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Women Prisoners and Health Justice Perspectives Issues and Advocacy for an International Hidden Population 1st Edition Dianne Hatton
Rather than making another attempt at proposing a single and unifying theory of global health justice, this timely collection brings together, instead, scholars from a range of traditions to frame the issue more broadly, highlighting not only different perspectives but also key topics and debates.
The volume features chapters that offer both new theoretical approaches to global health justice, as well as fresh takes on existing frameworks. Others adopt a bottom-up approach to tackle specific problems, including the sexual rights of children and adolescents, artificial intelligence (AI) in medicine, framing of neglected tropical diseases, securitisation of health, and trademarks in global health. Brought together within one volume, the breadth of these chapters provides a unique and enlightening contribution to the wider Global Health field.
This important volume will be a fascinating read for students and researchers across Global Health, Bioethics, Political Philosophy, and Global Development.
Himani Bhakuni is a Lecturer at York Law School, United Kingdom. Before that, she was the Assistant Professor of Justice in Global Health Research at the University Medical Center, Utrecht University. She primarily works on issues within global health and human rights, particularly on questions surrounding justice, reparations, and global health law.
Lucas Miotto is a Senior Lecturer in Law at the University of Surrey and a core member of the Surrey Centre for Law and Philosophy. He works at the intersection between legal, moral, and political philosophy, dealing with questions about coercion, manipulation, wrongful interference, and forms of just governance.
JUSTICE IN GLOBAL
HEALTH
New Perspectives and Current Issues
Edited by Himani Bhakuni and Lucas Miotto
Designed cover image: Getty Images
First published 2024 by Routledge
4 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 605 Third Avenue, New York, NY 10158
The right of Himani Bhakuni and Lucas Miotto to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers.
Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloguing-in-Publication Data
Title: Justice in global health : new perspectives and current issues / edited by Himani Bhakuni, and Lucas Miotto. Description: Abingdon, Oxon [UK] ; New York, NY : Routledge, 2023. | Includes bibliographical references and index. |
Identifiers: LCCN 2023020046 | ISBN 9781032508474 (hardback) | ISBN 9781032508450 (paperback) | ISBN 9781003399933 (ebook)
Subjects: LCSH: Right to health. | Human rights. | Public health laws. | Bioethics. Classification: LCC K3260.3 .J87 2023 | DDC 344.03/21 dc23/eng/20230802
LC record available at https://lccn.loc.gov/2023020046
ISBN: 978-1-032-50847-4 (hbk)
ISBN: 978-1-032-50845-0 (pbk)
ISBN: 978-1-003-39993-3 (ebk)
DOI: 10.4324/9781003399933
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Alice Trotter and Ioana Cismas
7 Reproductive Justice and Ethics of Consent in Assisted Living Facilities for Disabled People: A Critical Reflection for Socio-Legal Policies on Long-Term Care
Keerty Nakray
Himani Bhakuni and Lucas Miotto
CONTRIBUTORS
Alice Trotter is a PhD candidate at the Centre for Applied Human Rights at the University of York, United Kingdom. Alice has been involved in the pluridisciplinary project ‘Noma, The Neglected Disease. An Interdisciplinary Exploration of Its Realities, Burden, and Framing’. Her other research focuses on human rights in cities.
Alvaro Fernandez-Mora is a Lecturer at York Law School, United Kingdom. He holds a DPhil from the University of Oxford (DPhil) and an LLM from Harvard Law School (LLM). Dr Fernandez-Mora’s research interests lie at the intersection between intellectual property law and other fields – notably human rights and competition law and economics. Dr Fernandez-Mora’s work has been published in the Berkeley Journal of International Law (BJIL), the International Review of Intellectual Property and Competition Law (IIC), and the Intellectual Property Quarterly (IPQ), among others.
Daniel Elliot Weissglass is an Assistant Professor of Philosophy at Duke Kunshan University. His chief research interests with respect to health include models for improving the moral and political adequacy of global health governance, models of decision making for persons with compromised and/or variable cognitive capacities, assessing the values implicit in the tools used to measure and report health outcomes, and the risks and benefits of medical AI – especially in LMICs.
Erika Blacksher is the John B. Francis Chair at the Center for Practical Bioethics and Research Professor in the Department of History and
Contributors ix
Philosophy of Medicine at the University of Kansas School of Medicine. Dr. Blacksher studies questions of responsibility and justice raised by U.S. health inequalities and the potential for democratic deliberation to build shared purpose across race, class, and geography and to make health a shared value. Her current work focuses on intersectional health inequalities, with a focus on class, poverty, and race, and the methodology of democratic deliberation.
Gottfried Schweiger is a Senior Scientist at the Centre for Ethics and Poverty Research (CEPR) and a member of the Philosophy Department (KTH) of the University of Salzburg, Austria. His research revolves around social and political philosophy with a focus on poverty, social and global justice, migration, childhood and youth, social work, sports, and critical theory.
Hendrik Kempt works mostly in applied ethics, with a focus on the ethics of medical AI, natural language processing, and human–machine relationships. He has published several books and articles, his latest being on “Synthetic Friends”. He is a research associate at the Applied Ethics Group at RWTH Aachen.
Himani Bhakuni is a Lecturer at York Law School, United Kingdom. Before that, she was the Assistant Professor of Justice in Global Health Research at the University Medical Center, Utrecht University. She primarily works on issues within global health and human rights, particularly on questions surrounding justice, reparations, and global health law.
Ioana Cismas is a Reader and the Co-Director of the Centre for Applied Human Rights at the University of York, United Kingdom. Dr Cismas’ interests span the broad discipline of public international law, the specialist branches of international human rights law and international humanitarian law, and related fields, such as law and religion and transitional justice. Her work has attracted substantial research grants from the UK Economic and Social Research Council (ESRC), the Swiss National Science Foundation, the Swiss Network of International Studies (SNIS), and several non-governmental organisations and charities. Currently, Dr Cismas co-coordinates the SNIS-funded project Noma, The Neglected Disease. An Interdisciplinary Exploration of Its Realities, Burden, and Framing.
