The moral, aesthetic, and intellectual case for health

On creating the strongest possible philosophical foundation for our efforts.

A couple of weeks ago, I wrote a rather pragmatic essay about our engagement with colleagues in states that differ in their values. Today, I hope the reader forgives me for a bit more of an abstract essay, one that I have been mulling in my head for some time.

These Healthiest Goldfish essays are fundamentally about making a case for health. These essays, and the books they have helped shape, are, in a sense, efforts to bring together thoughts that have been germinating for a long time about how to create a healthier world. This process has been sharpened by the experience of COVID-19, arguably the most serious threat to public health in a century, which exposed how far we still have to go before we get to a world that is truly optimized for health. Underlying these efforts at sharpening my thoughts about health is the assumption that health matters—that it is a necessary factor for accessing everything we value in life, from the capacity to pursue productive, meaningful work to being able to spend time with family and friends. We all, I think, share the sense that health matters. Yet it is often just this—a sense, rather than a fully-formed idea or philosophical framework. The goal of this newsletter and its associated publications has been to shape a conversation—in partnership with you, the reader—that helps develop this sense into a new practical philosophy of health, one that can help ground our efforts towards a healthier world in the years to come.

Through this conversation, I have often found it helpful to engage with what is most foundational about health—the first principles of the case for a healthier world. Today, I would like to return to these first principles by formally making the moral, aesthetic, and intellectual case for health. I have touched on this before, in prior essays on balancing the moral and empirical case for health and on the aesthetics of a healthier world. However, it seems to me these three areas are fundamentally linked. I have long argued that we cannot talk about the uses and limits of data without talking about the values—which is to say, the moral sensibilities—which underly how we think about data and what we do with them. And our aesthetic sense is deeply connected to our morals and the intellectual processes that shape how we see the world. All of this is central to a vision of health which engages with the full range of human feeling and expression—moral, intellectual, and aesthetic—which has the power to shape a healthier world.

I will start with the moral case for health. By “moral,” I mean the systems by which we determine and codify the difference between right and wrong. We could well define morality in accordance with the categorical imperative of the philosopher Immanuel Kant, who said “Act only according to that maxim by which you can at the same time will that it should become a universal law.” Morality, then, reflects timeless principles of right and wrong, which, if universally applied, can create a better world for all. This means that in some ways, perhaps, the moral case for health is the easiest to make. Creating a healthier world means creating conditions which, if universally applied, can support better health for everyone, with no one left out. Just as we wish to be able to access these conditions for ourselves, morality urges us to ensure everyone else can also access them. Health matters because it is the foundation of living a full, rich life. As such, it is moral—it is just—that we engage in the business of generating health. Because what better vocation can there be than to ensure that everyone can live a healthy life?  

Core to these efforts is the moral imperative of addressing health inequities. The existence of inequities reflects how far we still are from the universal application of approaches that enable us to live healthy, full lives. These inequities are not just failures of policy or of resource allocation, they are moral failures, symptoms of injustice we have not yet done enough to address. A vision for health in the 21^st century is one which accepts the responsibility of creating the conditions where all have access to the social, political, and material resources to be healthy. It is not enough merely to have the freedoms that ostensibly let us pursue healthy lives; we must also have the resources that enable us to do so. This is consistent with Amartya Sen’s capability approach, which argues that the freedom to achieve wellbeing is a core moral imperative and that societies should be judged by how well they support a population’s functional—not just theoretical or aspirational—capacity to access this achievement.

Living up to the moral responsibility of promoting health means shaping a unified vision for health at all levels of human organization. The pursuit of this vision includes engaging with health at the level of aesthetics. I realize that it may sound strange to talk about aesthetics in the context of health. Aesthetics can seem to suggest something superficial, entirely concerned with appearances. It can also seem to mean “about beauty.” But that is not what I mean here. I mean aesthetics not in the sense of beauty or appearances but in the sense of a coherence of vision, a coming together of seemingly disparate elements in support of a healthier world. Just as a beautiful painting or piece of music reflects a harmony of different elements around a central creative goal, a healthier world reflects a harmony of political policies, cultural norms, public investment, and other structural forces, around the core goal of health.  

Aesthetics also intersect with the moral case for health, a link we can see in early philosophy about the connection between truth, beauty, and moral action. For Plato, notions of truth, virtue, and beauty exist as ideal forms in a divine realm. Aesthetic beauty, to him, is an imperfect approximation of beauty itself, suggesting a unity and coherence that belong to the realm of the gods even as we may catch glimpses of it here on earth. In this sense, Plato’s ideas about aesthetics echo his ideas about morality, as moral actions in an imperfect world point towards freestanding, eternal ideals of Goodness and Virtue. The pursuit of the ideal—in the case of both beauty and moral virtue—helps guide our efforts towards a world which, while never perfect, is as close to this vision as we can get.

Plato’s idea of forms reflects the importance of engaging with aesthetics in our pursuit of health. The visions with which we align ourselves, the ideals we pursue, shape the quality of our efforts. If we pursue a vision of health that lacks moral and aesthetic coherence—for example, a vision that supports the health of some but not all, or a vision that prioritizes healthcare over creating the conditions for health—our efforts will always fall short of where they should be. If, however, we embrace a vision which prioritizes health as a central, unifying focus—for our politics, economy, society, and investment—and which supports the health of all, not just some, we can truly shape a healthier world in this post-war, post-COVID moment.

For such a vision to succeed, however, it must be supported by a basis of sound data and robust scientific inquiry. This is where we move to the world of population health science, which reflects the intellectual case for health. Population health science can help us to quantify the value of a healthier world and the steps it will take to get us there. The moral and aesthetic cases for health reflect the feeling most of us have that a healthier world is indeed better for everyone. The intellectual case supplies the facts that confirm this feeling and help us to see how there is no better investment we can make towards creating a better future than an investment in health.

A healthier world is a better world on several fronts. For example, healthier communities have long been found to be more economically productive. According to the Blue Cross Blue Shield Health Index, which measures health across US counties, top-performing US counties enjoyed incomes about $4,000 higher than the national average, and GDP about $10,000 higher than the national average. Health, happiness, and longevity, which are linked, intersect with the material resources that support greater happiness and health, with higher national incomes supporting higher life satisfaction in countries. Income and wealth, for their part, are deeply and directly linked to health, with greater economic security linked to better physical and mental health. This information reflects the kind of data that support the intellectual case for greater investment not just in healthcare but in creating the conditions that generate healthier populations. Such data also point to the need for investment in health equity. Keeping with the economic example, just as the data paint a clear picture of the link between money and health, they also paint a picture of the deep and growing economic inequality in 21^st century. This inequality has significant implications for health, reflecting the need to address the conditions that create health haves and have-nots. It is not enough to pursue a vision that creates “better” conditions for all when better for some means a few extra pennies a week while better for others means tax breaks worth untold millions. We need to pursue a vision of health equity that lifts all boats while acknowledging that some boats need a bigger boost than others and it is on us to provide it, consistent with an approach to health grounded in the best possible data about the world we live in.

At core, our pursuit of a healthier world needs all three of the arguments I have presented here—moral, aesthetic, and intellectual—if it is to be most effective. We owe it to our work to ensure it rests on the strongest possible foundation. This means applying the fullness of all arguments that can be brought to bear on making the case for health. These essays are a small, hopefully helpful, part of trying to build such a foundation.