Health, Economics, and Feminism – on judging fairness and reform

Introduction: The point of departure in this thesis is that women live longer than men, while men have more power, infl uence and resources, and probably better health-related quality of life, than women. In order to judge and act from this situation, the classical idea that both facts and values are needed for conclusion is adopted. The diverse positions of the sexes are mainly assumed to depend on the gender system, i.e. the societal structure organising human activities and relations, ultimately privileges and burdens, by sex. Hence, abolition of gender is held to be associated with decreased differences in health. The handling of facts and values is divided into two principal questions: 1) how to compare women and men within a particular state of the world, and 2) how to choose from their positions between states. Aims: The overall aim is to propose a public health framework for judging fairness and change from the positions of women and men. The specifi c aims are to: illustrate how the choice of normative approach affects judgements on fairness and resource allocation (I), explore public health views regarding various ethical principles (II), study the relationship between aspects of gender equality in public/domestic and health (III), estimate costs, savings and health gains, associated with the Swedish parental insurance reform (IV). Methods: The methods used are: ethical analysis based on the normative theories of welfarism, extrawelfarism, egalitarianism, and feminism; and the notions of justice by separate spheres, equity as choice and attainment/shortfall principles (I), survey among public health workers regarding within-state and between-states ethical views (II), epidemiologic study on death and sickness leave among traditional, equal, and untraditional Swedish couples who had their fi rst child in 1978 (III), cost-effectiveness analysis based on men who took paternity leave 1978-1979 (IV). Results: The selected normative theories are likely to claim different opinions on fairness regarding women and men, and different proposals on resource allocations (I). Most public health workers support the idea of judging fairness by separate spheres, end-points, and shortfall equity. The rejection of health maximisation, and support for equality in life span and income, are convincing; although females and males differ signifi cantly in judging societal change (II). In comparison to being equal in the public sphere, traditional women have lower risks of death and sickness, while traditional men tend to have higher risks. Being equal in the domestic sphere seems to be associated with lower risks among both sexes (III). Men who took paternity leave run signifi cant lower death risks than other men. Base case cost-effectiveness of the reform is 6,000 EUR, and worst case 40,000 EUR, per gained QALY (IV). Conclusions: A public health framework for judging fairness and reform by women and men could look as follows: 1) identify facts at present and from past, 2) ask whether the situation is fair by within-state rules, 3) claim or refuse change, 4) identify consequences from reform, 5) consider whether the change was satisfying by between-states rules. The gains from more ethical analyses of public health based on sex/gender should overcome the many tricky issues involved. Since there is no common understanding on how to judge fairness and change from female/male differences in health and wealth, added research and exchange of views are called for. At Swedish state of gender (in)equality, it seems public health relevant to support further similarity in child-care. Provided an effective fraction of 25 percent, the entitlement to paternity leave is probably approved of by common welfarist, egalitarian, and feminist goals.