That’s not fair! But what are you willing to sacrifice to make it more equal?
People tend to have a natural desire for fairness. We dislike inequality, especially when the inequality is unfair. This dislike of inequality is sometimes so strong that we are willing to sacrifice overall benefits to achieve a more equal outcome.
For example, scientists have found that when young children were asked to distribute an uneven number of candy bars to two recipients, nearly all children would choose to throw the additional candy bar away instead of giving the extra to one of the recipients.
In the animal kingdom, aversion towards inequality has been observed in monkeys trained to perform tasks in exchange for treats. Some monkeys were given cucumbers as treats, the others were given grapes, which the monkeys much preferred. When the monkeys noticed this inequality, some started throwing their cucumbers back and many stopped performing the tasks. They were furious about the unequal distribution of treats and were willing to give up their treats in protest.
So, it should come as no surprise that when we see headlines about health inequalities by race and ethnicity, income, or zip code, we get mad, too. There is general agreement that these inequalities in health are unacceptable. What is less talked about is the fact that achieving more equal health often comes with a price. Prioritizing equality can sometimes mean less efficient distribution of resources, which can have real implications on population health. On the other hand, policies that focus primarily on maximizing efficiency and lowering costs can exacerbate health inequalities and disproportionately hurt groups that are already marginalized in our society, which is a price that most people are also unwilling to accept.
An example of this efficiency-equality tradeoff happened during the COVID-19 pandemic response. As vaccines became available, US policymakers had to choose between saving as many lives as possible by allowing vaccine companies to enroll people into vaccine trials as quickly as possible (maximizing efficiency), or to request that companies slow down their trials and include more racial and ethnic minorities (reducing inequality). They chose the latter. This willingness to delay the rollout of a life-saving vaccine to improve equality reflects the innate dislike towards inequality that people tend to have— a dislike that is so strong that they are willing to compromise on overall health gains for the population.
But just how much is too much to compromise? Depending on who you ask, the answer may be different. Although some studies have indicated that the US public cares about achieving a more equal distribution of health in our society, we do not yet have a consensus on the equality-efficiency tradeoff. But finding this consensus is important because policymakers should make health care decisions that reflect the values of the people. In other words, if the policymakers are making efficiency-equality tradeoffs that could affect the population’s wellbeing, then the trade-offs need to reflect the people’s desires.
The desire for fairness that drives small children to throw away extra candies is the same desire that can drive our healthcare system. This same desire can shift our attention from investing in healthcare expansion to addressing the root causes of inequality. It’s time these desires are measured and reflected in our policies.
References:
Paulus M. Children's inequity aversion depends on culture: a cross-cultural comparison. J Exp Child Psychol. 2015 Apr;132:240-6. doi: 10.1016/j.jecp.2014.12.007. Epub 2015 Jan 24. PMID: 25626404.
Shaw A, Olson KR. Children discard a resource to avoid inequity. J Exp Psychol Gen. 2012 May;141(2):382-95. doi: 10.1037/a0025907. Epub 2011 Oct 17. PMID: 22004168.
Wynne CD. Animal behaviour: fair refusal by capuchin monkeys. Nature. 2004 Mar 11;428(6979):140; discussion 140. doi: 10.1038/428140a. PMID: 15014490.
Khor S, Elsisi ZA, Carlson JJ. How Much Does the US Public Value Equity in Health? A Systematic Review. Value Health. 2023 Mar;26(3):418-426. doi: 10.1016/j.jval.2022.08.009. Epub 2022 Oct 8. PMID: 36216706.
Comerford, D. A., Tufte-Hewett, A., & Bridger, E. K. (2024). Public preferences to trade-off gains in total health for health equality: Discrepancies between an abstract scenario versus the real-world scenario presented by COVID-19. Rationality and Society, 36(1), 66-92.
Sara Khor is a graduate student at the Comparative Health Outcomes, Policy, And Economics Institute at the University of Washington. Her research explores the intersection of technology, decision making, and social impact.