Ethics and Spheres of Influence in Addressing Social Determinants of Health
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Center for Bioethics and Humanities and Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus Aurora, CO, USA; 2GoogleMountain View, CA, USA; 3Division of Palliative Medicine, Department of Medicine, University of California—San FranciscoSan Francisco, CA, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-05973-1 © Society of General Internal Medicine 2020
massive and ever-growing body of research supports the A idea that the social conditions into which individuals are born, live, work, and play—i.e., the social determinants of health (SDOH)—profoundly affect the health of all people. Spurred on by this recognition, as well as recent payment models that reward value (i.e., health outcomes and costs) rather than volume, there has been a major push to integrate upstream social care into the delivery of health care.1, 2 Clinics have started food banks, hospitals and insurers are investing in housing, and health systems are hiring preferentially from their local communities, among other activities. Efforts to address SDOH show promise for improving health and health equity and for enhancing the well-being of health care professionals, who find meaning and fulfillment in knowing and addressing patients’ underlying social needs more directly. Even when motivated by moral impulse, activities aimed at SDOH raise particular ethical issues. Existing scholarship has implicitly assumed that addressing SDOH is just the right thing to do, emphasized the need to manage unintended consequences, and asked whether SDOH screening should be targeted or universal.3, 4 Here, we expand this ethical discourse by applying the concept of “spheres of influence” to explore the ethical principles that should shape how clinicians, health care organizations, and the broader community address SDOH.
SPHERES OF INFLUENCE
“Spheres of influence,” as a technical concept, originated in international relations. It refers to the degree of influence one country has over another militarily, politically, economically, Received April 20, 2020 Accepted June 10, 2020
etc. Countries are able to exert more influence on some countries (e.g., those with whom they share borders) than others (e.g., those with whom they have few political or economic ties). Spheres of influence can be both descriptive in identifying where influence does occur and prescriptive in identifying where influence should occur. More recently, “spheres of influence” has gained traction in other contexts. For example, the United Nations used spheres of influence in describing companies’ roles and obligations related to human rights.5 While disagreement exists about just how far spheres extend, it is uncontroversial that individuals and institutions have core spheres—i.e., domains where their influence is most evident, meaning where they have the greatest responsibility. From the standpoint of ethics, core spheres should align with individuals’ and institutions’ primary ethical commitments. Regarding SDOH, core spheres offer practical et
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