Joanne Liu is an Associate Professor of Medicine at the University of Montreal, a Professor of Clinical Medicine at McGill University, and the former International President of Médecins sans Frontières. She is also a paediatric emergency medicine physician in Montreal.
Keerty Nakray is a Professor at Jindal Global Law School, NCR Delhi and Adjunct Faculty at the Centre for Ethics, Yenepoya University, Mangalore. She holds a PhD in Sociology and Social Policy from Queen’s University Belfast, Northern Ireland. Her research deals with topics such as genderbased violence, social policy, child poverty, and social exclusion.
Lucas Miotto is a Senior Lecturer in Law at the University of Surrey and a core member of the Surrey Centre for Law and Philosophy. He works at the intersection between legal, moral, and political philosophy, dealing with questions about coercion, manipulation, wrongful interference, and forms of just governance.
Luciano Bottini Filho is a Lecturer in Human Rights Advocacy at Sheffield Hallam University and an affiliated researcher at the Petrie-Flom Center for Health Law Policy, Biotechnology, and Bioethics at Harvard University. His research studies resource allocation, global health, and the right to health. He has been both a Modern Law Review Scholar for his PhD studies at Bristol and a Chevening Scholar by nomination of the UK Foreign, Commonwealth and Development Office (FCDO).
Man-to Tang is a Visiting Fellow at the Department of Public and International Affairs, City University of Hong Kong. His research interests are in phenomenology, classical and contemporary Confucianism, and political philosophy.
Nils Freyer works in the field of machine learning, especially active learning and natural language processing. His research interests also include questions of AI ethics, with a focus on medical AI. He is currently a research assistant at FH Aachen – University of Applied Sciences.
Ryoa Chung is a Full Professor in the Department of Philosophy of the University of Montreal and Co-Director of the Center for Research in Ethics. She works in the field of international ethics, feminist philosophy, political philosophy, and health inequality. She also teaches medical ethics/bioethics at the Faculty of Medicine of the University of Montreal. Her works have appeared in edited volumes published by Oxford University Press, Presses universitaires de France, and in journals such as Journal of Social Philosophy, Journal of Medical Ethics, Public Health Ethics, The Lancet, and Hastings Center Report.
Sridhar Venkatapuram is an Associate Professor of Global Health and Philosophy at King’s College London in the United Kingdom. He is based x Contributors
at the Global Health Institute, where he is Deputy Director, and Director of Global Health Education. He is the author of Health Justice: An Argument from the Capabilities Approach (2011), co-editor of Vulnerable: The Law, Policy and Ethics of Covid-19 (2020) and The Routledge Handbook of Philosophy of Public Health (2022). He can be found at @sridhartweet.
Xuanpu Zhuang is a PhD candidate at Bowling Green State University, Department of Philosophy. Xuanpu works on issues within political and practical philosophy, particularly on issues pertaining to equality, citizenship, and justice.
INTRODUCTION
Justice in Global Health
Himani Bhakuni and Lucas Miotto
As we write this introduction in early 2023, we are fortunate to have survived one of the most daunting global health emergencies of our time, but the world lost many to COVID-19. Health emergencies tend to refocus our attention not only on the value of life, but also on the centrality of health in preserving life. In the early days of the pandemic, COVID-19 was called “a great equaliser”, that it would affect everyone the same. But soon enough, that thought went out the window quite like almost everything else that has been called a great equaliser before. It is not news that our world is riddled with staggering inequalities. Everything that threatens humankind tends to threaten some bits of humankind more than others. But that we continue to bear these inequalities despite there being other ways to think, reason, and act is even more staggering.
This book is about that – not about continuing to bear the different forms of health inequalities – but about challenging them. Our contributors, from varied disciplines, have thought of some problems in global health and have given reasons for why we would all be better off in thinking of a given problem in a particular way. Some have provided legal solutions; others have questioned the way we frame issues. Some have proposed newer frameworks that could be used to tackle injustices in global health, while others have used pre-existing theories of justice and applied them to modern-day health issues. But the goal of each chapter in this edited volume is the same –to provide some guidance on what would aid the field of global health in achieving its lofty aspiration of improving health for all people worldwide. We choose the overarching language of justice to do so.
Up until a few decades ago the notion of justice (in academic circles at least) was predominantly territory bound. There was international justice,
DOI: 10.4324/9781003399933-1
2 Himani Bhakuni and Lucas Miotto
but it was largely about justice amongst nations. Lately, factors including globalisation, digitalisation, increasing climate change, economic interdependence, and enduring global effects of colonial histories, have all led to the expansion of the scope of justice. Today, we talk about global justice not only when we consider duties that we have towards others beyond nationstates, but also when we talk about worldwide inequalities as moral problems which are embedded in local contexts and shared norms. Global health justice then becomes an area of research that focuses on proposing, creating, and maintaining conditions that would enable everyone, not just a privileged few, to experience and achieve good health and life.
Philosophers and political theorists have attempted to provide an overarching theory of global health justice, wherein they have been particularly inspired by the capabilities approach.1 Some have extended preexisting theories of global justice and the rights-based approach to health.2 Despite all these commendable efforts, it is quite likely that, given the multitude of global health problems, a single overarching theory of justice would still at best be a partial explanation of the duties and obligations of various stakeholders involved in the debate. Which is why this edited volume adopts a mix of approaches to look at justice in global health, it provides some new philosophical frames and fresher takes on existing frames, but it also tackles some more specific problems that we believe that any successful overarching theory of global health justice must address. While general frameworks of justice help to provide a better understanding of our world and our responsibilities within it, more specific incursions on specific issues allow us to see solutions to problems that might not be immediately available or salient to those who attempt to provide unifying frameworks.
