The County Health Rankings paint a granular picture of morbidity and mortality in more than 3,000 U.S. counties. By ranking counties within each state, these data depict inequalities in health at the regional level; by framing these variations in terms of geography and social determinants, these data implicate broad social structures in health and disease; and by specifying health in terms of preventable morbidity and premature mortality, these data describe an important human good. In these ways, the County Health Rankings make vivid an important moral question: Are these inequalities in health ethically acceptable?
The County Health Rankings have brought this question home for hundreds of U.S. communities, many of which are making collective decisions to do better. But, the rankings and the moral questions they raise also are useful in other educational contexts. I have used them as a case study for the health policy ethics curriculum of the Kansas Legislative Health Academy, a program that convenes legislators from across the political spectrum to engage in constructive dialogue and innovative learning about system dynamics of health policy, ethics of health policy, and civic leadership. Created in 2009 by the Kansas Health Institute (KHI), Kansas Health Foundation, and Kansas Leadership Center, the Health Academy seeks to expose legislators to new ways of thinking through and engaging one another in the challenges of making health policy.
Those challenges include the value-laden nature of health policy. Public policy is based, implicitly or explicitly, on ethical considerations, as are the rules and procedures that guide legislators’ policy debates and decision-making (i, ii). The controversy that often surrounds health policy reflects disagreements not only over facts but also underlying ethical values. Like most people, legislators are not practiced at making explicit the ethical premises that inform, often implicitly, their policy preferences. With this in mind, the ethics curriculum sought to help legislators:
- Identify the normative dimensions of health policy content and process;
- Illuminate a plurality of values and principles pertinent to health policy; and
- Frame policy disagreements as opportunities for reasoned and respectful engagement and debate.
To achieve these objectives, case studies and hands-on exercises were developed to shape and motivate small and whole group discussions. The Kansas County Health Rankings are used as one of these exercises. First, Academy participants are asked to locate their county on a Kansas map that displays the health rank of each county and to discuss a series of open-ended questions to elicit observations and concerns. The presupposition is that these observations will include ethical considerations, which has proven to be the case. This content generates discussion to illustrate and introduce basic concepts: (1) ethics, (2) ethics in the context of health policy; (3) policy values, i.e., norms that guide the content of policy; and (4) process values, i.e., norms that guide the process of policy making; and “morally serious persons,” (i) the idea that others take their values as seriously as we take our own. Second, participants are placed in one of two small groups, one representing the county with the worst health, the other with the best. Academy participants are placed in the group least like the counties they represent and are asked to discuss a series of questions that aim to draw out their moral views about health, inequalities in health, as well as to cultivate the ‘moral imagination,’ i.e., their capacity to reflect and reason from a position other than their own.
Whether the Health Academy will have a long-term impact on policy making in Kansas is not yet known. But, in an era when political and public discourse seems more entrenched and polarized than ever, all efforts to cultivate habits of reasoned and respectful discourse and the capacity to think from a position other than one’s own seem worthy of continued study and investment.
i. Kenny N, Giacomini M. Wanted: A new ethics field for health policy analysis. Health Care Analysis 2005;13(4).
ii. Churchill L.R. What ethics can contribute to health policy. In Ethical Dimensions of Health Policy, eds. Danis M., Clancey C., Churchill L.R. (New York: Oxford University Press 2002).