Journal of Manipulative and Physiological Therapeutics
Volume 33, Issue 6 , Pages 407-411, July 2010

Chiropractic and Social Justice: A View From the Perspective of Beauchamp's Principles

  • Bart N. Green, DC, MSEd

      Affiliations

    • Associate Editor, Journal of Manipulative and Physiological Therapeutics, and Faculty Member, National University of Health Sciences, Lombard, Ill
    • Corresponding Author InformationSubmit requests for reprints to: Bart N. Green, DC, MSEd, Associate Editor, National University of Health Sciences, 200 E. Roosevelt Rd, Lombard, IL 60148.
    • ,
  • Claire Johnson, DC, MSEd

      Affiliations

    • Editor, Journal of Manipulative and Physiological Therapeutics, and Professor, National University of Health Sciences, Lombard, Ill

Article Outline

Abstract 

Social justice in public health involves the process and product of a community acting to fairly distribute advantages and burdens to improve the health of its population and to reasonably take care of the disadvantaged. Although publications are available about chiropractic public health history, programs, and policy, the potential role of chiropractic in social justice has received little attention. This article discusses Beauchamp's 4 principles of social justice and suggests actions that the chiropractic profession may consider to participate in the practice of social justice in the field of public health.

 

Clinical care focuses on the health needs of individuals, whereas public health deals with understanding the health of the population; public health emphasizes preventing disability and disease and promoting health.1 In the process of providing better population health, various factors of the population, known as determinants of health, are examined and how the burdens of disease, disability, or disadvantage can be better distributed among the members of the population are considered.2 The involvement of chiropractic in public health is a relatively recent phenomenon.3 Members of the chiropractic profession have become participants in the field of public health by involving themselves in community-based activities and becoming active members of organizations, such as the American Public Health Association's Chiropractic Health Care section.4 With a refreshing new perspective, several members of the chiropractic profession have recently written articles,5, 6, 7, 8, 9 authored book chapters,10 or given presentations at professional meetings about the involvement of chiropractors in looking out for the community and the health of the public. With such momentum, perhaps now the time is right to take the next step and reflect upon what the profession may be doing and may consider doing to contribute to social justice and the field of public health.

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What Is Social Justice? 

If we are to understand how a profession participates in social justice, a working definition of social justice is necessary. One challenge is that the term social justice is often not defined or poorly defined by authors,11 making it exceedingly difficult to address the concept. It is further complicated when various authors in discourse about social justice do not agree whether health or health care is the principle target.12 For this article, we define social justice as the process and product of a community acting to fairly distribute advantages and burdens to improve the health of its population and to reasonably take care of the disadvantaged.11, 13 Social justice involves understanding the many factors that contribute to health and that the greatest health threats inflict death and disability upon the minority of society; this represents an unjust distribution of morbidity and mortality upon the most disadvantaged.13 Thus, it has been suggested that justice is the core value of public health and that social justice functions14 “… to advance human well-being by improving health … by focusing on the needs of the most disadvantaged.”

Although there are many writings about social justice in public health, Beauchamp's early work13, 15 in this area is seminal and was further developed in other publications over the next several years.16, 17, 18, 19 Involving controversial topics such as rights, liberties, paternalism, and health care, the discussion of social justice is further complicated in that it involves the health of the population and not just an individual. To reduce mortality and morbidity among the disadvantaged, it may be necessary for the majority to accept new responsibilities or burdens and give up certain pleasures that they possess. This last point may not be popular for those in positions of power or affluence.

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Market Justice—a Barrier to Social Justice 

In most Western cultures, market justice is the predominant social model of justice. Market justice is based upon individualism, one's abilities to achieve success and stature through individual actions or accomplishments. This contrasts sharply with social justice.20 In a market system, health is viewed as a personal matter bestowed upon those who can afford good health and represents an ethic of the majority that shields it from the responsibilities of reducing the disease burden of society as a whole.14 Beauchamp has suggested that “The public health ethic is a counter-ethic to market justice and the ethics of individualism as these are applied to the health problems of the public.” Thus, asking people in the majority to give up some of their benefits to help those in need when those in the majority have worked hard to achieve their social status is contrary to the culture in which they have developed success. Some may feel that they have earned the benefits that they enjoy and do not feel that others should also benefit. However, it has been pointed out that the market justice model of health is not necessarily in the best interest of the whole. Budetti20 suggests that the market justice health care system is driven by self-interest and voluntary behavior, whereas social justice focuses on shared responsibility and communal well-being.

