[Moral dilemmas around health equity]

From the perspective of social justice and equality of opportunity, it is an important yet difficult aim of local governments to enhance the opportunity to be healthy among disadvantaged groups. Apart from a lack of knowledge about effective interventions, there can be uncertainty about what is morally the best thing to do. To get a better understanding of what these moral challenges are, we made an inventory of the ethical dilemmas faced by employees of the public health department of the Dutch City of Utrecht in their aspiration to achieve health equity. Based on both four structured discussions of these dilemmas with municipality employees, and central ideas and distinctions from the philosophical literature on social justice, we formulate five insights on what it means to take equality of opportunity as ideal in local public health policy. That is, 1) fostering equal opportunities to be healthy demands that moral choices are made within policy practice and the execution of policies; 2) fostering equal opportunities to be healthy demands a balancing act between realism and idealism; 3) substantial equality of opportunity in health demands more than formal opportunity; 4) fostering equal opportunities to be healthy works best by giving priority to the worst-off; 5) fostering equal opportunities to be healthy requires paternalism. These insights, together with the structuring questions, can support local policymakers in public health in the decisions they need to make, by clarifying which considerations contribute to health equity.