Global Health Unequal Distribution:The Need For Active Moral Imagination (Part 2)

Towards the Delineation of a Moral Framework

The increasing magnitude of global health inequalities demands an urgent plan of actions both at the national and the international level. This plan of action should be grounded in the ethical values associated with health and the moral fundamental anthropological understanding of human beings. I would suggest that bioethicists should be more actively involved in the imagination of moral frameworks that contribute to the identification of principles of action guiding national and international policies. The elucidation of the moral implications of global health inequalities presupposes the explanation of the reasons why they are morally disturbing and why efforts to reduce them are morally justified. The utilitarian, contractarian and neo-liberal theories maintain that global health inequalities do not possess any ethical valence that would support the moral obligation of eliminating them: societal welfare, collective security and self-interest constitute the only reasons urging their reduction. Overall, the utility value underpinning the current dominant approach to public health does not attribute any overarching value to the health of the individual person, especially when individual rights conflict with community’s health.

On the contrary, a theory of health ethics that integrates Aristotle’s political theory with Amartya Sen’s capability theory, considers individuals as the central moral unit of justice and emphasizes the instrumental value of health for human flourishing. In light of these presuppositions every society has the moral obligation to equally guarantee to each person the capability of achieving good health and being free from preventable morbidity and mortality. Therefore, health inequalities are morally troubling because they reduce the individual capabilities for properly functioning and flourishing. In a similar vein, a personalist view of health that rests on the personal nature of human beings acknowledges the instrumental value of health for the development and the fulfillment of the multiple dimensions of personal life.

A Personalist Understanding of Health

Personalism is a philosophical and ethical theory based on the notion of person as the ultimate criterion for defining all other ethical concepts: what is good for the human person.  Among the different versions of personalism that have been elaborated since the early 19th century, “realistic personalism”  supports an objective view of human health. The central tenet of realistic personalism is the commonly shared ontological value of the being and the dignity of the human person, regardless of any external recognition. Nevertheless, the notion of human person includes not only the commonly shared human nature, but also the subjective experiences of each individual person. From this notion of the human person stems the inviolability of human life that has to be respected in all its manifestations through the promotion of the basic human rights. The respect for the life of every human being does not justify the sacrifice of the interest of a individual for the advantage of the collectivity. These personalist presuppositions parallel the second principle of ethical practice of Public Health issued by the American Public Health Association in the year 2000 that states that “Public health should achieve community health in a way that respects the rights of individuals in the community” (#2). In addition, the personalist respect of the human freedom presupposes a more articulated concept of freedom than “the principle of authonomy” that characterizes bioethical principalism: it entails the reasonable use of one’s power of self-determination in accord with the objective moral order known through reason. A personalist view of health is based on the value of the absolute respect for the multidimensional nature of every person from which the following three principles emerge: 1. the principle of subsidiarity; 2. the principle of solidarity; and 3. the principle of justice.

Principles of Action

According to the principle of subsidiarity, rooted in Christian social ethics as well as in political philosophy, public health policies should always rely on public education rather than on constriction and prohibition. These policies should not be imposed by the nation-state or by global political authorities when they can be freely and responsibly chosen by individuals. In particular, this principle recognizes the central role of local communities and promotes respect for cultural differences.

In comparison to a centralized authority, smaller structures and communities can more effectively solve health problems by promoting human creativity and the development of less bureaucratized relations. However, the encouragement of individual and professional groups’ initiatives is not intended to foster individualism or particularism. In reality, subsidiarity alone does not guarantee the good and appropriate functioning of health care policies if personal choices do not care for the needs of the other members of the community. Therefore, the principle of subsidiarity has to be balanced with the principle of solidarity.

Through public education personalism encourages individuals to become responsible both for themselves as well as for the community in which they live and to promote the integral good that combines healthy personal lifestyles with a sustainable community life. On a global scale health can be promoted through a combination of responsible personal and communitarian choices.

The third principle of justice emerges as a consequence of the fact that for personalism the maximization of personal health benefits, namely the principle of subsidiarity, has to be balanced with the principle of solidarity. The principle of justice entails that global health interventions must fairly distribute risks and benefits among the population by promoting access to healthcare systems to all members of the community. In his theory of distributive justice that employs geometric proportion to support equal shares for equal needs and unequal shares for unequal needs, Aristotle introduced the concept of “disproportionate effort” that aims to bring disadvantaged people close to a threshold level of functioning within the limits of that person circumstances. Therefore, priority should be given to people who suffer from a gap between their health status and the threshold status they should achieve, provided that such efforts do not reduce the health functioning of the general population below the minimally acceptable levels.

A Moral Foundation for Global Health Care Policies

Based upon the recognition of health as an instrumental value to the respect of the dignity of every human being and the definition of the three principles of action, nation-states and international institutions and organizations like the WHO, the World Bank along with communities, non-governmental organizations (NGOs), families and individuals are called to cooperate for the reduction of global health injustices. Guided by the principles of subsidiarity, solidarity and justice, nation-states should create the adequate conditions for promoting individuals’ capability of being healthy, for guaranteeing equitable healthcare access, and for implementing participatory reforms and social services.

In summary, an interpretation of human health based on the commonly shared personal nature of every human being provides an appropriate moral framework grounding the obligation to reduce global health inequalities through the application of the principles of subsidiarity, solidarity and justice at a national and international levels. These principles, however, do not provide clear-cut answers to specific health issues, but they leave room for case-by-case ethical discussions

Though this ethical strategy grounded in the Western tradition of respect of the dignity of every human being might not be accepted in different cultural and religious contexts, it, however, can serve as a theoretical and operational paradigm for addressing global health issues. This model includes the following four sequential steps:

1. The assessment of global health inequalities and their economic, political and social determinants.
2. The identification of the basic moral value(s) about health and its distribution
3. The development of principles of action that should guide international and national policies
4. Finally, the coordination of the nation-state efforts with the supportive interventions of international institutions and organizations could reduce health inequalities and promote promoting health equity on a global scale.

At the same time the acknowledgment that moral discourse, narratives and commitments assume different connotations in relation to particular cultures and traditions calls into question the possibility of developing a global ethics, namely a common universal moral code, in a morally pluralistic world. Nevertheless, in the present multicultural context, an increasing respect of the richness and diversity of human values and moralities should foster a continuing moral dialogue on global health issues. This dialogue should be engrained in the right of each person to participate in global discussions about health and in his/her duty of living responsibly in a global diverse community.

Recommended articles

1. Ruger JP. Ethics and governance of global health inequalities. J Epidemiol Community Health 2006; 60: 998-1003

2. Petrini C, Gainotti S. A personalist approach to public health ethics. Bulletin of the World Health Organization 2008; 86: 624-9

3. Wolff J. Global justice and health: the basis of the global health duty. Pages 78-101 in Global Justice and Bioethics/ Edited by Millum J. and Emanuel EJ. Oxford University Press: New York, NY, 2012

4. Sgreccia E. The Human Person and His Body. Pages 105-49 in Personalist Bioethics Foundations and Applications . Translated by J. A. Di Camillo and M.J. Miller. The National Catholic Bioethics Center: Philadelphia, 2012