Forthcoming in PUBLIC HEALTH ETHICS

Two Models in Global Health Ethics

6400 words
Christopher Lowry, Ph.D.
Assistant Professor
Department of Philosophy
4/F Fung King Hey Building, Rm. 430
The Chinese University of Hong Kong
Shatin, N.T., Hong Kong

Udo Schuklenk, PhD

Professor of Philosophy and Ontario Research Chair in Bioethics
Department of Philosophy
Queen's University
Kingston, Ontario K7L 3N6
Canada

Electronic copy available at: http://ssrn.com/abstract=1489384

Abstract
This paper examines two strategies aimed at demonstrating that moral
obligations to improve global health exist.

The ‘humanitarian model’ stresses that all human beings, regardless of af-
fluence or global location, are fundamentally the same in terms of moral
status. This model argues that affluent global citizens’ moral obligations to
assist less fortunate ones follow from the desirability of reducing disease
and suffering in the world.

The ‘political model’ stresses that the lives of the world’s rich and poor are
inextricably linked because of harmful state-to-state actions and because
of currently existing transnational institutions. These institutions' design at
once secures the high standard of living of the affluent and reinforces the
continued foreseeable – and avoidable - deprivation of many of the global
poor; and these give rise to compensatory health-related moral obligations
beyond borders.

This paper argues that political reasoning is unsuitable for the crucial task
of determining priority in the receipt of health aid.

We conclude that in the context of global health ethics political reasoning

must be supplemented with, if not replaced by humanitarian reasoning.

Global disparities in health are a major form of injustice. A rich literature on

this ethical issue has firmly established the moral plausibility of obligations
to improve global health by means of health aid and institutional reform.
This paper assesses the relative merits of two models of argumentation
—‘humanitarian’ and ‘political’—that can be used to defend and flesh out

Electronic copy available at: http://ssrn.com/abstract=1489384

global health obligations. The term ‘political’ is intended here to have
roughly the same meaning as in the phrase ‘a political conception of global
justice’ (Nagel, 2005). We show why in the context of global health ethics
political reasoning shows serious deficiencies: it must be supplemented
with, if not replaced by humanitarian reasoning.1 To make that argument,
we show how political reasoning is unsuitable for the crucial task of
determining priority in the receipt of health aid.
For an initial picture of the contrast between the humanitarian and
political models, compare the response they offer to the argument that
global health obligations, though typically and sensibly carried out by
states, are ultimately owed by individuals to individuals (Singer, 2009;
O’Neill, 2002; Unger, 1996).
The humanitarian model, which we describe and evaluate in an
idealized form, provides a basis for arguing that global health obligations
are owed by individuals qua moral beings to individuals qua moral beings.
The humanitarian model focuses on what we are, pointing to our shared
humanity as the moral basis of global health obligations. It stresses that all
human beings, regardless of affluence or global location, are
fundamentally the same in terms of moral status; and this gives everyone
an obligation to assist others who are suffering from shortfalls in health2
provided the costs are not unreasonably high.
The political model, which we likewise present and evaluate in an
idealized form, provides a basis for arguing that global health obligations
are owed by individuals qua members of some state to individuals qua
members of another state that has been adversely affected by the actions
of the first state. The political model focuses on what we have done3,
pointing to the interaction between states4 as the moral basis of global
health obligations. This interaction can occur directly in the form of, for
example, an act of military aggression; or it can occur indirectly by means

3
of membership in an international institution, such as the World Trade
Organization. The political model stresses that the lives of the world’s rich
and poor are morally connected because of harmful state-to-state actions
and because of the entrenchment of transnational institutions whose
current design at once secures the high standard of living of the affluent
and reinforces the continued deprivation of many of the global poor; and
these give rise to health-related5 obligations beyond borders.
It is becoming clear in global health debates that an exclusive focus
on political reasoning is not defensible. The importance of humanitarian
reasoning must not be underemphasized. This paper clarifies where and
why political reasoning is deficient in the context of ongoing debates on the
moral foundations of a global health ethics.
We begin our analysis with a sketch of the factual background,
followed by brief generic accounts of how each of the two argumentative
models defends global health obligations. The case in favour of
humanitarian reasoning is then developed with respect to determining
priority in the receipt of health aid.

