equity and population health: toward a broader bioethics agenda

22 H A S T I N G S C E N T E R R E P O R T July-August 2006

Bioethics’ traditional focus on clinical relationships and exotic technologies has led the field away

from population health, health disparities, and issues of justice. The result: a myopic view that misses the

institutional context in which clinical relationships operate and can overlook factors that affect health more

broadly than do exotic technologies. A broader bioethics agenda would take up unresolved questions about

the distribution of health and the development of fair policies that affect health distribution.

E Q U I T Y

Population Health

b y N O R M A N D A N I E L S

TOWARD A BROADER BIOETHICS AGENDA

A N D

In its early decades, bioethics concentrated onproblems arising in two important areas: thedyadic, very special relationships that hold be-

tween doctors and patients and between researchersand subjects, and Promethean challenges—the pow-ers and responsibilities that come with new knowl-edge and technologies in medicine and the life sci-ences, including those that bear on extending andterminating life. The dyadic relationships yield im-portant goods, impose significant risks, are rife withinequalities in power and authority, and yet arebound by complex rights and obligations. They pro-vide a rich field for ethics to explore. The

Promethean challenges are the favorites of the media:how god-like can we become in our relations withpeople, with animals, and with our environmentwithout losing our moral footing? They attract seri-ous inquiries about how to use knowledge and tech-nology responsibly for the individual and collectivegood. Unfortunately, they also form the frontlinetrenches for the contemporary culture wars.

Bioethics’ focus on the largely noninstitutionalexamination of these dyadic relations and the emer-gence of exotic technologies means other importantissues concerning population health and its equitabledistribution are not addressed (although there are ex-ceptions to this generalization). The doctor-patientrelationship and the researcher-subject relationshipdo have a bearing on population health since medi-cine and medical research affect the health of indi-

Norman Daniels, “Equity and Population Health: Toward a BroaderBioethics Agenda,” Hastings Center Report 36, no. 4 (2006): 22-35.

H A S T I N G S C E N T E R R E P O R T 23July-August 2006

viduals and populations, but by notexamining the broader institutionalsettings and policies that mediatepopulation health, bioethics hassometimes been myopic, not seeingand not addressing the context inwhich these relationships operate.Similarly, the focus on exotic tech-nologies may blind bioethics to thebroader determinants of health andthus to factors that have more bearingon a larger good both domesticallyand globally.

To motivate a broader bioethicsagenda, I shall focus on issues of equi-ty in three areas: (1) health inequali-ties between different social groupsand the policies needed to reducethem, (2) intergenerational equity inthe context of rapid societal aging,and (3) international health inequali-ties and the institutions and policiesthat have influence on them. Eacharea has both domestic and interna-tional implications.

There are good reasons for pursu-ing this broader agenda. The agendaaligns bioethics with the goal of moreeffectively promoting a fundamentalgood—namely, improved populationhealth, especially for those who enjoyless of it, domestically and interna-tionally. It focuses bioethics on thepursuit of justice. Justice obliges us topursue fairness in the promotion ofhealth, but policy needs the guidanceof ethics in determining what thismeans. These population issues pro-vide the relevant institutional contextin which we should think about therole of new technologies and thedyadic relationships of health careand medical research. However, forbioethics to play this role, it mustdraw on—and train its practitionersin—a wider range of philosophicalskills and social science disciplines.

What Must We Do to PursueEquity in Health?

Health egalitarians and healthmaximizers. I take “health” to meannormal functioning, that is, the ab-sence of pathology, mental or physi-cal.1 This biomedical account of

health is clearly narrower than thewidely quoted definition offered bythe World Health Organization:“Health is a state of complete physi-cal, mental and social well-being andnot merely the absence of disease orinfirmity.”2 The WHO conceptionerroneously expands health to includenearly all of wellbeing, so it can nolonger function as a limit notion. Peo-ple who actually measure populationhealth, such as epidemiologists, con-centrate on departures from normalfunctioning. As we shall see, under-standing health as normal function-ing is quite compatible with taking abroad view of the determinants of

health revealed by the social determi-nants literature.

This characterization of health hasimplications for what counts as pur-suing equity in health.3 Every societyhas some healthy and some unhealthypeople. One natural way to under-stand the goal of equity in health—the goal of health egalitarians—is tosay that we should aim, ultimately, tomake all people healthy; that is, tohelp them to function normally overa normal lifespan.4 Pursuing equalitymeans “leveling up”—bringing allthose in less than full health to thestatus of the healthy.5 The ultimateaim of health maximizers is identicalto that of health egalitarians: We max-imize population health if all peoplefunction normally over a normal lifes-pan. Health is clearly different fromincome (and possibly wellbeing).There is no natural stopping point forincome—the rich can always be rich-er—but health is a limit concept.Being completely healthy is beingcompletely healthy (functioning nor-mally).

