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RevBioyDer.2015;Númeroextra,recopilatorioespecial:12‐21
RevistadeBioéticayDerecho
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www.bioeticayderecho.ub.edu
ISSN:1886‐5887
ARTÍCULO
TheState,Society,HumanRights&Health.
EthicalChallengesintheDevelopmentofNewInterventions1
SOLOMONR.BENATAR*
The Master in Bioethics and Law at the University of Barcelona supports the Bioethics and Law
Journal:www.bioethicsandlaw.es/master
*SolomonR.Benatar.ProfessorofMedicineattheUniversityofCapeTownandDirectoroftheUCTBioethicsCenter.
1
Thisarticlewaspublishedin:RevistadeBioéticayDerechoUB,no.1,2004.
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
TheState,Society,HumanRights&Health.EthicalChallengesintheDevelopmentofNewInterventions‐SolomonR.Benatar
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Abstract
The theme of this presentation is that major impediments to the development of new interventions to
improve global health comprise the combination of (1) an inadequate value system that is heavily
dominated by selfish individualism, (2) an excessively downstream focus on health and (3) overriding
emphasisonmarketforces.Moralimaginationisrequiredtomovebeyondthecurrentimpasseinwhich
thelivesofsomeseemtobeofinfinitevaluewhilethelivesofothersareapparentlydispensable.Abroader
discourse on ethics and human rights coupled to demonstration of high moral standards by influential
nations could facilitate the introduction of new interventions with the prospect of greatly improving
populationhealth.
Keywords:globalization;values;infectiousdiseases;populationhealth;ethics;HumanRights.
Introduction
As the first step in attempting to resolve an ethical dilemma is to have knowledge of the facts
underlyingthedilemma,Ishallbeginbybrieflyreflectingonsomefactsabouttheworldthatarerelevant
totheethicalchallengesinthedevelopmentofnewinterventionstoimproveglobalhealth.Thesefactswill
highlighttheglobalcontextwithinwhichover‐consumptionatoneextremeanddeprivationattheother
extreme promote diseases of affluence and foster the emergence and spread of infectious diseases that
threatenthehealthofwholepopulations.Ishallthenreviewsomeshortcomingsofavaluesystemthatis
characterizedbystrongindividualism,dominanceofmarket‘logic’andexcessivefaithinscientificprogress
andmedicalcareaspathwaystosolvingglobalhealthproblems.Thiswillleadmetosuggesttheneedfor
moralimaginationinchoosingrationalwaysofaddressingupstreamforcesaffectinghealth.Aframework
foranextendeddiscourseonethicsandhumanrightsisofferedasawedgetowardsdevelopingeffectivenew
interventions.
Somefactsinaglobalcontext
Whiletheglobaleconomyhasincreasedsix‐foldduringthesecondhalfofthe20thcenturytheforces
of economic globalization have perpetuated and aggravated centuries of exploitative processes that
facilitate the enrichment of some people at the expense of others ‐ within and between nations. Covert
erosionoftheeconomiesofmanypoorcountries,undertheimpactoftheneo‐liberaleconomicpolicies
drivingglobalisation,hasobstructedrealdevelopment,andpreventedachievementofwidespreadaccess
toevenbasichealthcareforbillionsofpeople.2AveragenationalpercapitaGNPhasrisentoaboveUS$
2
FalkR.PredatoryGlobalization:acritique.CambridgeUKPolityPress,1999.
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
RevBioyDer.2015;Númeroextra,recopilatorioespecial:12‐21
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25,000insomecountriesandremainedstaticordroppedtolessthanUS$300inothers.Thegapbetween
therichest20%andthepoorest20%oftheworld’spopulationhaswidenedcontinuouslyfrom9timesat
thebeginningofthecenturytoover80timesby1997.About1.2billionpeopleliveonlessthan$300ayear.
Many of these live under conditions of absolute poverty defined as a condition of life so limited by
malnutrition,lackofaccesstosafewaterandbasichealthcare,illiteracy,disease,squalidsurroundings,
highinfantmortality,andlowlifeexpectancy.