The Current State of Global Health

In the period since the Second World War, the planet has experienced a
remarkable overall improvement in health. Compared to only two
generations ago, global average life expectancy has undergone an almost
40 per cent increase and child mortality an almost 60 per cent decrease
(World Health Organization, 2003: p. 3; Moser et al., 2005: 203). Even so,
we should be careful not too focus too narrowly on averages. Several
studies in developed countries have pointed to a trend since at least the
early 1990s of widening health disparities that fall along socioeconomic,
and often also racial or ethnic, lines (Spencer, 2004; Singh and Kogan,
2007; Harper et al., 2007; Tomashek et al., 2006). Where the country’s

4
health care system is more market-driven, as for instance in the United
States, the comparably higher costs for health services coupled with a lack
of universal coverage tend to make these disparities more pronounced
(Bean 2005).
In the global context, the negative effects of health disparities are
much greater. Nine million children die before age five every year, mostly
because of the health resource gap between the developed and the
developing world (WHO, 2009). This gap is considerable, producing, for
instance, a tenfold difference between high- and low-child-mortality
countries according to one study.6 Moreover, global health disparities are
increasing. Over the last two decades, health gains have been slower in
the developing world, where they are most needed. There have also been
reversals to previous improvements in some regions—notably large parts
of sub-Saharan Africa (McMichael et al., 2004: p. 1156; cf. Mathers et al.,
2004).
Much of the world’s suffering and premature death is preventable.
Existing medical knowledge provides firm and confident instructions on
how millions more lives could be preserved each year. Staying with child
mortality as an example, experts estimate that more than 50 per cent of
the childhood deaths that occur globally each year are “easily preventable”
(Bryce et al., 2005). It would cost an estimated US $5.1 billion more in
health aid to fund the required increases in staff and supplies and the
requirement improvements in infrastructure. Given that the 2005 global
total for health aid was US $11.2 billion that would be a quite significant
increase.7 On the other hand, putting those figures into context, 1% of the
combined GDP of the G8 countries for 2006 was US $284 billion.8
Moreover, global military spending for 2006 – much of which was
ostensibly rationalized as peace-promoting – was approximately $1200
billion (Stålenheim et al., 2007). Surely, at least some of those funds would

5
be more efficiently spent by promoting political stability through improved
global public health. The magnitude of these figures illustrates why a
global perspective is essential for this issue.

Global Health Obligations

To make a case for global health obligations, we can start by asking why
health is important. Its importance is pervasive. Nearly every valuable
human activity is ultimately supported by health and undermined by illness.
There is a close connection between health and many prominent moral
values. Health has a strong tendency to contribute to happiness or utility.9
Of course, a happy life is neither guaranteed by good health nor ruled out
by illness, yet there is a clear enough correlation to ground a utilitarian
commitment to pro-health policies.10 The same holds true for economic
considerations. They give us sound utilitarian reasons to value health,
since no society can prosper without a healthy workforce. Furthermore,
from a liberal egalitarian perspective, health greatly affects how well people
can make use of their liberties; and it significantly shapes the range of
valuable options a person is able to pursue. Illness is a barrier to
education, employment and political engagement, and so health is also
important for equality of opportunity.
There is wide agreement about the importance of securing the
conditions that enable good quality and quantity of life. Those conditions
include not only good access to medicine and medical services, but also
broader public health measures that address all major social determinants
of health, as well as medical R&D, especially drug R&D. Of course, to
defend global health obligations, it must be shown not only that securing
health-promoting conditions is morally valuable, but also that the obligation
to do so extends globally. The next section examines how the humanitarian
and political models each seek to do that.

6
Two Models for Defending Global Health Obligations
The humanitarian model (in the idealized form we will be discussing) aims
to show that health-related moral obligations extend globally – rather than
only to fellow citizens – by arguing that geographic facts about an
individual are irrelevant for assessing moral status. The question, ‘How far
do health obligations reach?’ is answered by specifying the characteristics
required for moral personhood. There is disagreement about what those
characteristics are, but the model’s point is that specifying them is the right
way to answer the question about the reach of moral obligations to secure
good conditions for health.
An example of this is the following well-established utilitarian
argument (Singer, 1972; 2004; 2009; Unger, 1996): Sentience is the key
characteristic relevant to moral standing. Suffering has negative moral
value, and – all other things being equal - so has the premature,
preventable death of a life that is worth living. Preventable deaths caused
by poor conditions for health typically involve considerable suffering and
therefore have negative moral value. This moral badness is not lessened
or strengthened by geographical contingencies. The world’s well-off –
importantly, this includes for instance the growing middle-classes in
countries such as India and China – have an obligation to help those in
need whenever this can be done without comparable or higher cost to
themselves. Providing such aid is obligatory, rather than merely a
supererogatory act of charity. Health aid should be directed so as to
maximize expected utility, whether the recipients are next door or across
the world.
Given the current state of global health, efficiency considerations will
warrant substantial increases in the resources directed to the global poor.
We may differ in our answer to the question of how improvements of the