Despite convergence on ultimateaims, health egalitarians and healthmaximizers generally support differ-ent strategies or policies for achievingtheir common ultimate aim of pro-

ducing a completely healthy popula-tion.6 A maximizing strategy or policywill seek the highest achievable aggre-gate measure for resources invested,regardless of how the health is distrib-uted. Someone concerned with equityin health will put important con-straints on how the health is distrib-uted.

Unsolved rationing problems. Afamily of unsolved distributive prob-lems has been discussed by people inthe social sciences and bioethics.7 Inthese problems, maximizing strategiesare pitted against fairness or equityconsiderations. For example, when weselect an intervention because it has

the best cost-effectiveness ratio, weare maximizing health benefits at themargin regardless of how the benefitsare distributed—a maximizing strate-gy that conflicts with concerns aboutequity in three ways. First, it gives nopriority to those whose ill healthmakes them significantly worse offand puts them in greater need thanthose less ill. Most people want togive some priority to those who areworse off, even if they do not want togive them complete priority, possiblycreating a “bottomless pit” for thosewho benefit very little, while sacrific-ing significant benefits for otherssomewhat less ill. How much priorityshould we give? That is the prioritiesproblem. Second, cost-effectivenessanalysis allows us to aggregate minorbenefits, such as curing minorheadaches, to larger numbers so thatthey outweigh significant benefits,such as saving lives, to fewer people.But even though most people acceptsome forms of aggregation, they rejectunrestricted aggregation, refusing toallow, for example, lifesaving treat-ments to a few to be outweighed byvery minor benefits to very largenumbers. The aggregation problemasks, When should we aggregate?Third, cost-effectiveness analysis

Justice obliges us to pursue fairness in the promotion of health, butpolicy needs the guidance of ethics in determining what this means.


doggedly pursues “best outcomes”—for example, living many years aftertreatment—while denying fairchances for some benefit to thosewith worse outcomes, such as livingonly several years after treatment. Yetmost people reject a strict maximizingstrategy, preferring to give even peo-ple who have worse outcomes fairchances at some benefit. How shouldwe balance best outcomes against fairchances? This is the best outcomes/fairchances problem. We have consider-able trouble agreeing on what the ap-propriate middle ground is in each ofthese problems.

Reducing health inequalities andunsolved distributive problems. Thesame distributive problems arise whenwe think about eliminating health in-equalities, even unjust ones. Five ofthe eight internationally negotiatedMillenium Development Goalswould reduce inequality by aiming atpoverty reduction or providing pri-mary education to those who lack it.The three health targets, however, arestated in terms of reducing popula-tion aggregates of key measures—forexample, mortality of children underage five. David Gwatkin models twoextreme approaches to these aggregategoals.8 A maximizing approach aimsat rapid achievement of the targetgoal by directing resources to thosewho are already better off but easier toreach with strategies for improve-ment. An egalitarian approach aimsto help those who are worst off first,then the next worst off, and so on.Program incentives and the geopoli-tics surrounding the MDG programmean that the maximizing strategy ismore likely to be implemented, sincefunders want rapid results, although itactually increases health inequality inthe population.

The unsolved distributive prob-lems are raised in contexts where it isnot morally problematic that someare worse off—they are just sickerthan the others for whatever reason.In the MDG problem, as in the con-cern about intergroup health inequal-ities generally, the baseline distribu-tion is itself morally problematic be-

cause there is some social responsibil-ity for creating the basic health in-equality. Racial disparities in theUnited States, ethnic disparities in theUnited Kingdom, and gender in-equalities in the prevalence ofHIV/AIDS in sub-Saharan Africamay be clear examples. The injusticeof the existing baseline may give extraweight to the concern that we mini-mize inequalities, giving impetus toefforts to draw attention to race dis-parities in health in the United Statesand to stronger efforts to reduce classdisparities in the United Kingdom,Sweden, and elsewhere in Europe. In-deed, the WHO Commission on theSocial Determinants of Health en-courages broad attention to healthdisparities and their origins in the in-equitable distribution of various othergoods.