We are aware that this book is releasing at a time when people might be going through a health-topic fatigue. A lot has been written (and is being written) about health, daily. But we nonetheless believe that this volume adds much more than just noise to the conversation. The volume contains 13 original contributions, most of which were first presented online at the Justice in Global Health Workshop Series in October 2022. The contributions address a wide range of issues and topics within global health justice: from specific challenges associated with an overlooked disease, future injustices caused by the development of new technologies, role of law in addressing commercial determinants of health, and institutional reforms, to new theoretical frameworks for global health justice. As editors, we are proud of the volume’s thematic breadth. But we are also proud of the interdisciplinary dialogue that took place amongst contributors from different backgrounds and corners of the world. Such dialogue allowed us to identify some common threads and insights running across contributions, which we think would be valuable to anyone interested in global health and
global health justice. To make the threads clearer to our readers, we have divided the volume into five parts. This division, however, should not be seen as an attempt to draw hard boundaries; some themes, arguments, and concepts recur through the volume. In what follows we provide an overview of the volume’s contributions.
Part I. Citizenship, Power, and Relational Justice
The first part illustrates a pervasive theme in the book. Justice in global health requires more than a fair distribution of resources – it requires a fair distribution of the burdens necessary to maintain our health systems globally. It also requires addressing morally problematic relations of power and, more specifically, that we relate to one another as equals and respectfully in health-related contexts. Relational justice is, therefore, integral to global health justice. However, promoting relational justice in global health may require radical shifts in our current institutional and political architecture, as is argued by the two chapters in this part.
In World Citizenship and Global Health (Chapter 1), Xuanpu Zhuang argues for one of those shifts by favouring the introduction of the cosmopolitan ideal of world citizenship. “People are not just abstract moral beings”; their identity, rights, and obligations are shaped by their social and political arrangements. Citizenship marks an important form of membership in a social and political arrangement. It typically determines the political rights, liberties, and obligations that individuals have towards the state and towards other individuals living in the same territory. Often, however, social and political relations outgrow the confines of a state or territory: individuals interact as a global community on global matters. This raises a question about the need for a form of world citizenship which, Zhuang argues, is not simply national citizenship writ large. It is, instead, an extra layer of social and political association significant enough to ground certain entitlements to social goods, welfare, and capabilities.
Global health enters the scene because the capability of being healthy is, according to Zhuang, a necessary condition of functioning as a world citizen. To justify this claim, Zhuang introduces the four “Problematic Hierarchies”; four ways in which the absence of health undermines the sort of egalitarian relations which are constitutive of world citizenship. From the discussion, it becomes apparent that strengthening global health is necessary for maintaining the relational egalitarian ideal of world citizenship. But – the chapter also seems to entail – the relationship goes both ways: not only is the capability of being healthy a necessary condition of world citizenship, but some demands to promote global health justice also flow from and are (at least partly) constituted by broader demands of relational equality and respect enshrined in world citizenship.
4 Himani Bhakuni and Lucas Miotto
A good illustration of the relationship between global health justice and relational egalitarianism is found in AI-DSS in Healthcare and Their Power over Health Insecure Collectives (Chapter 2). In this chapter, Nils Freyer and Hendrik Kempt discuss a dilemma that arises from the introduction of artificial intelligence-led decision support systems (AI-DSS) in expert-scarce areas – for example, a system that diagnoses and recommends treatment for a disease without the interference of a medical expert. These systems require what is known as “explainability standards”: standards that allow humans to understand and assess the reliability of the conclusions and recommendations reached by an automated system. For optimal reliability, these standards must be stringent. But the costs, technology, and qualified personnel required to maintain stringent explainability standards cannot often be met by expert-scarce communities – or “collectives”, as the authors believe we should call them. Hence the dilemma: either expert-scarce collectives do not introduce automated systems and abandon their hopes to reap the health benefits that these systems bring, or these collectives settle for a cheaper alternative and accept whatever explainability standards are offered to them by the relevant corporations. Because the second horn of this dilemma is often the more tempting one, the emergence of a “colonial mindset” and the introduction of a relation of domination between collectives and corporations are obvious risks.
The main difficulty, then, is whether this relation of domination can be avoided without abdicating the potential health benefits introduced by AIDSS. The authors propose a way to negotiate explainability standards that do not require eschewing relational justice. The solution explored in the chapter is instructive, as it can be extended to contexts where a similar clash between health benefits and relational justice arises. For example, in contexts of clinical research where some researchers and participants are tempted to relax research regulations in the name of efficiency or short-term health benefits.
Part II. Responsibility for Justice: Law, Civil Society, and the Private Sector
The second part of the volume focuses on the role and responsibilities of courts, advocacy groups, and the private sector in the promotion of global health justice. The opening chapter, Everything Is Unconstitutional –Contesting Structural Violence in Health Systems with Legal Mobilisation (Chapter 3), highlights the use of constitutional remedies as a tool for the elimination of structural violence and inequality in global health. The author, Luciano Bottini Filho, centres the discussion on a case from 2021 where the Brazilian Supreme Court relied on the “state of unconstitutional affairs” doctrine to declare the entirety of the Brazilian public health system unconstitutional in light of its systematic and enduring violation of transgender people’s right to health, life, and dignity.
The Court’s decision helps to highlight the importance of relational justice in the context of global health justice. As we can infer from the chapter, not only was the declaration of unconstitutionality grounded on the denial of health resources, but it was also (and perhaps primarily) based on the systematic discrimination and exclusion of transgender people in the context of healthcare. The chapter also illustrates the vital role that courts can play in the broader transformation of health systems and society more generally. In so doing, it also aligns with the discussion about the just transformation of health systems that appears later in the volume (Chapter 10).