7
health status of people in the global south can most efficiently be achieved,
but that we ought to act is uncontroversial.
Humanitarian reasoning yields the conclusion that the most
important consideration in identifying the primary duty bearers of global
health obligations is their ability to provide aid without suffering
unreasonably high costs to their own quality of life and well-being. Let us
explain. In principle, health obligations apply from everyone to everyone in
virtue of universal undifferentiated moral standing; but the practical content
of the duty is not the same for all. The concrete demands of global health
obligations increase in proportion to the agent’s capacity to assist. Agents
with more resources will be called upon to make a larger funding
commitment in absolute terms. Our discussion will concentrate on state
governments as the relevant agents who carry out the collective global
health obligations owed by their citizens. Other than in exceptional cases,
countries – rather than individuals – have command over the kind of
magnitude of resources that need to be mobilized in order to seriously
address poor global conditions for health.11
Wealthy nations in the developed world have a special responsibility
to provide health aid because of how very large a benefit they can provide
to countries in the global south without putting their own continued
prosperity at jeopardy. For example, the United States, the world’s largest
economy, had a 2008 defense budget of $481.4 billion.12 At least a small
portion of this and similar expenditures could arguably be redirected to
improving global health without significant adverse effects on American
citizens’ security. Indeed, doing so would plausibly further the official goals
of defense spending by promoting global political and economic stability
through increased public health. Redirecting even just a small portion
would likely yield a great improvement in the health of many developing
world citizens, as well as a clear resource allocation improvement from the

8
perspective of utilitarian efficiency. The case for this view can probably
best be made by deploying the concept of diminishing marginal returns
(Gossen, 1854; cf. Brandt, 1979; Barry, 1989). The idea here, if applied to
our context, is essentially that once we have reached a certain threshold of
wealth or well-being an ever-increasing level of input would be needed in
order to produce an ever-diminishing level of improvement in outcomes. In
order to increase, for instance the quality of life and life-expectancy of the
average Canadian citizen we would have to increase our investments in
health infrastructure to an ever-increasing extent in order to generate, say,
a quality-adjusted life year equivalent. The same investment made in a
society that is much poorer would yield comparably higher health benefits.
An investment in Canada that would barely be noticed in the country's
health care system could be a game-changer in Sudan's health care
system. One can get a sense of the magnitude of the difference in health
expenditures by, for example, reflecting on the fact that Canada’s recent
$500 million investment in speeding up the implementation of electronic
health records13—which is quite sensible in the national context—is by
itself greater than Sudan’s total estimated government spending on health
in 2007.14
The political model, in comparison, is motivated by a reluctance to
defend positive moral obligations on the basis of universal claims
concerning moral status. It aims to establish global health obligations by
arguing that (most of the worst instances of) poor conditions for health,
especially in developing countries, are significantly caused, directly or
indirectly, by the actions of powerful global actors. The reach and content
of global health obligations is determined by assessing how well-off agents’
actions are related to the health conditions of particular disadvantaged
others. Thomas Pogge, for instance, argues that the extreme poverty of
the global poor is caused by the unjust structure of the ‘world economic

9
order’ that is collectively enforced by the world’s well-off (Pogge, 2008).
This political line of argument is easily extended to establish health
obligations, since extreme poverty is responsible for a large portion of the
inadequate conditions for health among the global poor. Moreover, political
arguments have been made by Steven Miles specifically with regard to the
sharing of benefits of international genomics research and by Richard Elliot
with regard to affordable access to medicines (Miles, 2006; Elliot, 2007).
The content of global health obligations grounded on political reasoning
would plausibly include a combination of institutional reform (for long-term
improvement) and global health aid (as an interim measure). There are at
least two reasonable criticisms of this line of political reasoning. Some
have argued, with some reason, that it is impossible to quantify the actual
harm done by the world economic order, and therefore it is risky to make
the health obligations owed to people in the global south subject to that
calculation.15 In fairness to Pogge, his critics’ squabbling over exact
numbers when it is undeniable that, for instance, the structural adjustment
programs the IMF forced upon developing nations led to foreseeable,
harmful and entirely preventable public health consequences, is somewhat
surprising.
The other objection applicable to political reasoning is that it falls far
short of what is required to flesh out global health obligations as it does not
address circumstances in which dire health needs occur as a result of
forces unrelated to the global world order. For instance, what if a country in
the global south had suffered from a devastating earthquake or tsunami?
Or what if the citizens of a country suffer from terrible economic
mismanagement (Zimbabwe and North Korea come to mind as cases in
point)? Political reasoning based on the global economic order would have
no reason to offer as to why we ought to help people in such dire need.
Utilitarian reasoning, with its single-minded focus on preventable suffering,