Thedebtowedtorichcountriesbythepooramountedto$2.2trillionin1997‐adebtdeveloped
andperpetuatedthrougharmstradingandillconceived'developmentprojects'thatdidmoreharmthan
goodandusuallybenefiteddevelopednationsmorethanthosetheywereallegedly'developing.'Suchdebt
canneverberepaidandperpetuateseconomicdependenceandhumanmisery.34Foreigndevelopmentaid
hasalsobeenfallingoverrecentyearsandisincreasinglydirectedtowardshumanitarianaidratherthan
towardssustainabledevelopment.5
Sub‐SaharanAfricahasbeenmostadverselyaffected.Thisregionnowhas3milliondisplacedpeople,
14millionAIDSorphans,475millionAfricanlivingonlessthan$2/dayandhungeraffecting40million.The
devastationresultingfromHIV/AIDSinAfricaneedstobeseeninthecontextofthreehundredyearsof
slavery(1441‐1870),seventyfiveyearsofcolonialism(1885‐1960),andaColdWar(1960s–1991),that
successivelydebilitatedthesub‐continent.Excitementandpridethatcamewithindependenceinthe1960s
turnedtodespairwithtyrantsinthe1970sandbythe1990smanyviewedAfricancountriesas‘political
andeconomicinfernos.’TheUSretreatfromAfricaaftertheColdwaraccompaniedbyongoingextraction
ofresources(skilledpeople,diamondsandoil)perpetuatescenturiesofexploitation.6Sub‐SaharanAfrica's
debtof$275.6billioncanneverberepaid,resultsinannualinterestpaymentsthatcanceloutthe$21.2
billionannualaiddonationtoAfrica,crippleshealthservicesandstultifiesdevelopment.7
Globalhealthchallenges
Healthandpovertyareintimatelyrelated.Povertyimpairshealthandpoorhealthsustainspoverty.
Growinginequalitiesintheburdenofdiseaseandmanyprematuredeathsareassociatedwiththegrowing
economic disparities described. 8 About one third of all human deaths each year are poverty related.
3
PettiforA.Debt,theMostPotentFormofSlavery:ADiscussionoftheRoleofWesternLendingPoliciesinSupportingtheEconomies
ofPoorCountries.London:DebtCrisisNetwork1996.
4
LabonteR,SchreckerT,SandersD,MeeusW.FatalIndifference:theG8andglobalhealth.UCTPressandInternationalDevelopment
ResearchCentre.Ottawa2004.
5
LancasterC.Transformingforeignaid:UnitedStatesassistanceinthe21stcentury.InstituteforInternationalEconomics.Washington
DC2000.
6
SchwabP.Africa:acontinentself‐destructs.PalgraveMacmillanNewYork,2002.
7
IntoAfrica:Specialreport.TorontoStar25MayFSectionpp1‐5(2003).
8
BenatarSR.Globaldisparitiesinhealthandhumanrights.AmerJPublicHealth.1998.88:295‐300.
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
TheState,Society,HumanRights&Health.EthicalChallengesintheDevelopmentofNewInterventions‐SolomonR.Benatar
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Moreover,disparitiesinwealtharenolongerdistributedalonga‘North’‘South’axisbutnowapplywithin
mostcountries,includingtheso‐called‘highlydeveloped.’
Disparities in wealth and health are accompanied by unsustainable consumption patterns and
distorted expenditure on health and medical research. Exuberant patterns of consumption of cannot be
emulated by all globally and would in any event be unsustainable. Yet many view development as
synonymous with increasing consumption! Global expenditure on health amounted to over $2.2
trillion/yearintheearly2000swith87%ofthisexpenditureonamere16%oftheworld’spopulationwho
bearabout7%oftheglobalburdenofdiseaseexpressedindisabilityadjustedlifeyears(DALYs).Annual
percapitaexpenditureonhealthcarearoundtheworldrangesfromlessthan$15toover$5000.Ofabout
$70billionspentannuallyonmedicalresearch90%isdevotedtothosediseasesthataccountfor10%of
the global burden of disease. Of 1393 new drugs marketed from 1975‐1999 only 16 were for tropical
diseasesortuberculosis. Itwouldseemthat medicinehas somehow forgotten itspurposeandhas been
hijackedtoservetheeconomicinterestsandscientificcuriosityofthemostprivileged!
