In every society, power is distributed unequally. A hierarchy is like a pyramid. Those at the top have a great deal of power while those further down have less. Often these differences in power are related to the social determinants of health, such as sex, gender, income, race, sexual orientation, age, disability, and place of residence. If we ignore or fail to identify hierarchies and their roots in the social determinants of health, we run the risk of siding with those who are powerful at the expense of those who are not. We may also end up treating those who are different or less powerful as deficient or we may blame them for problems that are rooted in systemic inequalities beyond their control.
In the case of hip and knee replacement surgery, the research seemed to suggest a hierarchy in which paid was seen as more important than unpaid work. As a result, employees and wage-earners might be referred for surgery in order to get them back to work while unpaid caregivers and homemakers might seem like less of a priority. Valuing paid over unpaid work also creates a gendered hierarchy because women are less likely than men to be involved in paid employment or they work in part-time and casual positions that give them the flexibility to provide unpaid caregiving for children and dependent adults.