1
would be able to address these problems. We discuss this issue further in
the next section.
With respect to identifying the primary duty-bearers of global health
obligations, political arguments give us reason to focus on states’ past and
ongoing actions that impose health-related disadvantages on others. When
the interaction takes a direct form, as in cases of military aggression, this
would create special responsibility to provide health aid. When, instead (or
in addition), the interaction takes an indirect form, as in cases related to
Pogge’s discussion of the world economic order, this would give us reason
to conclude that special responsibility for pursuing, or at least supporting
institutional reform, as well as providing health aid, should fall on the
countries that most strongly contribute, or enforce, those features of the
world economic order that produce and reproduce extreme poverty in
developing countries.
The two argumentative models we have discussed do not agree on
the moral basis of global health obligations or on the normative criteria for
assigning special responsibility for providing health aid and pursuing
institutional reform. Humanitarian arguments focus on the ability to assist,
whereas political ones concentrate on the degree to which powerful states
use global influence to promote unilateral interests. Nonetheless, there is
reason to think that this normative disagreement would not translate into
much practical disagreement about assigning responsibility at the policy
level. In light of economic globalization, it is reasonable to expect large
overlaps between the ability to assist and global influence. The countries
that prosper most tend to be those who have been able to effectively
harness the forces of globalization by shaping the global economic order to
suit their national interests. Conflict over finer details notwithstanding, there
is general agreement on which types of countries have a special

11
responsibility to provide health aid – namely, the rich countries of the
developed world.
The two models also agree on the need for both health aid and
institutional reform. Although political reasoning often focuses on the ways
in which international institutions create morally relevant transnational
connections, it would be a mistake to infer that the political model therefore
calls for institutional reform to the exclusion of health aid. Political
reasoning can be marshaled to support both forms of improving global
health. Likewise, humanitarian reasoning can be used not only to defend
health aid obligations, but also to push for institutional reform, since such
reform, if successful, could drastically improve the health of the global
poor. That being said, political reasoning falls short of what is required of a
plausible moral account of global health obligations in important respects,
which we will now explore.

Determining Priority for Receipt of Health Aid

Political reasoning is unsuitable for one of the main tasks involved in
fleshing out global health obligations—namely, making prioritization
decisions concerning the allocation of health aid. The humanitarian model
is better able to provide theoretical resources to help address the question:
Who, among all those deserving of health aid, should have priority? Let us
begin with a comparison of how each model identifies potential recipients.
A key feature of the humanitarian model is that moral standing is
shared in equal force by all, which gives equal importance to everyone’s
health. Therefore, the members of any population that cannot secure good
conditions for health would be identified as potential recipients of health
aid.
The implications of the political model are more restricted. Political
reasoning distinguishes between what we might call ‘artificial’ and ‘natural’

1
deprivation. Artificial deprivation is that which is caused substantially by
others; whereas natural deprivation is not. Political reasoning yields
obligations for agents to respond to any artificial deprivation that is
substantially caused by actions for which they are responsible. Therefore,
when a developing country’s poor conditions for health are caused by
natural deprivation, such as environmental disasters, political reasoning
identifies no injustice. Furthermore, when those poor health conditions are
caused by actions for which a given group of the world’s well-off is not
responsible, as in cases of governmental mismanagement, political
reasoning would seem to produce no health obligations for that group.16
It might, however, be possible to lessen these objectionable
restrictions concerning natural deprivation by developing political
arguments, such as Pogge’s, in a more expansive direction. Arguably the
policies of most developed world governments and the people they
represent contribute substantially to poor countries’ environmental
vulnerability. First, their vulnerability is caused largely by the poverty that is
imposed by the world economic order. Second, climate change, for which
the developed world is substantially responsible, is contributing
significantly to the increased frequency and severity of destructive weather
patterns.17 A controversial, but in our view beneficial, consequence of this
line of development is that it would to some extent obliterate the distinction
between artificial and natural deprivation. If so, then political reasoning
would also conclude that all those in need are potential deserving
recipients of the health aid.
Let us now compare the two models in terms of what help they can
offer for the task of priority setting. Needs, efficiency, and responsibility are
the main factors to be considered for that task. The remainder of this
section will demonstrate that political reasoning simply leads one to focus
exclusively on degrees of responsibility. For reasons explained below, that

