By Sandro Galea
October 5, 2018

This piece is part of an ongoing series by Boston University’s Dr. Sandro Galea on the intricacies of health care and public health.

In his book, A Theory of Justice, the political philosopher John Rawls proposed an idea for creating a better society. He imagined a new social contract, one designed from behind a “veil of ignorance,” where the designers are kept unaware of the position they will occupy in the society they are to build. This allows them to approach their task free from the biases of personal self-interest. They do not know if, in this new society, they will be born gay or straight, white or a person of color, privileged or lacking money and social clout. This way, they will have an incentive to build a world where all can thrive.

Unfortunately, we have fallen far short of Rawls’ vision, and our health has suffered for it. Far from being designed from behind a veil of ignorance, our society is one where entrenched, unearned privilege gives advantages to the few, at the expense of the many. In the US, the richest one percent of Americans now live between 10 and 15 years longer than those at the bottom of the economic ladder. Americans whose skin is not white or who are LGBT are likelier to face bigotry, exclusion, and poor health than those who do not share these characteristics. And, as the #MeToo movement has shown, our society has failed to prevent endemic sexual harassment and abuse.

Perhaps ironically, our shortcomings in this area have been thrown into sharp relief by the current contretemps over the Supreme Court. On the Court, power is concentrated in the hands of a small group of people we trust to pass judgement on those who do not occupy positions of similar power. We trust the Justices will use their power wisely because they display all the markers of privilege, in a society where privilege is often taken as a shorthand for high competence. Each Justice attended law school at Harvard or Yale (Ruth Bader Ginsburg is a partial exception, having begun at Harvard, before transferring to Columbia). Each benefitted from the assumption that people with elite backgrounds should be the ones we empower to interpret our laws.

Over the years, we have left this assumption unchallenged; the nomination of Brett Kavanaugh is, in many ways, the natural culmination of this. He was reportedly selected by President Trump, in part, because of his Ivy League credentials, and has been repeatedly defended on the basis of the schools he attended, the social circles in which he moves, and the prestige of his colleagues. These markers of privilege have led him to the brink of having the power to shape the law, and, through the law, the lives of millions. He has this opportunity despite his recent appearance before the Senate Judiciary Committee, where, facing allegations of sexual assault, his defended himself in bitter, partisan terms.

As Fortune Editor-in-Chief Clifton Leaf recently pointed out, Kavanaugh’s behavior at these hearings seems to reflect a temperament that is far from the measured impartiality we look for in Supreme Court Justices. Yet Kavanaugh may still be confirmed, in no small part because he embodies our view that power is something for the select few, for them to use on behalf of others. It is notable that Emily Witt, writing in The New Yorker about the upbringing of the prospective Justice, said “What Kavanaugh appears to have been taught, as a young person, is that goodness is working at a soup kitchen or volunteering on a mission to a poorer country; it’s granted to other people as an act of charity.”

We shall leave history to decide the extent to which that perspective shaped the behaviors of which Kavanaugh now stands accused. What is clear is that Kavanaugh reflects a privileged world that has long stood by as more and more Americans have been left behind, entrenching structures that amass privilege for the few rather than share it with the many. These structures have led to the acceptance and protection of behaviors that ultimately do not make for a better world.

Those who are born to privilege are rarely asked to reflect on the many, often unearned, advantages that led them to their positions of power. It then becomes easy for them to assume that they arrived where they are through hard work alone, and that anyone who falls short of similar eminence simply did not apply themselves enough. This allows them, when they come into the legislatures, the judgeships, and the other high offices to which privilege often ascends, to make policies and pass judgements that undermine the health of those who were not born with the head start they enjoyed.

This is well-illustrated by the debate over health care in this country. Opponents of Obamacare, and universal health care in general, have frequently characterized such policy, often from positions of privilege, as a way of forcing the healthy to subsidize the poor choices of the sick. In 2017, Republican representative Mo Brooks accused Obamacare of raising costs for people who have “done the things to keep their bodies healthy.”

This argument neglects the degree to which good health depends on privilege. We are healthy because we were able to grow up in a family with enough money to provide us with nutritious food and a safe environment, because we were able to attend good schools that gave us the capacity to make good decisions and get well-paying jobs throughout life, and, more broadly, because we live in a country that is prosperous and at peace. None of these advantages came to us as a result of our own hard work, yet all are essential for our health. Without these privileges, it would not take long for us to become reliant on the care people like Brooks are so eager to deny to those who need it.

The Kavanaugh nomination has made us face an uneasy truth: a country that proposes that all are created equal, is, in fact, home to systems of deeply ingrained privilege which shape everything from the health and opportunity of its citizens to the moral imagination of its policymakers. Changing these systems requires us to ask ourselves what kind of world we wish to live in.

Is it enough that privilege should rest in the hands of the few, as long as they signify to us they will use it wisely? Or should we aspire to create a more egalitarian world, one which Rawls would recognize? The choice, viewed from behind the veil of ignorance, is an easy one. In order to be healthy, we must create a world where health is not the exclusive provenance of the privileged, but, rather, accessible to all.

Sandro Galea is a professor and Dean of Boston University School of Public Health. His book, Healthier: Fifty thoughts on the foundations of population health, was published in June 2017. Follow him on Twitter: @sandrogalea.

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