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CIAO DATE: 01/03
Ethics & International Affairs
Annual Journal of the
Carnegie Council on Ethics and International Affairs
Volume 16, No. 2, 2002
Roundtable
The September 11 Effect
Introduction
Paige Arthur
Challenges to Humanitarian Action
Nicolas de Torrenté
Afghan Women: Recovering, Rebuilding
Sima Wali
New Priorities for Philanthropy
Robert L. Bach
Promoting Human Rights
James D. Ross
Special Section
Health and Global Justice
Introduction
Mira Johri and Christian Barry
Public Health or Clinical Ethics: Thinking beyond Borders
Onora O'Neill
For some decades the doctor-patient relationship has been the central concern of medical ethics. This focus has marginalized public health issues by concentrating on individual patients and individual practitioners, and thereby on one aspect of medical structures in the richer parts of the world. It has often neglected questions about justice and health, and especially about international justice and health, and the medical problems of poorer parts of the world. A normatively adequate public health ethics needs to be anchored in political philosophy rather than in ethics. Its central ethical concerns are likely to include trust and justice, rather than autonomy and informed consent. To approach these concerns effectively it will be important to think realistically about obligations (and perhaps less about rights) as well as about the range of state and nonstate actors whose capabilities might enable them to discharge some of the obligations most relevant to health outcomes.
Personal and Social Responsibility for Health
Daniel Wikler
Everyone wants to be healthy, but many of us decline to act in healthy ways. What bearing, if any, should these choices have on the ethics of clinical practice and health policy? Should risk-takers have the same claim on scarce resources, such as organs for transplant, as those whose plight is due to no choices of their own? And is there any reason not to impose fees and taxes on risk-takers, be they smokers or mountain climbers, to defray the added expense of the care they may need? In health resource allocation aimed at reducing the burden of disease, should we regard certain burdens as individual responsibilities: for example, dealing with stigma, or caretaking for family members?
Socioeconomic status (SES) and health expectancy are strongly linked. To the extent that this results from risk-taking by the poor, is reduction of SES-linked health inequalities a morally important social goal? International public health aims at improving health on a population level. The World Health Organization has been criticized for failing to distinguish genuine health risks from personal lifestyle choices, as when it speaks of a tobacco-related "epidemic" as if cigarette use were a contagious disease like malaria. Should personal responsibility for health be taken into account in setting the agenda for global public health, and in measuring progress by countries in improving health. This paper addresses applications of the notions of personal and social responsibility for health. It also looks at the vulnerability of the notion of personal responsibility for health to intentional manipulation by self-interested parties in health policy debates.
Access to Medicines and the Rhetoric of Responsibility
Christian Barry and Kate Raworth
There is no cure or vaccine for HIV/AIDS. The only life-prolonging treatment available is antiretroviral (ARV) therapy. WHO estimates, however, that less than 5 percent of those who require treatment in developing countries currently enjoy access to these medicines. In Africa fewer than 50,000 people—less than 2 percent of the people in need—currently receive ARV therapy. These facts have elicited strongly divergent reactions, and views about the appropriate response to this crisis have varied widely.
The intensity of the debate concerning access to life-prolonging medicines for the treatment of HIV/AIDS, and the heated rhetoric with which they are often conducted, suggest that these disagreements may be rooted in deeper disagreements of value. It is not obvious, however, what disagreements of value are at stake in this debate. By analyzing the statements of scholars, public officials, activist organizations, and private sector representatives, each of whom may endorse very different policy recommendations on access to HIV/AIDS drugs, we have identified and created a typology of the different sources of disagreement in the debate. We conclude that the central disagreements concerning access to medicines arise from competing understandings of how responsibilities for bringing remedy to hardships should be allocated to different agents and institutions. A central lesson that emerges from our analysis is that thinking about "health equity" must extend beyond the explanation and justification of goals, values, and ideals, and engage more honestly with the difficult question of how responsibilities for bringing remedy to health crises should be allocated in complex social contexts.
Responsibilities for Poverty-Related Ill Health
Thomas W. Pogge
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.
International Justice and Health: A Proposal
Gopal Sreenivasan
This paper discusses obligations of international distributive justice-specifically, obligations rich countries have to transfer resources to poor countries. It argues that the major seven OECD countries each have an obligation to transfer at least one percent of their GDP to developing countries.
The strategy of the paper is to defend this position without having to resolve the many debates that attend questions of international distributive justice. In this respect, it belongs to the neglected category of nonideal theory. The key to the strategy is to show that a significant amount of good would be accomplished by a one percent transfer, despite the fact that one percent is quite a small amount.
To make this showing, the paper takes health as a fundamental measure of individual well-being and examines the improvement in life expectancy that would likely result from devoting the one percent transfer to the major determinants of health. It adduces data indicating that substantial progress towards raising life expectancy in developing countries to the global average of 64.5 years can be expected from expenditures of $125 per capita, divided between health care, education, and basic nutrition and income support. A one percent transfer from the major seven is enough to cover expenditures on that scale for the poorest fifth of the world's population.