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Chiropractic and Social Justice 

The chiropractic profession was established during the 20th century, America's period of increased individualism and capitalism, and lead by charismatic individuals for most of its formative years. Thus, the profession was socially and professionally established in a market justice system. In a hostile market environment, the profession struggled to define itself, defended itself legally and intellectually against numerous foes, and has spent most of its first century in a defensive state of self-preservation. Although introspection and self-defense may have been necessary to establish this health care discipline, such self-focus may stand in the way of the profession setting a vision and taking action to benefit the health of the public in areas that need social justice.

In order for the chiropractic profession to engage in the public health ethic of social justice, it will need to evolve beyond its market justice behaviors and beliefs. At present, the focus of most members of the chiropractic profession is caring for individual patients in independent practices, sustaining a viable practice, and protecting the privileges to practice chiropractic. A change to a more patient and community-centered manner of thinking is requisite, one that involves placing the needs of society before those of the profession or its members.

Beauchamp's early writing provides 4 essential principles of social justice that are easy to understand and comprehensive. Furthermore, Beauchamp's 4 principles fit well within a musculoskeletal model of health care practice and resonate with the chiropractic paradigm. Thus, the purpose of this editorial is to examine 4 principles of social justice as proposed by Beauchamp and discuss current actions of the profession to contribute to social justice and postulate future directions the profession might take to better participate in the practice of social justice in the field of public health. Beauchamp's 4 principles involve the following: (1) controlling hazards of the world, (2) preventing death and disability, (3) participating in organized collective action, and (4) equally sharing the burden of health disparity.13

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Discussion 

Controlling Hazards 

Beauchamp suggests that we should investigate and develop methods to prevent known health hazards.13 The goal of these efforts would be to focus on the control and prevention of hazards on a group level instead of focusing on individual victims and behaviors.13 For example, if there is a problem with alcoholism within a community, it would be inappropriate to placing blame and responsibility solely on the victim (eg, the person with alcoholism). From a public health standpoint, the environment and other factors that led to community-wide alcoholism should be modified. Control of hazards focuses on removing or reducing the hazard that may eventually lead to death or disability. Because this may relate to neuromusculoskeletal injuries, the concept is to control the factors that contribute to dysfunction or injury instead of blaming the individual. This is a matter of addressing the cause of the problem instead of waiting for the injury to occur, then to treat the results and blame the individual for being injured or for needing care.

Preventing Death and Disability 

Prevention of death and disability is most effective for group health when it can be done on a population level, rather than relying on actions at an individual level. The profession can engage in efforts to prevent morbidity associated with musculoskeletal injuries and other disorders. Beauchamp suggests 3 ways to address prevention by creating rules to (1) minimize public exposure to hazards, (2) strengthen the public against potential damage, and (3) organize resources to minimize damage once a hazard has struck.13 Recent notable efforts within the chiropractic profession include the support of the World Health Organization's Tobacco-Free Initiative21 and to improve the posture of school children in multiple countries.22 However, there are additional opportunities to join existing efforts to prevent diseases such as osteoporosis, degenerative joint disease, rheumatic disorders, and musculoskeletal injuries such as falls and head injuries associated with noncompliance with helmet regulations. The profession could help to draft policies that would lead to minimizing exposure to certain hazards to reduce the incidence of specific injuries. For example, professional organizations could support public health prevention efforts to minimize falls in the elderly, which would represent a social effort by the profession that would benefit the population.

Participating in Organized Collective Action 

Beauchamp13 states that social justice efforts “must be undertaken by governmental or nongovernmental agencies through planned, organized, and collective action that is obligatory or nonvoluntary in nature.” He argues that we cannot rely on voluntary actions to support social change because some individuals in society are not willing to volunteer to support the greater good and therefore are not willing to share the burden. In a system of social justice, all persons should share equally in both costs and benefits. Thus, collaborations between governmental and volunteer associations may yield efforts that are representative of the population and socially just.

Chiropractic organizations can collaborate with governmental agencies and influence population-based efforts. For example, an opportunity in the United States is the Healthy People Consortium. Healthy People began in 1979 and is an initiative coordinated by US government agencies that include collaboration with more than 400 nongovernment organizations. The initiative is the most comprehensive roadmap to evidence-based prevention and health promotion in the United States and addresses 28 focus areas ranging from access to health services to arthritis, osteoarthritis, and chronic back conditions, to physical activity and fitness.23 It is in this initiative where population-based health promotion goals for Americans are constantly under development and revision.