How much should this considera-tion of the injustice of the baselineoutweigh our concern that we are notachieving best outcomes in the aggre-gate? Some may object that if we sin-gle out some groups as “more deserv-ing” because they were wronged, thenwe are abandoning the principle thatin medical contexts we ought to focusonly on need. We should not, then,give priority to fixing the broken legof the innocent mugging victim overthat of the risk-taking skier. When theChinese decided to give priority in ac-cess to antiretroviral treatments tovictims of infected blood, they werecriticized for stigmatizing as less de-serving those people infected in an-other way.

Moral disagreement about theseconflicting concerns will be sharp.There will be disagreements aboutwho is really responsible for the base-line, and some will try to explain itsinjustice away (perhaps in the form ofvictim-blaming). The unsolved dis-tributive problems are thus madeeven more difficult. Bioethics hasbarely risen to the challenge of solvingthem when the baselines are morallyneutral. It must also address theadded challenge posed by inequitablebaselines.

Social determinants and health in-equalities. Most Americans, and Isuppose most British, who are asked,“What does it take to assure people ofequity in health?” will respond withwhat they take to be a truism, “Givepeople equal access to appropriatemedical care,” such as through a uni-versal coverage insurance scheme. Atbest, this apparent truism is but asmall part of the answer; at worst, it ismisleading in important ways.

Equal access to medical servicesdoes not by itself assure equity if wehave made the wrong trade-offs inour health system between equity andthe maximization of aggregate healthbenefits. Just as important, we cannotproduce equity in health simply bydistributing medical or even publichealth resources equitably. Health in-equalities have more complex origins.We know from the longitudinalWhitehall studies of British civil ser-vants of different employment ranks,for example, as well as from otherstudies, that health inequalities in apopulation may not decrease, andmay increase, even with universal cov-erage.9 The Whitehall study involvesa study population that suffers nopoverty and has had basic education.Our health is thus affected not simplyby the ease with which we can see adoctor or be treated in a hospital, andnot simply by the reduction in risksthat come from traditional publichealth measures—though these fac-tors surely matter—but also bybroader aspects of social policy inter-acting with our social position andthe underlying inequality of our soci-ety.10

If we accept as otherwise just theinequalities we allow in our society,but these inequalities contribute tohealth inequalities, then should weview these health inequalities asthemselves just? Or are significanthealth inequalities across groups al-ways grounds for altering the distrib-ution of other goods? Our answermay depend on the kinds of other in-equalities that we see as producinghealth inequalities.11


Turn from class, for the moment,to race. American data reveals a signif-icant but complex independent effectof race—or racism—on health.African Americans have worse healththan whites at every income and edu-cational level. Institutional and overtracism must be included as further so-cial determinants of health. For exam-ple, the increasing de facto residentialsegregation that we see in Americacontributes significantly to these in-equalities. The complex pattern byrace and ethnicity of key behavioralrisk factors (diet, tobacco, alcohol,substance use and abuse, violence)contributes to, but does not accountfor, race and ethnic inequalities inhealth. In addition, medical treat-ment patterns differ by race—a result,perhaps, of conscious and uncon-scious stereotyping. A society that hasa legacy of caste structure and exclu-sion creates psychosocial stresses inmany institutional settings (schools,the workplace, shopping malls) thatare implicated in health inequalities.Similar issues affect many immigrantethnic minorities in European coun-tries.

Racial inequalities seem to be theeasy case. What about the inequalitieswe began with—those induced by so-cioeconomic status? We live in soci-eties that tolerate and even encouragesome significant degree of inequali-ty—as incentives, as justifiable desert,as an expression of diversity. Shouldwe count as unfair or unjust healthinequalities that result from other so-cial inequalities that we think accept-able or justifiable?

In earlier work, I argued thatRawls’s principles of justice as fairnessquite unexpectedly capture what thesocial epidemiological literature picksout as the key social determinants ofhealth—ranging from effective politi-cal participation rights to educationand early childhood training to signif-icant restrictions on income andwealth inequalities to supports for thesocial basis of self-esteem.12 Conform-ing with them would flatten socioeco-nomic gradients of health more thanany we see around us. Social justice—

that is, fair terms of social cooperationdeveloped in abstraction from think-ing about health—is good for our ag-gregate health and leads to a more eq-uitable distribution of it.

This conclusion is portrayed in thefollowing argument:

1. Completely maximizing popu-lation health requires making all peo-ple healthy. Making all people healthyalso achieves complete equity inhealth. (This is a conceptual point.)