In Framing Noma: Human Rights and Neglected Tropical Diseases as Paths for Advocacy (Chapter 4), Alice Trotter and Ioana Cismas discuss the strategic importance of framing to strengthen the efforts of advocacy groups and campaigns and to bring about changes in global health. Roughly, to “frame” a given issue is to choose the way in which the issue is communicated to a selected audience; thus, a “frame” can be seen as a rhetorical device. In the chapter, the authors discuss the findings from their own empirical research on the uses of alternative frames for tackling noma, a relatively unknown disease that, despite being preventable and treatable, has an estimated mortality rate of around 90% in children. Noma primarily affects those living in extreme poverty, and its effects were initially framed as a medical or humanitarian emergency which, despite the relative success in attracting aid from charities and doctors from the Global North, also brought with it relations of dependency and “signalled a ‘white saviour’ trope”. Here the chapter brings us back to the importance of relational justice to global health: the alternative framings considered by the authors –framing noma as a neglected tropical disease and as a human rights issue –were used precisely to make both material progress in combating the disease and relational progress, as it were, in avoiding the emergence of problematic social relations in the context of health. The chapter, therefore, illustrates how civil society and advocacy groups can play an effective role in tackling global health injustices by carefully choosing how to frame these injustices.
In this part’s last chapter, Trade Marks and the Right to Health: A Growing Tension (Chapter 5), Alvaro Fernandez-Mora discusses policymakers’ use of trade mark-restrictive policies to protect health and health rights. Such policies range from advertisement bans to more aggressive restrictions on packaging and aim at making harmful products less attractive to consumers. These policies stem from the assumption that manufacturers of such harmful products – most notably the tobacco industry – cannot be exempted from a responsibility to promote health. Hence, the sacrifice of their rights to intellectual property and freedom of expression in the name of health seems justified. Be this as it may, Fernandez-Mora identifies a rapid expansion of such health-oriented restrictions into the control of alcoholic products and foods high in fat, sugar, and salt. There, the justification of
implementing such restrictions may not be straightforward, and the risk of undesirable spillover effects is higher. Courts, being key to the success of health-promoting policies, must be mindful of these hurdles when deciding on the adequacy and legality of such expansionist policies. Though tempting, the “protect health by any means” approach can sometimes cause more harm than the prospective harms from which health-oriented policies seek to protect us. Doing justice in global health – and this is a lesson that we can draw from the chapter – sometimes requires that we take a counter-intuitive step away from the short-term protection of the right to health and focus our efforts on other rights which can sometimes be more important to societal well-being in the long run.
Part III. Sexual Rights and Reproductive Justice
The third part of the volume considers some significant issues within a specific branch of global health justice: sexual and reproductive justice. Sexual health and rights are often subsumed under reproductive health and rights, but both are conceptually distinct, albeit related, areas. WHO’s working definition of sexual health states that it “requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence”.3 While much has been written about sexual rights of adults and able-bodied persons, two groups stand out as understudied and undertheorized in this area: children and adolescents and persons with disabilities (PWDs). The chapters included in this part address these two groups.
In The Capability Approach and the Sexual Rights of Children and Adolescents (Chapter 6), Gottfried Schweiger considers how sexual rights reflect the developmental dynamics of child and adolescent autonomy and what aspects of well-being, or what capabilities, these rights protect and enable. Schweiger uses the capability approach to enumerate the sexual rights of children and adolescents, while also focusing on the differences between children and adolescents. His argument is that while sexual rights of children largely deal with defence against dangers and attacks, they must not be limited to that. By relying on the capabilities approach, he proposes a conceptual expansion of sexual rights for children and adolescents: sexual rights should also empower and enable children and adolescents to develop in a sexually healthy way so that they can express their agency according to their level of maturity. This conceptual expansion places sexual education policies as well as measures to raise awareness of contraceptives and sexually transmitted diseases amongst teenagers at the forefront of children and adolescent health. The capabilities approach assists in clarifying that sexual development is part of healthy development and that there are good reasons
to break some of the taboos associated with the talk about sexual health of children and adolescents if we want to make progress in global health.
In Reproductive Justice and Ethics of Consent in Assisted Living Facilities for Disabled People: A Critical Reflection for Socio-Legal Policies on LongTerm Care in India (Chapter 7), Keerty Nakray claims that people suffering from severe intellectual disability are subjected to what is known as “erotic segregation”: the conception according to which disabled people are asexual and not supposed to engage in sexual activities. She uses the framework of critical disability studies to diagnose the cause for this as stigma and discrimination faced by not only the PWDs but also their carers. Her chapter summarises the Indian legal framework dealing with consent of PWDs and discusses leading precedents that demonstrate that despite having a legally recognised right to consent over sexual and reproductive matters, this right for PWDs is barely upheld. Given this and other issues with long-term social care in India, Nakray proposes that some individuals might be able to achieve sexual decision-making capacity through the assistance of a decisionmaking support network. And that such “network consent” could create opportunities for new social justice paradigms and assure long-term humane care of PWDs.
Part IV. Health Governance, Security, and Transitions
Global health governance refers to the use of formal and informal institutions, processes, and rules created and employed by various stakeholders to effectively deal with challenges to global health that require collective action within and across borders. Since its inception, the World Health Organization (WHO) has been the primary institution dealing with health governance as it remains the only international health organisation that can promulgate treaties and regulations with the power to legally bind member states. But (sometimes) with great power, comes greater scrutiny. In the chapter Justice in Global Health Governance: The Role of Enforcement (Chapter 8), Daniel Elliot Weissglass scrutinises some key provisions of the WHOs legally binding International Health Regulations (IHR) and establishes a pattern of pervasive noncompliance with those provisions. He argues that noncompliance with IHR creates not only practical, but political problems, as it creates an environment for the continuation of both substantive and procedural injustices.