Itisagainstthisbackgroundthatmanyinwealthycountries(andmanyemergingmiddleclasspeople
elsewhere) are increasingly suffering from diseases of affluence (obesity, type 2 diabetes and vascular
diseases), while new infectious diseases, exemplified by HIV and SARS, with the potential to spread
throughoutthewholeworldhavebeenemergingoverthepast25years.Thesesignsofchangeintheglobal
system result from complex processes that include population growth, rapid urbanization, economic
growthwithwideningdisparitiesinwealth,overandunderconsumptionoffoodandenergy,andwarand
ethnicconflictwithresultingmigrationanddisplacementofmillionsofpeople.Additionalforcesinclude
profoundpovertytraps,alteredrelationshipswithanimals,ecologicaldegradation,andagrowinginformal
economyinwhichdrugs,peopleandsexaretradedacrosstheworld. 9Ongoingattemptstosolvethese
problemswithtechniquesthatareinadequatetothetaskwillnotimprovethefuture.Afreshlookisneeded
athowwelive,whatwevalueandwhatcanbedonetoimprovehumanlivesandhealthglobally
Reflectionsonourvaluesystemanditsshortcomings
Althoughdisparitiesinwealthandhealthareincreasinglystatedfactsaboutanunjustworld,most
privileged people remain complacent and continue to pursue their own short‐term economic goals
seeminglyoblivioustotheplightofmillionsofpeople,andwithlittleinsightintotheimplicationsfortheir
ownfuture.Someprivilegedpeoplejustifytheircomplacencythroughbelievethatpovertyisnotthefault
ofwealthycountries,butrathertheresultofbadgovernmentelsewhere,andcanbealleviatedbymarket
forces.Othersmayberemorsefulbutbelievethattheproblemsassociatedwithpovertyareofsuchgreat
magnitudethatthereislittlethatcanbedonetoamelioratethem.However,asPoggehasarguedbecause
9
Benatar S R. The coming catastrophe in international health: an analogy with lung cancer. International Journal (Journal of the
CanadianInstituteofInternationalAffairs).2002.LV1(4)595‐610.
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
RevBioyDer.2015;Númeroextra,recopilatorioespecial:12‐21
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wealthy nations, and by implication their citizens, are implicated in the generation and maintenance of
social injustice and poverty they need to face their responsibilities to alleviate the lives of those most
adverselyaffected.10
Understanding the dominant values driving behaviour in the modern world can assist our
understandingofhowtheworldhasbecomesopolarised. 11Firstly,thereisgreatfaithinthebeliefthat
manyoftheproblemswefacewillbeamelioratedthoughscientificprogress.Asaresultmoreandmore
money and scientific effort is devoted to seeking reductionist solutions. For example, solutions to the
problem of millions of starving and sick people in the world are seen in the development and use of
geneticallyengineeredcropsandintheapplicationofnewgenetictechnologythroughvaccinesandnovel
treatment.12Whilethepotentialvalueofsuchprogressshouldnotbeunderestimated,weshouldnotallow
over‐emphasisonacquiringnewknowledgetodistractusfromapplyingtheknowledgewealreadyhave.
Inparallelwithmakingscientificadvancesweshouldbealsobeseekingmeanstodistributetheexcessfood
producedintheworld(muchofwhichiswasted),andtomakeessentialdrugsandhealthcaremorewidely
accessible.
Thisshortcomingisamplifiedbyasecondideainwhichmuchfaithisplaced:namelythateconomic
growthistheanswertopoverty.Sadlynotenoughattentionisgiventohowmassiveeconomicgrowthin
recentdecadeshasfailedtoalleviatepovertyintheabsenceoffairrewardforworkandgreaterjusticein
theredistributionofresourcestowardsthoseinmostneed.Botheconomicgrowthandimprovedmethods
ofeconomicdistributionarerequired.1314
A third ‘belief’ thataggravatesthis situation is the exclusive focus on ‘human rights’ asa modern
‘civilising’moralagenda.Whilethehumanrightsapproachhasgreatpotentialthisismuchdiminishedbya
narrowfocusonuninhibitedindividualfreedomwithlittlesincereattentionpaidtothesocial,culturaland
economicrightsthatareessentialforhumanflourishing. 15Commitmenttohumanrightsinitsbroadest
senseisrequired.