2. There is no social justice with-out equity in health. (This is a widelyheld normative belief.)

3. There can be no equity in healthwithout social justice. (This is an em-pirical and causal claim that depends

on what we know about the social de-terminants of health, combined withthe hypothesis that distributing themin accord with Rawlsian principles ofjustice flattens health inequalities.13)

4. Therefore, achieving the bestlevel of population health by makingall people healthy requires (causally)that we pursue social justice morebroadly.14

If social justice is important topopulation health and its fair distrib-ution, then the policies aimed at equi-ty in health must be intersectoral inscope. All socially controllable factorsthat affect the distribution of healthbecome the concern of those pursu-ing equity in health. In a striking way,this perspective challenges one ver-sion of the view that we should treathealth as a separate “sphere”—focus-ing on health benefits without think-ing about the contributions thathealth makes across spheres.

We live in a nonideal world thatdoes not comply with Rawlsian prin-ciples of justice. We face importantquestions left unanswered by idealtheory. Many health-improving inter-ventions we may undertake increase

the levels of health of all parts of thepopulation even as they may increasehealth inequalities.15 For example,black infant morality rates were 64percent higher than white rates in1954 but were 130 percent higher in1998, even though white ratesdropped by 20.8 per thousand andblack rates dropped by 30.1 per thou-sand. David Mechanic concludesfrom this and other cases that we mayreasonably accept increasing healthinequalities caused by policies thatimprove population health, as long asthe health of all groups is being im-proved.

Suppose, however, that we havetwo interventions (whatever sector,

whatever novel technology) that bothraise the health of all groups. If inter-vention A does less than B for thosewho are worse off but much more forthose much better off, then both in-terventions satisfy Mechanic’s criteri-on. Yet we may have strong viewsabout whether to pursue A or B, de-pending on further facts about themagnitude of the effects or other factsabout the sizes of the groups and thusthe total impact of the programs. Ifsociety is responsible for causing theinitial inequality through unfair poli-cies, it may have special obligations togive more weight to equity than max-imization and to consider the speed atwhich it rectifies the effects of past in-justice.

The complexity of inequality itself.Policy choices about reducing healthdisparities are especially complex be-cause they are at the interface ofclaims about injustice and standarddistributive problems about whichreasonable people disagree. Unfortu-nately, another source of complexityderives from what Larry Temkin hasidentified as the complexity of in-equality itself.16

Bioethics has barely risen to the challenge of solving distributiveproblems when the baselines are morally neutral. It must now alsoaddress the added challenge posed by inequitable baselines.


Temkin describes situations inwhich two or more groups of individ-uals differ in their levels of wellbeing.He then asks the normative, not de-scriptive, question, Which group hasthe worse inequality? Someone who isworse off has a complaint about theunfairness of the inequality, and thestrength of that complaint dependson whether we compare those whoare worst off with (a) those who arebest off, (b) all those better off thanthey are, or (c) the average. To deter-mine when one inequality is worsethan another, we must not only assessthe strength of each complaint, butaggregate those complaints withineach situation. There are three ap-proaches to aggregation: a “maximin”egalitarian view, an additive view, or aweighted additive view. The ninecombinations of these bases for judg-ing inequalities better or worse yielddivergent judgments about cases, in-cluding ones with multiple groupsand ones involving welfare transfersamong groups. All nine approaches,for example, prefer to make theworst-off individual or group betterbefore adding comparable benefits toany of the other individuals or (equal-sized) groups, but they differ on judg-ments about other cases.

Temkin argues that none of thesenine combinations can be dismissedoutright as inconsistent or otherwisecompletely implausible. Consequent-ly, Temkin’s egalitarian must acceptthe fact that reasonable people willoften disagree about when one situa-tion is worse with regard to inequali-ty than another. Since egalitarians willgive more weight to reducing worseinequalities than ones that are not asbad, they will have reasonable dis-agreements about which inequalitiesto give priority to reducing. This ex-planation for the disagreement injudgments about when one inequalityis worse than another may underliesome disagreements about how muchpriority to give worst-off individualsor groups.

Broadening the bioethics agenda.Bioethics is not the right field to findthe relevant policy levers to reduce

health inequalities. That is a task ofsocial epidemiologists and other so-cial scientists. But bioethics shouldprovide guidance, in light of the com-plexity we have discussed, to the poli-cy decisions that involve differentways of trading off equity againstmaximization. There are two key di-mensions to that body of work.