1
guidance is highly questionable. Yet the political model has no theoretical
means to offer further guidance. That leaves need and efficiency as the
two remaining considerations in play. The humanitarian model is able to
resolve this impasse, ultimately supporting efficiency for this task.
Political arguments hold that one country’s health obligations to
another depend on the extent to which the former is responsible for
causing (directly or indirectly) the latter’s poor conditions for health. This
line of argument suggests a possible strategy for priority setting – namely,
a rich country should give priority to potential recipients depending on its
own degree of responsibility for their poor conditions for health.
Responsibility would be measured in degrees depending on how tight a
connection there is between a rich country’s actions and a recipient’s poor
health conditions.
However, responsibility alone proves to be a poor guide for priority
setting. Assessments of degrees of responsibility are imprecise and
controversial. Furthermore, if responsibility were taken to be the only
relevant condition in setting health aid priorities, the result would be an
arguably excessive priority for domestic health problems. Recall that
disparities within developed countries create poor health conditions for
segments of their own populations. The relation of government actions to
those poor conditions will very often, if not always, be clearer than to the
health conditions of any population outside its borders. If degrees of
responsibility were employed as the exclusive consideration in priority
setting, domestic populations with deficiencies in conditions for health, no
matter how minor, would nearly always receive a higher priority ranking
than international populations experiencing far more severe health
deprivations. The health of disadvantaged segments of developed
countries is surely important; however, it is inappropriate to given it
absolute priority in light of the far greater deprivations in the global south.

1
 But is this a fair characterization of the implications of the political
model? Couldn’t that model take into consideration both responsibility and
need? One might be tempted to argue, for example, that if a rich country is
partially responsible for very severe health deprivations in one country, and
more fully responsible for minor health deprivations in another country,
then political reasoning would recommend giving priority to the first, rather
than the second. This is plausible guidance; but unfortunately the political
model does not in fact provide a moral basis to support it.
To get a better understanding of why political reasoning translates
into an exclusive focus on responsibility, consider the difference between
the following two claims: (A) a rich country’s (degree of) responsibility for a
population’s poor health conditions increases its obligation to respond
those needs; and (B) a rich country’s responsibility for a population’s poor
health conditions creates its obligation to respond those needs. The
political model is committed to (B). It holds that health deprivations per se
do not give rise to aid obligations. Considerations of need exert a moral
pull only when, and only to the extent that, considerations of responsibility
are also in play.18 The political model cannot support the mixed strategy
suggested above, in which considerations of responsibility are weighed
against considerations of need, because political reasoning grants no
independent moral weight to health needs per se.
Alternatively, one might try to hold on to political reasoning by
employing responsibility as a threshold criterion. Once one country’s
degree of responsibility for another’s poor health exceeds a stipulated
threshold, the first country would be taken to have health obligations to the
other. If one adopts this strategy, then it matters only whether the degree of
responsibility in a given case meets or falls below the threshold. The
benefit of this approach is that it might avoid the undesirable implications
described earlier. However, it is unclear how political arguments could help

1
set the threshold itself; and it is unclear whether such a threshold approach
would be fine-grained enough to adequately address the complexity of
health aid allocation.
In short, political reasoning is too narrowly focused on responsibility
to be helpful for resolving prioritization challenges. Instead, priority should
be determined by how greatly a potential recipient would be wronged if
health aid were denied. But should the magnitude of such wrongs be
assessed by appeal to need or efficiency? And, can the humanitarian
model provide helpful guidance here?
Consider the implications of focusing on levels of need. This view
provides two imperatives: (i) provide aid to wherever there is the greatest
need, and (ii) employ aid resources in whatever way would yield the most
significant reduction in poor health states in those high-need locations.
There might be discord on whether short-term or medium- to long-term
outcomes ought to be the decisive allocation factors. However, likely on
this approach, life-preserving emergency relief would be given very high, if
not absolute, priority.
Now consider efficiency. Need and efficiency pull in different
directions in some cases because of the many different causes of high
levels of need, some of which produce barriers to the efficient use of health
aid resources. War and corruption are the clearest examples of this. They
typically produce high levels of need and at the same time undermine, or
at least impede, efficient and sustainable improvements in conditions for
health.19 This highlights how achievements in political and economic
development are often prerequisites for advances in health (Anand et al.,
2004).
The humanitarian model offers a moral basis for preferring efficiency
over need in this context. Let us explain. There is no denying the
importance of relief or the moral praiseworthiness of the aims of