Weissglass regards noncompliance as a violation of the Rawlsian ‘principle of fidelity’, which in short means that promise keeping under appropriate circumstances is a fundamental principle of justice. When states fail to meet their obligations under IHR they violate this principle which leads to unfairness in the outcomes of the global health system and perpetuation of health disparities. He further argues that noncompliance leads to unfairness
in the processes of global health governance as it erodes the very normative force of IHR and results in weaker perceived obligations by state parties, thereby feeding further noncompliance. But Weissglass does not stop at merely making a factual and philosophical case for the role of compliance in global health governance. As steps towards increasing compliance, he suggests that the WHO could name and shame noncompliant states, provide conditional support (for instance, by ‘outcasting’ or make access to funds and other cooperative enterprises contingent on compliance of member states), and deploy sanctions (beginning with least severe and coercive and escalating based on the situation).
Global health governance is not only suffering from a problem of noncompliance, but also reeling from some adverse consequences of the narrative of securitisation of health. In The Ethical Issues Raised by the Securitization of Health (Chapter 9), Ryoa Chung and Joanne Liu consider the moral conundrums associated with framing health issues as national and international security threats. The salience of framing established in Chapter 4 is also illustrated in this chapter. Framing and elevating matters as security threats provides governments a podium through which emergency and other non-standard measures can be hoisted upon people, and often these measures subordinate human rights of people both within and outside national borders.
The authors provide three illustrations of the clash between securitisation of health and human rights. The first being states’ responses to SARS-Cov-2 which, among other human rights violations, disproportionately exacerbates health nationalism. The second example involves instrumentalisation of health issues in the context of armed conflict or violent political tensions (e.g., attacks on hospitals and health workers during armed conflicts or violent tensions). And the third example builds upon the perception of refugees, asylum seekers, and irregular migrants as security threats and a burden on the health system. Chung and Liu argue that securitisation of health can aggravate the perceived threat posed by migrant populations to the health systems and well-being of nationals. By combining topical illustrations and philosophical reflection on the ethical issues raised by the narrative of securitisation of health, the authors urge us to strengthen the human right to health, at least until other conceptual and practical alternative proves itself more successful.
The last chapter in this part is by the editors of this volume. In Transitional Health Justice (Chapter 10), we find important similarities between failing political systems in conflict-affected states and failing health systems post health emergencies, viz., pervasive structural inequality, normalised individual or collective wrongdoing, existential uncertainty, and uncertainty about authority. These similarities led us to borrow some theoretical insights from the traditional transitional justice framework and to derivatively name 8
Himani Bhakuni and Lucas Miotto
our account “transitional health justice” (THJ). If transitional justice aims at just transformation of a society, THJ demands just transformation of health systems. But transforming our health systems within a background of resource scarcity and inequality would not be easy. It would require the relevant actors to make important choices about how to deal with past failures and the wrongs perpetrated by their respective health systems. These choices would also require a balance between distributive and reparative demands, blame and forgiveness, truth and efficiency.
In proposing a structure of THJ, we look to improve the circumstances of transitional health justice. Essentially this would require institutional reforms; reforms which will aid in the rebuilding of social trust in health institutions, abating of existential uncertainty, and tackling the uncertainty regarding the authority of health experts and governments on questions of health. These reforms will also aid in reducing structural health inequalities and in reckoning with the truth of past wrongs. We offer some ways in which heath systems in transition could do all this and conclude the chapter by positing that THJ can have an important role in allowing for broader projects of societal transformation which are typical of transitional justice initiatives.
Part V. Global Health Justice: New Frames, New Approaches
The fifth, and last, part of the volume is where three authors present the foundations of three general frameworks – or theories, if you like – of global health justice. Erika Blacksher opens this part by extending Nancy Fraser’s two-dimensional theory of justice to matters of global health. Her contribution, titled “Redistribution and Recognition in the Pursuit of Health Justice: An Application of Nancy Fraser’s Framework” (Chapter 11), aptly distinguishes between distributive and relational injustices (i.e., “maldistribution” and “misrecognition”) while acknowledging that these forms of injustice intersect and interact. Under Fraser’s (and Blacksher’s) framework, the legitimacy of claims of maldistribution and misrecognition – i.e., the measure of justice – is given by participatory parity: the requirement “that social and economic arrangements permit all (adult) members of society to interact with one another as peers”. Health and health inequalities are relevant to justice (and questions about health injustices are genuine questions of justice) – Blacksher argues – because health is both instrumentally and intrinsically valuable to participatory parity. Health is, therefore, as relevant to participatory parity as the latter is to health justice. Blacksher also considers in some detail the application of the proposed Fraser-inspired framework to population health studies. In so doing, she demonstrates the practical upshot of the framework, which grants it some plausibility points and, arguably, a comparative advantage over rival
theoretical frameworks. It should be noted at this point that despite some of the examples of epidemiological and population health studies as well as some examples of social relations discussed in the chapter being from the United States, they are not confined to the United States. They illustrate much broader population trends and relations: relations of oppression, domination, and discrimination in the context of health which are unfortunately omnipresent. For that reason, these are important examples to think about in global health justice. Additionally, the United States has a particular history of class and race inequalities – and a particular approach to healthcare – that cannot be ignored by any theory of justice that strives to be global in character.
It is also worth mentioning that Blacksher closes her chapter with some initial thoughts on how the proposed framework could be further extended to address questions of children and young people’s health. Interestingly, this brings us back to Gottfried Schweiger’s contribution (Chapter 6) and to the importance accorded to the development of children’s and adolescent’s health capabilities. Perhaps the ability to explain the challenges associated with children’s health is more important to a theory of global health justice than is acknowledged by previous theorists of health justice.