First, there is the purely normativework of searching for consensus onprinciples that might guide us in therange of cases posed by our policy op-tions, including those that arise in de-veloping and disseminating new tech-nologies. These bioethics agendaitems bear on this normative work:

1) advance the existing ethicalwork on the unsolved distribu-tive problems;

2) clarify when a health inequali-ty is unjust;

3) explain how that injustice af-fects the unsolved distributiveproblems;

4) clarify what counts as a rea-sonable rate of progress towardreducing health inequalities; and

5) test the implications of 1-4 inthe context of actual policychoices about reducing healthdisparities, including those thatinvolve the dissemination of newtechnologies.

Second, bioethics must considerwhat to do when we cannot achieveconsensus on principles that can re-solve the disagreements we encounterin these five agenda items. All theseproblems must be solved in ways thatare perceived to be fair and legitimatein real time. Where we lack consensuson distributive principles, we mustrely on procedural justice to give usfair and legitimate resolution tomoral disagreements. In effect, proce-dural justice must supplement princi-pled approaches to problems wherev-er the principles we can agree on aretoo indeterminate or coarse-grainedto resolve disputes.

Jim Sabin and I developed an ap-proach we call “accountability for rea-sonableness,” and we have used it toexamine medical resource allocationin managed care contexts in the Unit-ed States.17 The approach appeals tokey elements of deliberative democra-tic theory to characterize the featuresof fair process in a range of decision-making contexts and institutions. Ihave used it, for example, to addressissues of equity in scaling up anti-retroviral treatments in countries withhigh rates of AIDS, in the context ofthe WHO effort to “treat 3 millionby 2005”—the “3 by 5” program.18 Itis also being used to improve the le-gitimacy of decision-making aboutcoverage of treatments within the cat-astrophic insurance scheme of theMexican Seguro Popular. It is cited asa framework for ethical deliberationabout the implications of cost-effec-tiveness analysis in a recent IOM re-port on regulatory contexts.19 Othersare using it to improve decision-mak-ing in publicly managed systems inCanada, Norway, Sweden, NewZealand, and the United Kingdom(where the National Institute of Clin-ical Evidence’s citizens council derivessome support from our approach).Still, there are many problems in de-veloping appropriate versions of thisapproach at the various institutionallevels where policy regarding healthinequalities is made and implement-ed.

My expanded agenda calls forbioethics to:

6) develop the general account offair process so that reasonablepeople who disagree can viewpolicies as fair and legitimate;and

7) apply the account to the vari-ous institutional contexts atwhich they must be addressed.


Equity between Age Groupsand Birth Cohorts in theContext of Societal Aging

Societal aging, especially in devel-oping countries, will emerge as a

major public health problem of thetwenty-first century. Societal aging in-tersects with and complicates two un-deranalyzed problems of intergenera-tional equity. Although I have earlierwritten about the problems of equitybetween age groups and equity be-tween birth cohorts, I underestimatedthe difficulty of integrating solutionsto these problems in the face of per-sistent societal aging.

Societal aging is greeted as a crisisin many recent book titles (whichrefer to an “age quake,” “age wave,” or“generational storm,” to note a few ofthe popular terms20), even though it isa result of the success, not the failure,of widely pursued health and familyplanning policies aimed at reducingmortality and fertility rates. It is ac-centuated when some birth cohort ismuch larger than the one followingit—as with the American postwarbaby boom or the Chinese cohortthat enjoyed dropping mortality ratesbut preceded the “one child” policy.Societal aging is a global phenome-non that has broad impacts on socialstructure, not just health.

In the United States, Kotlikiff andBurns observe that “walkers replacestrollers.”21 By 2030, nearly 20 per-cent of the U.S. population will besixty-five or over, whereas only 4 per-cent were in 1900. By 2040, thenumber of Americans over eighty(26.2 million) will exceed the numberof preschool children (25 million).22

European countries, including theUnited Kingdom, have alreadyreached “zero population growth.” InItaly, the fertility rate (1.2 children forevery couple) is well below the level atwhich a population can reproduce it-self (2.1), and the working age popu-lation is already shrinking (as it also isin Japan).23 America’s fertility rate of2.1 helps insulate it from the more ex-treme aging Italy faces. The UnitedNations predicts that Italy will have amedian age of fifty-four by 2050, sec-

ond only to Spain. But Italy is notalone. All the European G-7 coun-tries are below the replacement levelin fertility rates. By 2050, half ofContinental Europe will be forty-nineor older, and well before that, by2030, one of every two adults in de-veloped countries will have reachedretirement age. The United Nationsprojects that the ratio of working ageadults to elderly in the developedworld will drop from 4.5 to 1 todayto 2.2 to 1 in 2050.

