PUBLIC HEALTH ETHICS • 2009 • 1–6 1 Implementing the Marmot Commission’s Recommendations: Social Justice Requires a Solution to the Equity–Efficiency Trade-Off

TheWHOCommission on Social Determinants of Health has documented pervasive inequalities in health inmany countries. Theseare clearly associatedwithunfair distributionof the social determinantsof health. Policiesdirected at reducing this unfair distribution should be promoted across all sectors and institutions responsible for securing equal opportunities and freedom for all citizens. This article argues that such policies will need to balance the competing goals of reducing social group inequalities in health and improving average health. We need a public debate about how to make such difficult choices. This paper outlines a framework that can help us structure our thinking about this dilemma. The recently published WHO Commission report ‘Clos-ing the gap in ageneration ’ has documented deep inequal-ities in health in and between countries (World Health Organization, Commission on Social Determinants of Health, 2008). The call for action is clear: ‘The Commission calls on the WHO and all gov-ernments to lead global action on the social deter-minants of health with the aim of achieving healt