Finally, the disproportionate belief in the pursuit of short‐term self‐interest, fostered by market
fundamentalism,emphasisesproductionofgoodsforconsumptionbyindividualswhilelong‐terminterests
andtheproductionofpublicgoodsareundervalued.16
PoggeT.Responsibilitiesforpoverty‐relatedillhealth.EthicsandInternationalAffairs.2002;16(2)71‐79.
10
BenatarSR.HumanRightsintheBiotechnologyEra.BioMedCentral2002:www.biomedcentral.com/1472‐698X/2/3.
11
SingerPA,DaarAS.Harnessinggenomicsandbiotechnologytoimproveglobalhealthequity.Science2001;294:87‐89.
12
HongE.Globalisationandtheimpactonhealth:Athirdworldview.ThePeoples’HealthAssembly,Savar,Bangladesh,December
13
2000.
PoggeT.WorldPovertyandHumanRights:CosmopolitanResponsibilitiesandReforms.PolityPress,CambridgeUK2002.
14
FalkR.Humanrightshorizons:thepursuitofjusticeinaglobalizingworld.NewYork:Routledge;2000.
15
KaulI,GrunbergI,SternMA,(Eds).GlobalPublicGoods:InternationalCo‐operationinthe21stCentury.NewYork:OxfordUniversity
16
Press(publishedforTheUnitedNationsDevelopmentProgramme(UNDP),1999.
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
TheState,Society,HumanRights&Health.EthicalChallengesintheDevelopmentofNewInterventions‐SolomonR.Benatar
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Such high profile values are underpinned by a strong sense of individualism within atrophying
communitieswherethevirtuesofciviccitizenshiphavebeenerodedandhighervalueisplacedonthelives
ofthosewithresourcesthanonthelivesofthepoor.17
Moral imagination: developing new values to address upstream forces
affectinghealth
In order to make progress it is necessary to be able to reflect deeply on the above‐mentioned
upstreamforcesthatshapehumanhealthandwellbeing,andtoattempttodevelopconstructivesolutions.
JonathanGlover’sdescriptionofrepeatedgenocideacrosstheworldduringthe20thcenturyremindsusof
humaninhumanitytofellowhumans,andofhowdifficultitwillbetochangedominantwaysofthinking.
Heconcludesthatitisonlyourmoralimagination―ourabilitytoimagineourselvesintheshoesofothers―
thatcouldenableustosignificantlyalterouroutlookandactions.18Thoseofuswhohaveledprivileged
livesneedtoreflectontheabominableconditionsunderwhichsomanylive,withminimalaccesstothe
productsofprogress.Indoingsoweneedtoimaginefirstlyhowwewouldfareundersuchconditions,and
thenwhatweshouldandcoulddoatrelativelyminimalcosttoourselvesthatcouldgreatlyenhancethe
livesofmany.InthisshortpresentationIcanonlysuggestdirectionsforsuchprogressbydrawingattention
toasmallselectionofrecentscholarlyworkthatprovidesguidance.
PeterSinger,inanextensionofhispreviousworkonpovertyalleviation,askswhataglobalethic
meansinaninterdependentworld,inwhichallarelinkedthroughexposuretothesameatmosphere,a
globaleconomy,internationallawhumanrights,andaglobalcommunity.Hedoessothroughacriticaland
provocative examination of climate change, the World Trade Organization’s role, the concept of human
rights,theplaceforhumanitarianinterventionsandshortcomingsinforeignaid.Hedevelopsthethesisthat
‘…howwellwewillcomethroughtheeraofglobalization(perhapswhetherwecomethroughitatall)will
dependonhowwerespondethicallytotheideathatweliveinoneworld.Fortherichnationsnottotakea
globalethicalviewpointhaslongbeenseriouslymorallywrong.Butnowitisalso,inthelongterm,adanger
totheirsecurity.19
Intheirbook“Howmightwelive?Globalethicsinthenewcentury”Booth,DunneandCoxremind
usthat‘choiceliesattheheartofethics,’thathumanchoicesareneitheralwaysfreenoralwaysdetermined.