While the proportion of the elder-ly in developed countries is due todouble over the next fifty years, from15 percent to 27 percent, it is due totriple in East Asia, from 6 percent to20 percent. By 2050, there will be332 million Chinese sixty-five yearsor over, equivalent to the entireworld’s elderly population in 1990.24

The two billion people over age sixtywho will live in our aging world by2050 will mostly be living in develop-ing countries.

The rapid societal aging in devel-oping countries will take place with-out the wealth and the sophisticatedeconomic institutions that exist in de-veloped countries. As one commenta-tor noted, China will grow old beforeit grows rich.25 And China is notalone. The rate of increase in thenumber of older people between1990 and 2025 is projected to be

eight times higher in developingcountries, such as Colombia,Malaysia, Kenya, Thailand, andGhana than it is in the United King-dom and Sweden.26 By 2050, thetransitional economies of Eastern Eu-rope will have populations with 28percent elderly, and Latin Americawill have over 17 percent, well overthe U.S. rate today.27

Two effects of societal aging. Soci-etal aging dramatically changes theprofile of needs in a country, creatingnew and intensified forms of compe-tition between age groups for scarceresources. It also reduces society’s abil-ity to sustain measures for meetingthose needs, sharpening competitionbetween birth cohorts. Together theseeffects bring questions about inter-generational equity to the fore thatmay have not been noticed under dif-ferent demographic conditions.

We all know, for example, that therapid growth of those over seventy-five—Bernice Neugarten’s “old-old,”those elderly who face especially in-creased disability and dependency—will bring with it increased burdensfor the management of chronic dis-ease and long-term care.28 Despite thepresence in some developed countriesof publicly funded, long-term care,most care is provided by family mem-bers, so the burden of societal agingwill increasingly fall on adult workingchildren, usually women. Yet nearly aquarter of all the elderly in the UnitedStates in 1989 had no children, andanother 20 percent had only onechild. With more women in theworkforce, the problem of providingfamily care is intensified, sincewomen have traditionally been theprimary caregivers. Pressures will in-crease to provide costly public pro-

grams at the same time that the work-ing age population is shrinking.

In developing countries, the prob-lem is not the sustainability of thekinds of publicly supported social andmedical services provided for the el-derly in developed countries, but thesustainability of informal, socialstructures of support, such as the tra-ditional patterns of care that involve

Policy choices about reducing health disparities are especially complex because they are at the interface of claims about injusticeand standard distributive problems about which reasonable people disagree.


aged parents living with adult chil-dren, as in China. China, for exam-ple, must face the specific conse-quence of the success of its very strictpopulation policy: one child forurban couples, two for rural ones.Like the United States, China willhave many elderly with no children,and it will have even more elderlywith only one child to support themthan is the case in the United States.The Chinese refer to this as the “1-2-4” problem: one child must care fortwo parents and four grandparents. In1996 the Chinese government madeit a legal requirement that adult chil-dren support their elderly parents, ob-viously anticipating that traditionalfilial obligations would be strained tothe breaking point by the new demo-graphic realities. But the law is notgoing to solve the problem. Norwould such a law work in other devel-oping countries in which rapid aging,extensive urbanization and industrial-ization, and a lack of existing healthcare and income support systems forthe elderly collide with traditionalfamily values.

The increase in medical needs andthe shift in the profile of those needswith societal aging is much broaderthan the problem of long-term carefor frail, elderly people. With societalaging there are increases in the preva-lence of cardiovascular disease, chron-ic pulmonary disease, diabetes, arthri-tis, and cancer, as well as Alzheimerdisease and other dementias. The in-creased cost of treating the greaterprevalence of these illnesses imposesenormous strains on resources and in-tensifies competition for them in de-veloped countries. The problem willbe even worse in developing countryhealth care systems that have barelybegun to gear up to meet the needsposed by chronic diseases. In poorlyfunded systems, beefing up medicalservices for the chronic illnesses ofmiddle and older age means divertingresources from primary care and pre-ventive care for the whole population.

Age groups and birth cohorts: twodistributive problems. Age groups andbirth cohorts are easy to confuse, for

the term “generation” is ambiguousbetween them. But they are different.Birth cohorts age, but age groups donot. At any given moment, an agegroup consists of a birth cohort; overtime, it consists of a succession ofbirth cohorts.