In “Beyond Egalitarianism: A Confucian Approach to Justice in Global Health” (Chapter 12), Man-to Tang proposes an alternative to theories of global health justice centred around health rights and egalitarian principles. Drawing from both contemporary and classical Confucian doctrine, Tang defends the primacy of sufficientarian principles of distribution and an agent centred, as opposed to institution-centred, approach to global health justice. The core sufficientarian idea in global health justice entails the provision of sufficient health resources and conditions. The measure of sufficiency is a flourishing life, a life where one can cultivate harmony of social relations and expand one’s cardinal virtues. Harmony of social relations may require the introduction of hierarchies, and this may raise some questions about whether Tang’s account can meet the demands of relational justice in the context of global health. Tang, however, emphasises that the virtue of Ren – the motivation and desire to care for oneself and for others – is a necessary condition of harmonious social relations, which suggests that the proposed account may have the theoretical resources to explain some forms of relational injustice.
Despite rejecting egalitarian principles, Confucian justice – Tang argues –is sensitive to egalitarian considerations in a specific context: in extreme circumstances where “resources are insufficient to maintain basic human needs”. In such contexts, all must bear the burdens equally. This idea also illustrates another core aspect of Confucian justice: that it is agent centred. The responsibility to promote global health justice lies, according to Tang’s account, on all individuals – and not exclusively (or primarily) on
10 Himani Bhakuni and Lucas Miotto
institutions. Health justice arises from the gradual expansion of our virtues: we first show concern for our own health, and then expand this concern to our relatives, neighbours, friends, and ultimately to the global community. Tang’s account is not intentioned to simply lay down some ideals for global health justice; he sees it as belonging to the realm of non-ideal theory. Tang illustrates the feasibility of his Confucian approach to health justice by describing how a similar approach was implemented in Hong Kong during the early stages of the COVID-19 pandemic.
The concern for a theory of global health justice to be feasible and apply to real-world situations is shared by both Blacksher and Tang – despite both endorsing largely distinct approaches to global health justice. In the final chapter of this volume – What do We Want from a Theory of Global Health Justice? (Chapter 13) – Sridhar Ventakapuram takes a step back and proposes three criteria for a successful theory of global health justice. Not surprisingly, the concern for feasibility and real-world application is the first among them. This is what he calls the criterion of “relevance”, and it involves both a theory’s ability to explain and identify real-world injustices (theoretical relevance) as well as its ability to guide the elimination of such injustices (practical relevance). Ventakapuram proposes two further criteria: perseverance and inter-theoretical coherence. The former is a requirement to avoid parochialism: theories of global health justice must not be solely concerned with a specific health problem of the here and now; they must have enough generality to deal with a broad spectrum of health injustices over time. This may suggest that the criteria of perseverance and relevance are mutually reinforcing. To guide the elimination of a broad spectrum of health injustices over time, a theory of health justice must persevere. And to persevere, the theory must remain relevant.
The final criterion, inter-theoretical coherence, works as a justificatory standard: the more a theory of global health justice coheres and integrates insights from other disciplines – such as economics, epidemiology, medical and social sciences, anthropology, and so on – the more robust it is. Hence, Ventakapuram invites global health justice theorists to get out of the confines of their own disciplines and actively engage in cross-disciplinary work. He briefly shows that some global health justice theorists have tried to do so, but to a limited extent. He highlights the need to integrate a theory of global health justice with history, something that he is trying to do in his ongoing work. Towards the end, Ventakapuram offers a brief argument – couched in some recent examples – in defence of a capabilities approach to global health justice. According to him, the capabilities approach can not only meet all the proposed criteria, but also offer a more refined and capacious understanding of health which allows us to see a theory of global health justice “as an argument for not only more justice in global health but for more global justice”.
12 Himani Bhakuni and Lucas Miotto
Notes
1 Venkatapuram S, Health Justice: An Argument from the Capabilities Approach (Polity Press 2011); Ruger JP, Global Health Justice and Governance (Oxford University Press 2018).
2 Pogge TW, ‘Human Rights and Global Health: A Research Program’ (2005) 36 Metaphilosophy 182; Segall S, Health, Luck, and Justice (Princeton University Press 2009); Shue H, Basic Rights: Subsistence, Affluence, and U.S. Foreign Policy (Second, Princeton University Press 1996); Daniels N, Just Health: Meeting Health Needs Fairly (Cambridge University Press 2007); Ruger JP, Global Health Justice and Governance (Oxford University Press 2018).
3 World Health Organization (WHO), Definition of Sexual Health, 2006a.
PART I Citizenship, Power, and Relational Justice
1 WORLD CITIZENSHIP AND GLOBAL HEALTH
Xuanpu Zhuang
1.1 Introduction
Although contemporary theorists usually endorse the ideal of moral equality as one of the fundamental premises in social and political life, people do not agree on what the ideal of moral equality requires.1 Egalitarians usually assert some stronger claims on social life, e.g., certain egalitarian policies and arrangements. There are two main groups of egalitarians in the discussions: distributive egalitarians and relational egalitarians. To put it simply, distributive egalitarians pursue the distribution of certain social goods in a way that reflects the ideal of equality.2 Differently, relational egalitarians believe the point of equality is to live as equals.3 For relational egalitarians, justice requires that people relate to one another as equals. And as the standard question of justice focuses on a single society, an intuitive and direct claim for relational egalitarians is that everyone ought to relate to one another as equal citizens. 4 But the claim based on the notion of national citizenship meets some difficulties when we consider global justice. It is not hard to recognise huge global distributional inequalities.5 In 2019, for example, around a tenth of the world’s population lived on less than $1.90 a day and more than 40% of the world’s population (almost 3.3 billion people) lived below the $5.50 line, while individuals in high-income economies made $12,696 or more.6,7 But what would the claim on the ideal of living as equals demand from us regarding global inequalities? And what does relational egalitarianism require for people who are not co-citizens in the usual sense?