History,power,context,biologyshapeourchoices,asdoourpowersofimaginationandourcapacityto
WorldCitizenship:AllegiancetoHumanity.RotblatJ(Ed)Macmillan,London,1997.
17
GloverJ.Humanity:amoralhistoryofthe20thcentury.NewHaven:YaleUniversityPress,2001.
18
SingerP.Oneworld:theethicsofglobalization.YaleUniversityPress,NewHaven2002.
19
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
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chooserationally.Everychoicealsohasaprice.Politicsandethicsareinseparable,likepoliticsandpower,
andforeignpolicyshouldbeunderstoodasethicsinaction―thechallengebeingtobuildabetterworld.20
TheRoyalDanishForeignMinistryhassummarizedextensivedebatesonhowtobuildamoralglobal
community. The major conclusion of this work is that economic globalization, propagating a model of
development based solely on freedom of individuals and consumerism, is not sufficient to create a
harmonious world community. Further, it is proposed that to focus on the common good will require a
synthesisaroundthreesubstantivegoals(democracy,ahumanistpoliticalcultureandaneconomyoriented
tomeetinghumanneedsinthewidestsense)andtwoproceduralgoals(developingacoalitionofsocial
forceswithaglobalagenda,andbuildingastructureformultilateralgovernance).21
Crockerposesseveralquestionsaboutdevelopmentethicsandglobalization.Whatshouldbemeant
by development? In what direction and by what means should a society ‘develop’? Who is morally
responsibleforbeneficialchange?Whataretheobligations,ifany,ofrichsocietiestopoorsocieties?How
shouldglobalization’simpactandpotentialbeassessedethically?22Addressingthesequestionscouldshape
newwaysoflookingattheworldandpromotedeeperunderstandingofwhatitmeanstobeacitizeninan
increasingly interdependent world that could embrace renewed concepts of solidarity, and concern for
others,eventhoseverydistantfromourowndailylives.Newparadigmsofthinkingcouldbothpromote
deeper insights into how complex systems function and facilitate novel approaches to international
finances.
We have attempted to address the moral challenges posed by global health considerations have
identifiedseveralvaluesthatneedtobewidelypromoted.23
 Respectforalllife&universalethicalprinciples
 HumanRights,ResponsibilitiesandNeeds
 Equity
 Freedom
 Democracy
 Environmentalethics
 Solidarity
Wehavealsosuggestedawayforwardthroughfivetransformationalapproaches
BoothK,DunneT,CoxM.Howmightwelive?Globalethicsinthenewcentury.CambridgeUniversityPress.2001.
20
RoyalDanishMinistryforForeignAffairs.Buildingaglobalcommunity:globalizationandthecommongood.Copenhagen:RDMFA,
21
2000.
CrockerD.Developmentethicsandglobalization.Philosophy&PublicPolicyQuarterly.2002;22(4)13‐19.
22
BenatarSR,SouthAfrica'stransitioninaglobalizingworld:HIV/AIDSasawindowandamirror,InternationalAffairs77(April
23
2001),347‐75.
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
TheState,Society,HumanRights&Health.EthicalChallengesintheDevelopmentofNewInterventions‐SolomonR.Benatar
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 Developingaglobalstateofmind
 Promotinglong‐termself‐interest
 Strikingabalancebetweenoptimismandpessimismaboutglobalizationandsolidarity
 Strengtheningcapacity
 Enhancingproductionofglobalpublicgoodsforhealth
It is proposed that such progress could be initiated by expanding the discourse on ethics from
interpersonal relationships, to the ethics of relationships between institutions and even to the ethics of
relationshipsbetweennations.