1
international relief organizations. However, with respect to determining
priority in the receipt of health aid, when poor conditions for health greatly
outstrip available aid, great moral weight attaches to what we will refer to
as the Ease-of-Prevention Principle: the easier it is to prevent suffering and
death, the morally worse it is for it to persist. Humanitarian arguments help
to explain the importance of the principle. With respect to identifying the
duty-bearers of global heath aid, we saw above that humanitarian
reasoning suggests that the concrete content of a donor’s obligation
increases depending on the donor’s ability to assist – or more precisely, a
donor’s obligation to assist increases in proportion to the ease with which
the donor is able to produce a benefit. The flip side of this line of thought is
that a recipient’s claim to aid is stronger or weaker depending on the ease
with which the recipient can be benefitted. The easier it is to prevent
suffering and death, the morally worse it is for it to persist.
Countries whose poor health conditions can be ameliorated only at
great expense should not be given priority if doing so would hold hostage
initiatives in other locations that promise greater and more certain results.
Countries with conditions that are favorable to health development (such
as a low threat of military outbreaks, together with good potential for
institutional reform to curb corruption and improve infrastructure) should,
all other things being equal, be given priority over war-torn or corrupt
countries with higher levels of need. In a situation of globally inadequate
health aid, the lion’s share of resources should be devoted to areas with
better prospects for amelioration. The moral wrong of health aid denial is
greatest when the health deprivations of the denied population are most
easily preventable.
This goal can also be supported by utilitarian reasons, so long as
there are no conflicts in this type of case between minimizing the suffering
of badly off populations and increasing the happiness of well off ones.

1
Moreover, since the goal does not permit tradeoffs of that sort, its
maximizing orientation does not open the door to the standard liberal
critique of utilitarianism: that utilitarianism allows the interests of badly off
groups to be sacrificed for the sake of a greater benefit for groups who are
already well off. Empirically this has never been a plausible scenario. The
utilitarian focus on aggregate utility has traditionally translated into support
for public health based policies, including in developing countries a
prioritization of primary care facilities over cost-intensive technology-heavy
solutions such as those proposed, for instance by Acharya and colleagues
(Acharya et al., 2004).
However, doesn’t the Ease-of-Prevention principle sacrifice the
interests of some badly off people for the sake of others who are also badly
off? Despite protestations to the contrary by medical NGOs such as
Médecins sans Frontières (Landman, 2006), in the absence of infinite
resources and corresponding overwhelming demand prioritization is
inevitable. Should priority be given to emergency relief or health
development? The humanitarian model is able to provide guidance here.
Emphasis should be given to building, in sustainable ways, the capacity of
the local community, rather than aiming for immediate results through high
levels of medical intervention that risks undermining existing community
capacity (Fuller, 2006). To some extent this goes against the modus
operandi of health NGOs, who happen to be among the most successful
fundraisers. Donors' hearts and wallets seem more favourable to
supporting high-emergency relief than long-term community capacity
building. However, ultimately health development should aim to secure
good conditions for health so that future generations will need less (or no)
high-cost emergency relief.20
The practical importance of priority setting for health aid does not
lessen the degree to which it is deeply unsettling. Being committed to an

1
efficient use of available resources does not imply an endorsement of the
status quo in levels of health aid, despite protestations to the contrary
(Zachariah, 2006). The current levels are woefully inadequate. A morally
appropriate response to global health obligations requires greatly
increasing the world’s health aid commitments.

Conclusion
The writers and most of the readers of this article live in a world of virtual
abundance, where basic health services and essential medicines (and
much else) are taken for granted. Humanity has the resources to make
that so for everyone, but we have not. Our rate of progress on this front
must be quickened. Millions of people lack these basic requirements, and
many of them, mostly in developing countries but some also in developed
ones, suffer and die needlessly. In this paper, we examined two models of
argumentation for defending global health obligations. Several conclusions
warrant restatement. At the policy level, humanitarian arguments and
political ones agree that citizens of affluent countries, individually and
collectively, have an obligation to support global funding regimes for
securing good conditions for health, including medical care, access to
medicines, effective public health measures, and drug R&D for neglected
diseases. The superior merits of the humanitarian model, however,
become apparent with respect to the task of setting priorities in the
allocation of health aid. The political model fails to yield helpful guidance,
whereas the humanitarian reasoning explains why efficiency should be
given more moral weight in this context than responsibility or need. The
moral case for a radical change in the existing approach to global health
resourcing is powerful indeed; and it is clear that humanitarian reasoning
must be employed – either alone or together with political reasoning – in
pursuit of that change.