In this chapter, I argue for a weak notion of equal world citizenship, which implies that individuals in the world ought to live as equal world citizens in a significant sense, and then discuss its implications in global health. In
DOI: 10.4324/9781003399933-3
Section 1.2, I present a relational egalitarian version of cosmopolitanism, which requires people to relate to one another as equal and full participants in global political and social activities. To support this conception of equal world citizenship, I follow the capabilities approach, which requires sufficient social goods for everyone to function as an equal world citizen in Section 1.3. Among those social goods, medical support is crucial, as people who lack health support are vulnerable and thus live as inferiors in different aspects. Specifically, the lack of medical support causes, follows, and strengthens some problematic social hierarchies in which some people do not live as equal world citizens, which are exemplified in various ways. I examine several cases to show why medical support is crucial in sustaining equal world citizenship in Section 1.4. Finally, Section 1.5 discusses the importance of certain egalitarian arrangements in the international order to sustain equal world citizenship.
1.2 World Citizenship and Relational Egalitarianism
Equality is not always incompatible with differences in treatment. For example, assume that Alf is a member of a dance club and Betty is a member of a music club. As such, Alf, but not Betty, is allowed to enter the dance club’s locker room. Alf and Betty are treated differently: they have different rights and benefits associated with their identities (specifically, the club memberships). But this case of inequality seems neither unjust nor unreasonable; Betty does not become inferior to Alf even without the right to enter the locker room, as long as other conditions associated with her equal memberships (e.g., being an equal fellow student on campus) are fulfilled.
Things become more difficult when we consider the inequalities between citizens and foreigners (non-citizens) living in the same country. In this context, it is unclear which inequalities, if any, would be justified. This problem follows two seemingly conflicting intuitions. On the one hand, it seems wrong if a foreigner is treated as inferior. On the other hand, there are at least a few defensible differences between citizens and foreigners concerning their statuses. For example, in some circumstances, it seems impermissible for foreigners to have a say in a country’s long-lasting political decisions. So, a country may be justified in depriving foreigners from the right to vote or participating politically. But this is not devoid of problems, after all political equality is usually the main indicator of the ideal of equality today.8 For instance, suppose that a certain policy may harm the interests of foreigners, e.g., some rules that may deprive them of opportunities to get a better education in their country of residence.9 It is usually disallowed for foreigners to donate money to a political candidate who argues against this. But foreigners could choose to demonstrate or sign a petition. The latter kind of action seems to be a reasonable claim on one’s interests, while the former
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CHAPTER XXXIV.
I was getting dark when the dogcart drove up to Oldcastle Farm. The front door which had been partly destroyed by the forcible entry of the police was open, and both gentlemen were inclined to the conclusion that the lonely tenant of the house had left it. They were confirmed in this opinion when, on ringing the bell, they found no notice taken of their summons.
“Poor lad’s turned it up,” said Captain Mulgrave turning to Thurley with a nod.
“It looks like it.”
They tied the horse up to an iron ring in the farm-house wall provided for such purposes, and went inside, leaving Freda, who now hung back a little, to come in or not, as she pleased. As soon as the two gentlemen had gone down the entrance hall, Freda slipped in after them, and waited to see which way they would turn. After a glance into the rooms to right and left, they went through into the court-yard. Taking for granted that Dick had at last followed the only possible course of abandoning the old shell of what had been his boyhood’s home, they were going, by Thurley’s demand, to explore those recesses where the smuggled goods had formerly been stored.
Freda knew better than they. Tripping quickly through the empty rooms and passages, she reached the door of the banqueting-hall, but was suddenly seized with a fit of shyness when she heard the sound of a man coughing. However, she conquered this feeling sufficiently to open the door under cover of the noise Dick made in poking the fire, and then she stood just inside, shy again. Dick felt the draught from the open door, turned and saw her. He was sitting in his own chair by the fire, with the old dog still at his feet. The shadows were already black under the high windows on the side of the court-yard, but the light from the west was still strong enough for Freda to see a flash of pleasure come into his face as he caught sight of her.
“You have a bad cold,” she said in a constrained voice, coming shyly forward as he almost ran to meet her.
“Yes, there’s a broken window up there,” said he, glancing upwards, “and—and the curtains the spiders make are not very thick.”
“Poor Dick!”
She said it in such a heartfelt tone of commiseration that the tears came into his eyes, and when she saw them, a sympathetic mist came over her eyes too.
“They think you have gone away,” she said in a whisper, glancing up at the windows which overlooked the court-yard, “but I knew better!”
“Who are ‘they’?”
“My father and Mr. Thurley.”
“Your father! I didn’t know that he was alive till yesterday. What will he do? There will be all sorts of difficulties about the trick he played.”
“He will have to go away. But he seems rather glad; he is tired of living up here, he says.”
She spoke rather sadly.
“And you?” said Dick.
“Oh, I’m not tired of it. I think the old Abbey-church the most beautiful place in the world. I should like to spend my life here.”
“And will you go away with him?”
“No, he is going to take me back to the convent.”
“What! For ever? For altogether? Will you be a nun?”
“Yes.”
“Do you like that?” asked Dick very earnestly, “to go and waste your youth and your prettiness, shut up with a lot of sour old women who were too ugly to get themselves husbands?”
Freda laughed a little.
“Oh, you don’t know anything about it,” she said, shaking her head, “they are not at all like that.”
“But do you seriously like the thought of going back as much as you liked the thought of being a nun before you left the convent?”
There was a long pause. At last:
“No-o,” said Freda very softly. “But—it’s better than what I should have had to do if I hadn’t chosen that!”
“What was that?”