The idea that bioethics can serve as a tool for progress is supported by Wildes’ contention that
bioethics is a form of social philosophy. He reminds us that industrialized countries have constructed
multiplebureaucraciestoenable,governandregulatehumanlifeandthatthesestructureshelptodefine
humanlifeandoftenactasaformofsocialcontrol.Becausesystemsofmedicineandhealthcaredelivery
areoneofthesebureaucraticstructures,medicineisasocialinstitutionandethicalissuesinmedicineand
healthcarecanonlybeaddressedadequatelyiftheyareunderstoodinthesocialcontextofthepracticeof
medicine.Bioethicsprovidesalensthroughwhichtoexaminesecularsocietiesandgaininsightintopolitical
authorityanditsappropriateexercise.24
Resourcesfornewglobalhealthinterventions
Acknowledgmentthatresourcesneedtoberaisedformanynewinterventionsthatcouldimprove
health globally has stimulated generous philanthropy. Much hope is now being placed on such recent
projectsasPresidentBush’sEmergencyPlanforAIDSRelief(PEPFAR),theWorldBankMultisectorAIDS
Project(MAP),theGlobalFund,theClintonFoundationandotherambitiousdonoragencies.However,while
philanthropyisnecessaryitwillnotbesufficienttosustainimprovementsinglobalhealth.Severalother
potentialmeansofsustainingpovertyreductionstrategiesalsoneedtobeconsidered‐‐althoughallare
contentiousandwillberesisted.
Firstly,ashifttowardsunderstandingthatwarisexpensive,aggravatesillhealth,andplaysarolein
promotingtheemergenceofnewdiseases,couldallowsomeoftheUS$750billionspentgloballyeachyear
tobedivertedtohealthpromotingactivities.25Associatedreductioninconflictandthepromotionofpeace
couldcontributetosustainableprogresstowardsbetterlivesformanyandencouragenewvisionsofglobal
WildesKWm.Bioethicsassocialphilosophy.SocialPhilosophy&PolicyFoundation.2002;19:113‐25.
24
KassalowJS.WhyhealthisimportanttoU.S.ForeignPolicy.CouncilonForeignRelations&MilbankMemorialFund,NewYork2001.
25
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
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security.TheexampleofhowexcessiveexpenditureonmilitarizationinSouthAfricaimpededdevelopment
inthatcountryissalutary.26
Secondly,acknowledgementbywealthynationsoftheirroleinsustainingpoverty,couldincrease
their sense of responsibility to providing development aid in a manner that progressively reduces
dependenceonphilanthropy.Sreenivasan,likeotherspreviously,suggeststhatifOECDcountriesdonated
1%oftheirGDPforforeignaidthiswouldtotal$222.25billion–asignificantadvanceoverthe$56.378
billiondonatedin1999(0.24%GDP).Hearguesthat1%isamodestamountthatisimplausibletocontest
giventheamountofgoodthatcouldbeachievedwiththissum.Heexplorestheimplicationsofhowtouse
suchresourcesanddealswithobjectionstohisproposalthatcouldberaisedfromtheperspectiveofideal
theory.27
Acomplimentaryapproachistoreconsiderabolishingdebtsthatcanneverberepaid.Maintaining
thirdworlddebtintheknowledgethatitwastoalargeextentcreatedthroughinappropriatearmstrading
anddefectivedevelopmentprojectsunderminesboththehumanityofthosewhodemandrepaymentand
thelivesanddignityofthethosewhoareeffectivelyenslavedbydebt.Debtreliefwillnotremovetheneed
forloansandfinancialassistance,butwillrequireaccountabilityfornewloanstoensuretheirlegitimacyin
thefuture.Debtcrisesneedtobeaddressedwithinthebroadercontextoftheinternationalfinancialsystem
thathasbeenimposedbyfinanciallypowerfulnationsandwhomustassumesomeoftheresponsibilityfor
itsadverseeffects.28
Pettiforhasdescribedthefollowingprinciplesforfairlydealingwithdebt.Firstly,acknowledgement
thattotheextentthatbothpartiestoaloancanbehaverecklesslyandirresponsiblyincreatingdebtsso
both should share the burden of crises that may ensue. Secondly, there should be respect for the legal
principleofimpartialjudgementandthatthoseinvolvedinadisputeshouldnotbejudges.Thirdly,there
should be accountability to citizens and taxpayers for debt crises that are public and involve the use of
taxpayerfunds.26
Yetanotherapproachwouldbetoraiseresourcesfromnewtaxes.Globaldailyfinancialtransactions
exceed $1 trillion, of which less than 10% is spent remunerating people for services rendered. The
remainder is merely repackaged and resold within what has been called a `casino economy.’29 It is
reasonabletosuggestthatitwouldbelegitimatetotaxsuchmonetarytransactionsforaglobaldevelopment
fund.Similarly,currentconceptsoffreetradeshouldbemodifiedtoincludeenvironmentalcostsinbusiness
Fine B, Rustomjee Z, The Political Economy of South Africa: From Minerals‐Energy Complex to Industrialization Johannesburg:
26
WitwatersrandUniversityPress1996.