However, the chiropractic profession has not engaged in the Healthy People effort so far. For example, not one chiropractic organization is represented in the Healthy People 2010 Consortium (http://www.healthypeople.gov/Document/HTML/Volume2/G_HP_Consort.htm), and therefore, chiropractic appears to have no representation in the largest initiative in the history of the United States to affect the health (as opposed to disease) of Americans. By participating in the Healthy People program, chiropractic organizations have an opportunity to influence research and policy through the power of collaboration, which can benefit society. With resources within the chiropractic profession being finite, joining powerful coalitions that will benefit the health of the public in the future should remain a priority of the chiropractic profession, and the profession should be vigilant for emerging opportunities to do so.24 The professional chiropractic organizations need to become aware of and participate in these types of public health efforts.

Sharing the Burden of Health Disparity 

One challenge for market-driven individualists to accept Beauchamp's 4 principles of social justice is the fair sharing of the burdens. In this model, all persons should be equally responsible for sharing the burdens and benefits of protection against mortality and morbidity.13 The only time when this is violated is when unequal burdens provide a protective effect for the population as a whole. Although this burden sharing may be unequal, it is meant to be fair. For example, it may be necessary to provide more resources for the poor during an emergency than for those with greater financial means; although the distribution of resources in this case is unequal, it is fair.14

Can the chiropractic profession better participate in sharing the burdens of health disparities on a population level? As suggested by Ottenritter,25 one solution is to involve our students in activities that promote social justice, such as caring for the disadvantaged through service learning opportunities. A couple of training opportunities for chiropractic interns to provide care to the needy are reported in the literature.26, 27 Most chiropractic training programs have some type of clinic that provides care to the disadvantaged, many at no cost.28 Thus, perhaps the profession is contributing to social justice through its educational programs, but can it do more?

Kass29 provides an analytic tool that may be used to consider health burdens and social justice when planning public health interventions, research, or policy. This tool could be a useful one for the chiropractic profession to use when designing public health research studies or considering health promotion programs. Among other considerations, this tool provides a systematic process for considering potential health burdens associated with programs or research, minimizing any social burdens arising from such efforts, implementing programs and research fairly, and considering how benefits and burdens of programs or research may be fairly balanced in society. With public health research building some momentum only recently, those involved in this area of inquiry may find the framework of Kass helpful.

Including Prevention/Population/Public Health in the Chiropractic Research Agenda 

Social justice could be approached by the chiropractic profession through its research agenda. For example, in the future, when the profession revisits its chiropractic research agenda,30, 31 it should consider adding a sixth major area of inquiry, a domain about prevention, population, and public health, to the 5 existing agenda domains (ie, basic sciences, clinical sciences, outcomes research, health policy research, educational research). Adding a population/public health domain to the research agenda would represent a genuine interest for the profession to focus research energy on the health of the public and set a course to address hazards pertinent to neuromusculoskeletal health and wellness. Here, the chiropractic profession could act socially to address burdens associated with hazards and attempt to improve the health of society by improving prevention and public health measures.

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Conclusion 

Understanding social justice, public health, and the ethics of public health is challenging. Because various countries around the globe wrestle with ailing economies and public health issues that show how interconnected our communities actually are, conflicts pertaining to justice, liberty, and privacy will unfold.32 A cadre of members of the chiropractic profession has led the way through participation in the American Public Health Association, the World Health Organization, and the production of literature relevant to this field. However, the chiropractic profession has much more work to do to contribute substantially to social justice.

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Funding Sources and Potential Conflicts of Interest 

No funding was received for this article. Bart Green, DC, MSEd, is the associate editor of the JMPT, JCM, and JCH, and a part-time faculty member of the National University of Health Sciences. Claire Johnson, DC, MSEd, is the editor of the JMPT, JCM, and JCH, a full-time professor at the National University of Health Sciences, peer review chair for the Association of Chiropractic Colleges, a board member of NCMIC, and a member of the American Chiropractic Association, American Chiropractic Board of Sports Physicians, International Chiropractors Association, Association for the History of Chiropractic, Counsel of Science Editors, American Public Health Association, Committee on Publication Ethics, World Association of Medical Editors, American Medical Writers Association, and American Educational Research Association.

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PII: S0161-4754(10)00162-4

doi:10.1016/j.jmpt.2010.07.001

Journal of Manipulative and Physiological Therapeutics
Volume 33, Issue 6 , Pages 407-411, July 2010

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