doctor with the financial security that comes with that, but I know in my head that my life could have had a very different outcome.

I will always now talk about Moral Determinants of Health and ask us all to reflect on what John Rawls can teach us about Fairness.

Donald Berwick MD,

The Moral Determinants of Health https://ja.ma/37oTbQV