SreenivasanG.Internationaljusticeandhealth:aproposal:EthicsandInternationalAffairs.2002;16(2):81‐90.
27
PetifforA.Resolvinginternationaldebtcrisesfairly.EthicsandInternationalAffairs,2003;17(2)2‐9.
28
www.globalexchange.org;SusanStrange,CasinoCapitalism,Oxford:Blackwell1986.
29
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.
TheState,Society,HumanRights&Health.EthicalChallengesintheDevelopmentofNewInterventions‐SolomonR.Benatar
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activities.Thiswouldindicateacceptancethattherecannotbefreeaccesstothe`naturalcommons'tothe
disadvantageofdistantotherselsewhereorfuturegenerations.30
Finally,thepromotionoffairtraderuleswouldgenerateverysignificantresourcesfordeveloping
countriesbyallowingthemtoselltheirproductsatpricesthatwouldincreasetheirindependence.Annual
farmingsubsidiesofUS$350billioninindustrialisedcountries31andtradeprotectionismcostdeveloping
countries$50billionannuallyinpotentialexportearnings.32
SettingaMoralExample
Aspowerfulasscience,themarket,humanrightsandothermorallanguagesmaybe,theinfluenceof
wealthycountriessettingamoralexampleispotentiallymorepowerful.Neglectofthepoorwithinrich
societies,perpetuationofunsustainableconsumeristlifestyles,lackofuniversalaccesstohealthcarewithin
theUnitedStates,andthecontinuingproductionofweaponsofmassdestruction,33arepoorexamplesfor
other nations. Trends in aid donations to developing countries reveal that progressively smaller
proportionsofashrinkingtotalarebeingspentonrealdevelopmentwhileagrowingproportionisspent
onhumanitarianassistance4for‘man‐made’tragediesthatcouldbeprevented.
Conclusions
Globalhealthdisparitiesposethegreatestpotentialsecurityrisktohealthandlivesofall.Moreover,
itisnotonlythesedisparitiesintheirownrightthatposechallengestodevelopmentofnewinterventions,
butmoreparticularlyitisthoseforcesthatgeneratethedisparitiesthatposethemajorimpedimentsto
improvementsinglobalhealth.Upstreamcausesshouldbeunderstoodandacknowledged,thepoliticalwill
musteredtotakeappropriateactionandmechanismsforsuchactiondefinedandactedon.Thisagenda
couldallowscientificprogresstobeaccompaniedbymoralprogress,andremovalofimpedimentstonew
interventionsthatcouldimproveglobalhealth.
LouN,GleesonB,SocietyandNature,London:Routledge1998.
30
ElliottL.Don’tlettherichcrypooroveraid.GuardianWeekly,May22‐28.Pp12.2003.
31
KristofND.WhatdidyoudoduringtheAfricanHolocaust?NewYorkTimes.May27,A252003.
32
SivardR.WorldMilitaryandSocialExpenditure16thEd,WashingtonDC:WorldPrioritiesPress1996.
33
Estaesunarevistaelectrónicadeaccesoabierto,loquesignificaquetodoelcontenidoesdelibreaccesosincostealgunoparaelusuarioosuinstitución.Losusuarios
puedenleer,descargar,copiar,distribuir,imprimiroenlazarlostextoscompletosdelosartículosenestarevistasinpedirpermisopreviodeleditorodelautor,siempre
quenomedielucroendichasoperacionesysiemprequesecitenlasfuentes.EstoestádeacuerdoconladefiniciónBOAIdeaccesoabierto.