Debate
Human Rights and the Politics of Victimhood
Robert Meister
A Human Rights Discourse that emerged in the 1990s supplanted the dialectic of revolution/counterrevolution that dominated the twentieth century. On the revolutionary side, the aim had been to produce unreconciled victims who would continue to struggle against the beneficiaries of past injustice even after the perpetrators were defeated; the counterrevolutionary response was to exploit the fear of passive beneficiaries in oppressive regimes that they would be treated no better than perpetrators should the revolution prevail. Human Rights Discourse hopes to end this dialectic by allowing the victims of past injustice a moral victory on the understanding that ongoing beneficiaries will get to keep their gains without being held responsible for the evils of the past. In this respect, Human Rights Discourse continues by more benign means the counterrevolutionary project of depoliticizing the effects of systemic injustice.
The article argues for a renewal of the politics of victim and beneficiary that avoids moral pitfalls of the revolutionary project. These pitfalls inhere in a politics of victimhood that allows self-conscious victims to experience themselves as the objects of hostile desires that they do not (simultaneously) experience themselves as having. Fin-de-siècle Human Rights Discourse does not directly confront and transcend this syndrome. By attempting to make future violence (terror) "unthinkable," it merely enables the continuing victims and beneficiaries of structural injustice to dissociate from and defend against the underlying desires and fears that would have made them comprehensible to each other as victim/perpetrator. Diverse theorists, such as Carl Schmitt, Walter Benjamin, and Judith Shklar, have called attention to this feature of moral psychology, and the psychoanalyst Melanie Klein helps us to understand and criticize it. Through what Klein describes as "splitting," the beneficiary of past injustice can defend against the fear of being treated as a guilty perpetrator by engaging in "mock reparation" with the good (innocent) victim, while demonizing the "bad" one who deserves to be treated as a threat.
The article concludes by suggesting that, in addition to the individuating project of liberal Human Rights Discourse and its concern for what perpetrators do, the politics of human rights must also focus on what beneficiaries support, wish, and condone. A re-politicized discourse on human rights must enable us to discuss questions of collective responsibility for the past outside the context of vengeance. To begin such a discourse, we must understand that the fear of being treated as a perpetrator is part of what it means to be a beneficiary of injustice over time.
Human Wrongs and the Tragedy of Victimhood: Response to "Human Rights and the Politics of Victimhood"
Catherine Lu
Robert Meister asserts that mainstream Human Rights Discourse in transitional politics has become a component of a reactionary project that has as its ultimate goal the perpetuation of social injustice. I disagree with him over the utility of the discourse and politics of revolution and counterrevolution in illuminating the path to moral regeneration. The problem with the politics of victimhood, as it has been conducted by revolutionaries and counterrevolutionaries engaged in ideological conflict, is that it creates a morally arbitrary hierarchy of victims that can then be used to justify the worst moral transgressions against the "other." This adversarial discourse is counterproductive; driven by a Schmittian conception of the political, it fails to escape the logic of cruelty, which is perhaps why the politics of revolution/counterrevolution has so often translated into a politics of cruelty. Such discourse and politics need therefore to be overcome or transcended. Liberalism—in particular, Judith Shklar's "liberalism of fear"—can provide a route to transforming that politics of victimhood by encouraging an alternative discourse and politics—of redemptive tragedy—that I believe can more adequately capture the complex reality of victimhood, and guide us toward building morally constructive legacies from the experience of injustice.
The Liberalism of Fear and the Counterrevolutionary Project: Reply to Catherine Lu
Robert Meister
While Lu invokes Shklar's "liberalism of fear" as a "transcendence" of the politics of friend and foe, I regard it as an attempt to give liberalism political purchase by identifying its true foe, those whose political convictions make them insensitive to cruelty, and especially to physical cruelty. Lu's liberalism is thus not without enemies; rather, it finds its enemies in those who engage in a Schmittian conception of politics, including Schmitt himself. This liberalism is expressly antirevolutionary (even when the revolution has liberal aims) and implicitly counterrevolutionary in the sense that the revolutionary resort to violence is a prima facie affront to human rights that liberals who "put cruelty first" must treat as casus belli. Unlike Lu, I do not believe that the infliction of physical pain is a uniquely evil form of injustice, nor do I regard it as prototypical of social injustice generally. I agree, however, that revolutionary victims producing victims in the turn of the historic cycles is tragic, and calls for transcendence of the politics of victimhood itself. Where, however, is such transcendence to be found? Lu's conception of "redemptive tragedy" is better understood, I think, as a form of social melodrama that allows continuing beneficiaries of injustice to pity victims without fearing them, because they see the victim's grief as disconnected from a sense of grievance. Unlike the melodramatic victim whose cause Lu can embrace, the tragic victim undergoes a transformation of grief into grievance, and thus calls forth a mixture of pity and fear. This distinction sums up my criticism of the pathos of Human Rights Discourse today, and, also, of Lu's response to my essay.
Liberals, Revolutionaries, and Responsibility: Final Rejoinder
Catherine Lu
Many liberals would agree with revolutionaries that the social and economic legacies of political oppression require rectification. Where liberals part company with revolutionaries is over the nature and means of political struggle. Whereas revolutionary warriors tend to dismiss their own responsibility for the tragic costs of their struggle, liberals acknowledge that the advancement of social justice and moral regeneration in the aftermath of violence and oppression must begin with institutions of moral accounting, such as trials and truth commissions, that, however imperfectly, revitalize notions of individual, social, and political responsibility.
Review Essays
The Three Ways of Globalization
The Advantage to Trade: Bhagwati and Irwin
Stephen L. S. Smith
The Politics of Economy: Roberto Unger
Samuel Moyn
The Values of the Market: Stiglitz and Soros
Jedediah Purdy