The age group problem raisesthese questions: How do we treat agegroups fairly within distributiveschemes, such as health care systems?What is a just allocation of resourcesto each stage of life, given that needsvary as we age? When is a distributivescheme age-biased in an unfair way?Is age itself a morally permissible cri-terion for limiting access to new tech-nologies?

Medicare in the United States re-cently approved three very expensivetechnologies: left ventricular assist de-vices as “destination therapy” for pa-tients ineligible for heart transplantsbut suffering from advanced conges-tive heart failure; lung volume reduc-tion surgery for select patient groupswith chronic obstructive pulmonarydisease; and implantable defibrilla-tors.29 Only the last one fell withinany usual cost-effectiveness threshold.No consideration of opportunitycosts entered the deliberation. SinceMedicare is a system only for the el-derly, unlike universal coverage sys-tems in other countries, equity issuesin allocation over the lifespan wereimpossible to raise. We could, for ex-ample, produce more health for boththe young and the old were properscreening and treatment for highblood pressure implemented instead.The billions spent on these technolo-gies would arguably be better spenton other forms of care for the elderlythemselves.

How should we think about healthcare resource allocation across agegroups? The key to thinking aboutthis age group problem is the observa-tion that we all age, though we do notchange race or sex.30 Treating peopledifferently at different ages, providedwe do so systematically over the lifes-pan, creates no inequalities across per-sons. Treating people differently byrace or class or gender creates inequal-

ities that are always in need of justifi-cation. Indeed, treating ourselves dif-ferently at different stages of life canmake our lives go better overall—weinvest in our youth, at some sacrificeof immediate revenues and pleasures,in order to be rewarded more later inlife. We take from ourselves in ourworking years in order to make ourlater, retired years go better.

Prudent allocation over the stagesof life should be our guide to fairtreatment among age groups (even ifprudence is not a general guide to jus-tice). This “prudential lifespan ac-count” must be properly qualified byassuming we already enjoy just distri-butions across persons and that wewill live with the results over ourwhole lifespan.31 Specifically, weshould allocate health care so that itpromotes the age-relative fair share ofopportunities (or capabilities).

On this view, rationing by age ispermissible under some scarcity con-ditions because it would not be im-prudent to so allocate. This argumentdoes not rely on specific, contestedintuitions about the fairness of age ra-tioning (as do Allan Williams’s claimthat the old have had their fair in-nings32 or Frances Kamm’s claim thatthe young need extra years more thanthe old33). It relies only on the gener-al prudential allocation model. Sincereasonable people disagree about theacceptability of this model and aboutspecific issues, such as age rationing,we will need fair procedures of thesort I noted before to resolve disputesabout priority setting among agegroups. Properly used, a transferscheme based on prudential alloca-tion or on some other view of fairoutcomes that emerges from fairprocess would solve the age groupproblem.

A solution to the age group prob-lem must also be compatible with so-lutions to the birth cohort problem.Imagine that over time, differentbirth cohorts pass through a schemethat solves the age group problem toour satisfaction. These cohorts areeach treated fairly, I proposed twodecades ago, if they have comparable


“benefit ratios” as they age throughthe schemes. New technologies thatwere not available for the elderlywhen they were young but will beavailable over the lifespan of thosenow young pose a special problem ofintercohort equity.

This approach to the birth cohortproblem can adjust for temporary de-mographic shifts, such as those pro-duced by the U.S. baby boom cohort.It is less clear how it can be modifiedto accommodate persistent popula-tion decline. That is the new chal-lenge we find in global aging, and ithas some similarities to stability prob-lems in seniority and relatedschemes.34

The bioethics agenda I am propos-ing must:

8) address the distributive issuesraised by the age group problem,including the impact of newtechnologies on resource alloca-tion over the lifespan; assess thepermissibility of rationing by age;consider age-bias in health sys-tems, such as the inadequacy oflong-term care in the UnitedStates and elsewhere, and in ourmethodologies, such as cost-ef-fectiveness analysis; and considerfair process where reasonablepeople disagree about these is-sues; and

9) address how persistent societalaging affects the complex prob-lem of treating cohorts equitablywhile at the same time not un-dermining proper solutions tothe age group problem.35

International Equity and Health

Isuggested earlier that health in-equalities are unjust if they arise

from an unjust distribution (as speci-fied by Rawls’s principles of justice asfairness) of the socially controllablefactors that affect population health.Judged from this ideal perspective,there are indeed many health in-equities—by race and ethnicity, byclass and caste, and by gender—

around the world. Health inequity ispervasive globally.

