Hostname: page-component-7c8c6479df-fqc5m Total loading time: 0 Render date: 2024-03-27T00:49:07.935Z Has data issue: false hasContentIssue false

Responsibilities for Poverty-Related Ill Health

Published online by Cambridge University Press:  28 September 2012

Abstract

In a democratic society, the social rules are imposed by all upon each. As “recipients” of the rules, we tend to think that they should be designed to engender the best attainable distribution of goods and ills or quality of life. We are inclined to assess social institutions by how they affect their participants. But there is another, oft-neglected perspective which the topic of health equity raises with special clarity: As imposers of the rules, we are inclined to think that harms we inflict through the rules have greater moral weight than like harms we merely fail to prevent or to mitigate. What matters morally is not merely how we affect people, but how we treat them through the rules we impose. While current (consequentialist and Rawlsian) theorizing is dominated by the first perspective and thus supports purely recipient-oriented moral conceptions, an adequate approach to social justice requires a balancing of both. Such balancing results in a relational conception of justice, which distinguishes various ways in which an institutional scheme may causally affect the quality of life of its participants.

This essay argues that the strength of our moral reason to prevent or mitigate particular medical conditions depends not only on what one might call distributional factors, such as how badly off the people affected by these conditions are in absolute and relative terms, how costly prevention or treatment would be, and how much patients would benefit from given treatment. Rather, it depends also on relational factors, that is, on how we are related to the medical conditions they suffer. It then discusses some implications of this view for understanding responsibilities for international health outcomes.

Type
Articles
Copyright
Copyright © Carnegie Council for Ethics in International Affairs 2002

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1 The first three of these figures are from United Nations Programme, DevelopmentHuman Development Report 2002 2002 New YorkOxford University Press 2129Google Scholar. The last two are UNDP, fromHuman Development Report 1999 1999 New YorkOxford University Pressp.22Google Scholar, UNDP, andHuman Development Report 1998 1998 New YorkOxford University Pressp.49Google Scholar, respectively. These figures compare to a world population of about six billion.

2 Food and Agriculture Organization of the United Nations The State of Food Insecurity in the World 1999 1999 RomeFood and Agriculture Organization of the United Nationsp.11Google Scholar; also available at http://www.fao.org/news/1999/img/sof199-e.pdf.

3 World Health Organization (WHO) World Health Report 2001 2001 GenevaWHO Publications 144–49Google Scholar; also available at http://www.who.int/whr/2001.

4 Pogge, Thomas WWorld Poverty and Human Rights 2002 CambridgePolity PressGoogle Scholar), section 4.3.1.

5 UNDP, Human Development Report 2002, pp.165193Google Scholar (figures are for the year 2000).

6 In fact, it is claimed that the world's richest individuals could comfortably solve the problem out of their income from safe investments: “The additional cost of achieving and maintaining universal access to basic education for all, basic health care for all, reproductive health care for all women, adequate food for all and safe water and sanitation for all is less than 4% of the combined wealth of the 225 richest people in the world” (UNDP, Human Development Report 1998, p. 30). The WHO Commission on Macroeconomics and Health (chaired by Jeffrey Sachs) has sketched how deaths from poverty-related causes could be reduced by 8 million annually at a cost of $62 billion per year (Economist, December 22, 2001, pp. 82–83).

7 Rawls, JohnThe Law of Peoples 1999 CambridgeHarvard University Pressp.108Google Scholar.

8 See Carens, JosephAliens and Citizens: The Case for Open Borders Review of Politics 1987 49 251–73CrossRefGoogle Scholar.

9 See Lam, RickyWantchekon, Leonard Dictatorships as a Political Dutch Disease 1999Working Paper, Yale UniversityGoogle Scholar); Wantchekon, Leonard Why Do Resource Dependent Countries Have Authoritarian Governments 1999Working Paper, Yale UniversityGoogle Scholar), available at http://www.yale.edu/leitner/pdf/1999-11.pdf; and Pogge, World Poverty, chs. 4 and 6.

10 Only in 1997 did the developed states sign the Convention on Combating Bribery of Foreign Officials in International Business Transactions, which requires them to enact laws against the bribery of foreign officials. “But big multinationals continue to sidestep them with ease” (Economist, March 2, 2002, pp. 63–65).