“Marry Mr. Thurley.”
Dick started and grew very red.
“Oh, yes, it is better than that, much better,” he assented heartily.
“Yes, I—I thought you’d think so.”
She said this because they were both getting rather flurried and excited, and she felt a little awkward. Both were leaning against the table, and tapping their fingers on it. Something therefore had to be said, but in a moment she felt it was not the right thing. For Dick began to breathe hard, and to grow restless, as he said quickly:
“You see it’s not as if some young fellow of a suitable age, whom you—whom you—rather liked, could ever have a chance of—of asking you to be his wife. That would be a different thing altogether.”
“Ah, yes, if I were not lame! If I could ride, and row, and—and sail a boat!” said Freda with a quavering voice.
“No, no, just as you are, the sweetest, the dearest little——”
He stopped short, got up abruptly, and rushed at the fire, which he poked so vigorously that it went out. Then, quite subdued, he turned again to Freda, and holding his hands behind him, as he stood in a defiant attitude with his back to the fireplace, he asked abruptly:
“Would you like to know what I’ve been making up my mind to do, during these days that I’ve been living here like a rat in a hole?”
“Ye-es,” said Freda without looking up.
“Well, you’ll be shocked. At least, perhaps you won’t be, but anybody else would be. I’m going to turn farm-labourer, and here, in the very neighbourhood where I was brought up a gentleman, as they call it.”
The girl raised her head quickly, and looked him straight in the face, with shining, straightforward eyes.
“I think it is very brave of you,” she said in a high, clear voice.
“Hundreds of well educated young fellows,” he went on, flushed by her encouragement, “go out to Manitoba, and Texas, and those places, and do that or anything to keep themselves, and nobody thinks the less of them. Why shouldn’t I do the same here, in my own country, where I know something about the way of farming, which will all come in by-and-by? You see, I know my family’s disgraced, through my—my unfortunate cousin’s escapade; for even if it’s
brought in manslaughter in a quarrel, as some of them say, he’ll get penal servitude. But, disgrace or no disgrace, I can’t bring myself to leave the old haunts; and as I’ve no money to farm this place, I’ll get work either here, if it lets, or somewhere near, if it doesn’t. I’ve made up my mind.”
The obstinate look which Freda had seen on his face before came out more strongly than ever as he said these words. During the pause that followed, they heard voices and footsteps approaching, and then Captain Mulgrave opened the door. The breaking up of the organisation he had worked so long seemed already to have had a good moral effect on him, for he spoke cheerfully as he turned to John Thurley, who followed him.
“Here’s the hermit! but oh, who’s this in the anchorite’s cell with him? Why, it’s the nun!”
John Thurley looked deeply annoyed. He had an Englishman’s natural feeling that he was very much the superior of a man who looked underfed; and it was this haggard-faced young fellow who, as he rightly guessed, had been the chief cause of the failure of his own suit. Captain Mulgrave’s good-humored amusement over the discovery of the young people together woke in him, therefore, no responsive feeling. Before they were well in the room, Freda had slipped out of it, through the door by the fireplace, and was making her way up to the outer wall. Dick was at first inclined to be annoyed at the interruption; but when Captain Mulgrave explained the object of his visit and that of his companion, the young man’s joy at the project they came to suggest was unbounded. This was the setting up of himself to farm the land, for the benefit of his aunt, to whom it had been left for life.
“Mr. Thurley is a connection of hers and wishes to see some provision made for her. So, as I felt sure you would be glad to do your best for her too,” continued Captain Mulgrave, “and as you have some knowledge of farming, I suggested setting you up in a small way as farmer here, and extending operations if you proved successful. How would that meet your views?”
Dick was overwhelmed; he could scarcely answer coherently.
“I never expected such happiness, sir,” he stammered, in a low voice. “I would rather follow the plough on this farm than be a
millionaire, anywhere else. Why,” he went on after a moment’s pause, in a tone of eager delight, “I might—marry!”
He flushed crimson as Captain Mulgrave began to laugh.
“Well,” said the latter, “I don’t know that you could do better. You were always a good lad at heart, and my quarrel was never with you, but with your cousin. He used your services for his own advantage, but I must do you the justice to say it was never for yours. So find a wife if you can; I think you’re the sort to treat a woman well.”
Dick took the suggestion literally, and acted upon it at once. Leaving the two other men together in the darkening room, with some sort of excuse about seeing after the house, he went outside into the court-yard, and soon spied out Freda on the ruined outer wall. He was beside her in a few moments, looking down at her with a radiant face.
“I’m going to stay here—on the farm—to manage it myself—to be master here.”
“Oh, Dick!” was all the girl could say, in a breathless way.
“It sounds too good for belief, doesn’t it? But it’s true. That old Thurley must be a good fellow, for he’s going to help to start me. It’s for my aunt’s benefit he’s doing it; he’s a connection of hers.”
“Oh, Dick, if you had had a fairy’s wish, you couldn’t have chosen more, could you?”
There was a pause before Dick answered, and during that pause he began to get nervous. At last he said:
“There is one more thing. Your father said——”
A pause.
“Well, what did my father say?”
“He said—I might marry. Is—it true?”
And it took Dick very few minutes to find out that it was.
THE END.
TRANSCRIBER’S NOTES.
Florence Warden was the pseudonym of Florence Alice (Price) James.
Minor spelling inconsistencies (e.g. back-door/back door, farmhouse/farm-house, etc.) have been preserved.
Alterations to the text:
Add TOC.
Punctuation fixes: sentences missing periods, quotation mark pairings, etc. [Chapter XIII]
Change “in which the jury had veiwed her father’s body” to viewed. [Chapter XXXI]
“and the other asked the way to Oldastle Farm.” to Oldcastle. “a good suggestion; and Dick took advantage af it.” to of.
[End of text]
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