1
2
1
We acknowledge that by choosing the term 'humanitarian' as the label for one of the two types of reasoning
discussed in this paper, we are using the term in a narrower way than it is often used in common political
debates. In those debates, anyone who supports international aid for whatever reason is typically considered to
be humanitarian. We, however, argue that there is an important distinction between the different types of reasons
that justify such support. Consequently, we reserve the term 'humanitarian' for people whose support of
international aid (and/or institutional reform) is based on reasoning that focuses on our shared humanity.
2
This paper concentrates on global health obligations; however, the reasoning used to defend such obligations
often also supports more general obligations to assist others in need.
3
Or more specifically, the actions for which we are morally accountable.
4
Or more specifically, the interaction between citizens of different states by means of the actions of their
respective governments.
5
See note 1.
6
207.3 deaths before age 5 per 1000 live births versus 20.6 (Ruger and Kim, 2006: pp. 934-5).
7
The 2005 global total for health was estimated at US $11.2 billion (Lane and Glassman, 2007).
8
Calculation based on the CIA’s 2006 estimates of GDP with Purchasing Power Parity, available at
https://www.cia.gov/library/publications/the-world-factbook/index.html.
9
This claim holds true for all the major conceptions of utility: preference satisfaction, mental states, etc.
10
Disability scholars have persuasively criticized ‘ableist’ assumptions that overemphasize a conception of
health that unduly prioritizes physical capacities, see Asch, 1998.
11
That being said, O’Neill, Unger, Singer and others have presented strong arguments in favor of
conceptualizing the duty to aid others in need as ultimately a moral duty belonging to individuals, rather than
countries or governments (O’Neill, 2002; Unger, 1996; Singer, 2002).
12
For the defence budget, see http://www.whitehouse.gov/omb/budget/fy2008/defense.html. For national health
spending, see Kaiser Family Foundation, 2007.
13
See http://www.budget.gc.ca/2009/home-accueil-eng.asp.
14
At the time of writing CAD $500 million was equivalent to approximately 1040 millions Sudanese pounds;
whereas Sudan’s estimated total government expenditure on health in 2007 was 911 million Sudanese pounds—
see http://www.who.int/nha/country/sdn.pdf.
15
For discussion of this and related issues, see, e.g., Risse, 2005.
16
Unless, that is, considerations related to indirect forms of interaction also apply to the particular case.
17
An argument of this sort has recently been made to the UN General Assembly by a coalition of small island
states, see http://islandsfirst.org/20080911_pressrelease.pdf.
18
As noted earlier, considerations of responsibility may involve direct or indirect interactions.
19
For utilitarians, it is important to keep in mind that it is possible, though unlikely, for a government with
normally objectionable political structures and practices to be very efficient in making use of health aid, despite
or even because of its corrupt politics.
20
That being said, resources should be devoted to emergency relief insofar as this facilitates health development
efforts. Infrastructure improvements require the support of the community if they are to be feasible and
sustainable. Efficiency considerations can sensibly direct policy makers to addressing need if doing so is
important to maintain community support for health development projects whose benefit will be felt primarily
over the long term.

References

Acharya, T., Daar, A.S., Thorsteinsdóttir, H., Dowdeswell, E., Singer, P.A. (2004)
'Strengthening the Role of Genomics in Global Health', PLoS Medicine. 1(3): e40.

Asch, A. (1998). ‘Distracted by Disability’. Cambridge Quarterly of Healthcare Ethics 7: 77-

87.
 Anand, S., Peter, F., and Sen, A.K. (2004). Public Health, Ethics, and Equity. Oxford: Oxford
University Press.

Barry, B. (1989). Theories of Justice. Berkeley: University of California Press.

Bean, J.R. (2005). ‘National Healthcare Spending in the US and Japan: National Economic
Policy and Implications for Neurosurgery’. Neurologia Medico-Chirurgica (Tokyo) 45: 18-24.

Brandt, R.B. (1979). A Theory of the Good and the Right. Oxford: Oxford University Press.

Bryce, J., Black, R.E., Walker, N., Bhutta, Z.A., Lawn, J.E., and Steketee, R.W. (2005). ‘Can
the World Afford to Save the Lives of 6 Million Children Each Year?’ Lancet 365: 2193-2200.

Elliot, R. (2007). ‘Delivering on the Pledge: Global Access to Medicines, WTO Rules, and
Reforming Canada’s Law on Compulsory Licensing for Export’. McGill International Journal of
Sustainable Development Law & Policy 3(1): 23-67. www.jsdlp.mcgill.ca.

Fuller, L. (2006). ‘Justified Commitments? Considering Resource Allocation and Fairness in

Médecins sans Frontières-Holland’. Developing World Bioethics 6: 59-70.

Gossen, H.H. (1854/1983). The Laws of Human Relations and the Rules of Human Actions
Derived Therefrom, translated by R.C. Blitz. Cambridge, MA: MIT Press.

