Ethics and spheres of influence in addressing social determinants of health

A massive and ever-growing body of research supports the 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. 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.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.