11 Representative examples of such lines of argument are Singer, PeterFamine, Affluence and Morality Philosophy & Public Affairs 1972 1 229–43Google Scholar; Rachels, JamesKilling and Starving to Death Philosophy 1979 54 159–71CrossRefGoogle Scholar; Kagan, ShellyThe Limits of Morality 1989 OxfordOxford University PressGoogle Scholar); and Unger, PeterLivingHighand Letting Die: Our Illusion of Innocence 1996 OxfordOxford University PressCrossRefGoogle Scholar).

12 Witness Rawls's generic natural duty to promote just institutions, which leaves all such more specific questions of responsibility out of account. Rawls, JohnA Theory of Justice 1999 CambridgeHarvard University Press1971]), pp.99216293–94Google Scholar.

13 The main champion of the view that all such factors—social institutions and practices, conventions, ethi, and personal conduct—should be pressed in the service of promoting a just distribution so understood is Cohen, G ASee his On the Currency of Egalitarian Justice Ethics 1989 99 no. 4906–44CrossRefGoogle Scholar; Incentives, Inequality, and Community in Peterson, GretheThe Tanner Lectures on Human Values 1992 vol. 8 Salt Lake CityUniversity of Utah PressGoogle Scholar); Where the Action Is: On the Site of Distributive Justice Philosophy & Public Affairs 1997 26 no. 1330CrossRefGoogle Scholar; and If You're an Egalitarian, How Come You're so Rich 2000 CambridgeHarvard University PressGoogle Scholar). For a detailed critique of this view, see Pogge, Thomas WOn the Site of Distributive Justice: Reflections on Cohen and Murphy Philosophy & Public Affairs 2000 29 no. 2137–69CrossRefGoogle Scholar.

14 Advocates of the first view could also be accused of callousness in that the huge demands they make on behalf of persons whose health is poor through no fault of their own will, in the real world, shrink the domain of recipients—typically in line with national borders. The billions of dollars required for providing our compatriots with all the “services needed to maintain, restore, or compensate for normal species-typical functioning” (Daniels, NormanJust Health Care 1985 New YorkCambridge University Pressp.79CrossRefGoogle ScholarPubMed) would suffice to save countless millions abroad who now die from poverty-related causes, such as malnutrition, measles, diarrhea, malaria, tuberculosis, pneumonia, and other cheaply curable but all-too-often fatal diseases.

15 Some main contributions are Sen, Amartya Equality of What in Choice, Welfare and Measurement 1982 CambridgeCambridge University PressGoogle Scholar), and Inequality Reexamined 1992 CambridgeHarvard University PressGoogle Scholar); Rawls, JohnSen, AmartyaWilliams, Bernard Social Unity and Primary Goods in Utilitarianism and Beyond 1982 CambridgeCambridge University PressGoogle Scholar); Cohen, “On the Currency of Egalitarian Justice”; Arneson, RichardEquality and Equality of Opportunity for Welfare Philosophical Studies 1989 56 7793CrossRefGoogle Scholar; and Elster, JonRoemer, JohnInterpersonal Comparisons of Well-Being 1991 CambridgeCambridge University PressCrossRefGoogle Scholar). Cf. also Thomas, W PoggeThree Problems with Contractarian-Consequentialist Ways of Assessing Social Institutions Social Philosophy and Policy 1995 12 241–66Google Scholar.

16 Other things must be presumed to be equal here. The moral weight of the health impact declines as we go through the list. But a morally less weighty impact may nevertheless outweigh a weightier one if the former is more severe or affects more persons or is more cheaply avoidable than the latter. In this way, an advantage in reducing scenario-4 type deficits may outweigh a much smaller disadvantage in engendering scenario-3 type deficits, for exampleGoogle Scholar.

17 This implicit attitude of social institutions is independent of the attitudes or intentions of the persons shaping and upholding these institutions: only the former makes a difference in how just the institutions are—the latter only make a difference in how blameworthy persons are for their role in imposing themGoogle Scholar.

18 The case of smoking, for instance, may exemplify a fluid transition between scenarios 2 and 6 insofar as private agents (cigarette companies) are legally permitted to try to render persons addicted to nicotineGoogle Scholar.