Harper, S., Lynch, J., Burris, S., and Smith, G.D. (2007). ‘Trends in the Black-White Life
Expectancy Gap in the United States, 1983-2003’. Journal of the American Medical Association 297:
1224-32.

Kaiser Family Foundation (2007). Health Care Costs: A Primer. Menlo Park, CA: Kaiser
Family Foundation. http://www.kff.org/insurance/upload/7670.pdf.

Landman, W.A., Schuklenk, U. (2006). Medecins sans Frontieres under the spotlight.
Developing World Bioethics 6(2): iii-iv.

Lane, C., and Glassman, A. (2007). ‘Bigger and Better? Scaling Up and Innovation in Health
Aid’. Health Affairs 26: 935-48.

Mathers, C., Moesgaard Iburg, K., Salomon, J.A., Tandon, A., Chatterji, S., Ustüm, B., and
Murray, C.J.L., (2004). ‘Global Patterns of Healthy Life Expectancy in the Year 2002’. BMC Public
Health 4: 66. [doi:10.1186/1471-2458-4-66].

McMichael, A.J., McKee, M., Shkolnikov, V., and Valkonen, T. (2004). ‘Mortality Trends and
Setbacks: Global Convergence or Divergence?’ Lancet 363: 1156.

Miles, S. (2006). ‘Human Genomic Research Ethics: Changing the Rules’, in J.C. Cohen, P.
Illingworth, and U. Schüklenk (eds.) The Power of Pills: Social, Ethical and Legal Issues in Drug
Development, Marketing and Pricing. London: Pluto, pp. 203-214.

Moser, K., Shkolnikov, V., and Leon, D.A. (2005). ‘World Mortality, 1950-2000: Divergence
Replaces Convergence from the late 1980s’. Bulletin of the World Health Organization 83(3): 202-209.
 Nagel, T. (2005). ‘The Problem of Global Justice’. Philosophy & Public Affairs 33(2): 133-147.

O’Neill, O. (2002). ‘Public Health and Clinical Ethics: Thinking beyond Borders’. Ethics &
International Affairs 33: 35-45.

Pogge, T.W. (2008). World Poverty and Human Rights, 2nd ed. Cambridge: Polity.

Risse, M. (2005). ‘Does the Global Order Harm the Poor?’ Philosophy & Public Affairs 33(4):
349-76.

Ruger, J.P., and Kim, H.-J. (2006). ‘Global Health Inequalities: An International Comparison’.
Journal of Epidemiology and Community Health 60(11): 928-36.

Singer, P. (1972). ‘Famine, Affluence, and Morality’. Philosophy & Public Affairs 1: 229-41.

Singer, P. (2002) One World: The Ethics of Globalization. New Haven: Yale University Press.

Singer, P. (2004). ‘Outsiders: Our Obligations to Those Beyond Our Borders’, in D.K.
Chatterjee (ed.) The Ethics of Assistance: Morality and the Distant Needy. Cambridge: Cambridge
University Press, pp. 11-32.

Singer, P. (2009). The Life You Can Save: Acting Now to End World Poverty. New York:
Random House.

Singh, G.K., and Kogan, M.D. (2007). ‘Widening Socioeconomic Disparities in US Childhood
Mortality, 1969-2000’. American Journal of Public Health 97: 1658-65.

Spencer, N. (2004). ‘The Effect of Income Inequality and Macro-Level Social Policy on Infant
Mortality and Low Birthweight in Developed Countries: A Preliminary Systematic Review’. Child:
Care, Health & Development 30: 699–709.

Stålenheim, P., Perdomo, C., and Sköns, E. (2007). ‘Military Expenditure’, in SIPRI Yearbook
2007. Oxford: Oxford University Press, pp. 267-97.

Tomashek, K.M., Qin, C., Hsia, J., Iyasu, S., Barfield, W.D., and Flowers, L.M. (2006). ‘Infant
Mortality Trends and Differences Between American Indian/Alaska Native Infants and White Infants in
the United States, 1989-1991 and 1998-2000’. American Journal of Public Health 96: 2222-27.

Unger, P. (1996). Living High and Letting Die: Our Illusion of Innocence. New York: Oxford
University Press.

World Health Organization (2003). The World Health Report 2003: Shaping the Future Geneva:
World Health Organization.

World Health Organization (2009). World Health Statistics 2009. Geneva: World Health
Organization.
 Zachariah, R., Janssens, V., Ford, N. (2006). ‘Do Aid Agencies Have an Ethical Duty to
Comply with Researchers? A Response to Rennie’. Developing World Bioethics 6: 78-80.