This account is unfortunatelysilent about important questions ofinternational justice. When are in-equalities between different societiesunjust? What do better-off societiesowe as a matter of justice (not charity)by way of improving the health of thepopulation in less healthy societies?Suppose countries A and B each dothe best they can to distribute the so-cially controllable factors affectinghealth fairly, and there are no glaringsubgroup inequities. Nevertheless,health outcomes are unequal betweenA and B because A has many more re-sources to devote to populationhealth than B. Is the resulting interna-tional inequality in health a matter ofjustice? Suppose B democraticallychooses not to protect its populationhealth as best it can, preferring in-stead other social goals, leading againto population health worse than A’s.Is the resulting health inequality amatter of international justice?

Recasting the problem as an issueof a human right to health and healthcare recognized by internationaltreaties and proclamations does notimprove the situation for two reasons.First, the international, legal obliga-tion to secure a right to health for apopulation falls primarily on each sig-natory state for its own population.Although international human rightsagreements and proclamations alsoposit international obligations to as-sist other states in securing humanrights, the international obligationscannot become primary in thehuman right to health and healthcare. External forces cannot assurepopulation health across national

boundaries in the way they might in-tervene to prevent violation of someother rights, even when they can af-ford assistance.

Second, even when a right tohealth is secured in different states,health inequalities between them mayexist. Since conditions do not alwayspermit everything to be done to se-cure a right in one country that maybe feasible in another, the right tohealth and health care is viewed as“progressively realizable.”36 Reason-able people may disagree about howbest to satisfy this right, given thetrade-offs that priority setting inhealth makes necessary. Consequentlysome inequalities may fall within therange of reasonable efforts at “pro-gressive realizability.” In addition, be-cause of their unequal resources, dif-ferent states may achieve unequalhealth outcomes while still securing aright to health and health care fortheir populations. Arguments that de-pend on appeals to human rights can-not tell us whether these inequalitiesare unjust and remain silent on whatobligations better-off states have toaddress these inequalities.

Though nearly all people recog-nize some international humanitarianobligations of individuals and statesto assist those facing disease and pre-mature death wherever they are, thereis substantial philosophical disagree-ment, even among egalitarian liberals,about whether there are also interna-tional obligations of justice to reducethese inequalities and to better pro-tect the rights to health of thosewhose societies fail to protect as muchas they might. Nagel, who affirmsthese humanitarian obligations, ar-gues that socioeconomic justice,

Societal aging dramatically changes the profile of needs in a country, bringing questions about intergenerational equity to thefore: How do we treat age groups fairly within distributive schemessuch as health care systems? How do we justly allocate resourcesto each stage of life, given that needs vary as we age?


which presumably includes the justdistribution of health, applies onlywhen people stand in the explicit rela-tion to each other that is character-ized by a state. Specifically, concernsabout equality are raised within statesby the dual nature of individuals bothas coerced subjects and as agents inwhose name coercive laws are made.37

Rawls also did not include interna-tional obligations to assure a right tohealth on the list of human rights thatliberal and decent societies have inter-national obligations of justice to pro-tect.38

This “statist” view encounters astrong counterintuition. Life ex-pectancy in Swaziland is half that inJapan.39 A child born in Angola is seventy-three times likelier to die be-fore age five than a child born in Nor-way.40 A mother giving birth insouthern sub-Saharan Africa is onehundred times likelier to die from herlabor as one birthing in an industrial-ized country.41 Many of us thinkthere is something not just unfortu-nate and deserving of humanitarianassistance, but something unfair,about these gross inequalities.

Those who claim that gross healthinequalities are unjust have quite dif-ferent, incompatible ways of justify-ing that view. For example, those whoregard as unjust any disadvantage thatpeople suffer through no fault orchoice of their own would assert thatthe disadvantage facing the Angolanchild is therefore unjust. The underly-ing principle of justice is applied toindividuals wherever they are in thecosmos and regardless of what specif-ic relationships they stand in to oth-ers—contrary to the Rawls-Nagel ac-count, which applies principles of jus-tice to the basic structure of a sharedsociety. The disadvantage of the An-golan child might also be thought un-just by those who, like Rawls orNagel, think principles of justice are“relational” and apply only to a basicsocial structure that people share, butwho, unlike Rawls or Nagel, believewe already live in a world where inter-national agencies and rule-makingbodies constitute a global basic struc-

ture appropriately seen as the subjectof international justice, developedperhaps through a social contract in-volving representatives of relevantgroups.42 Fair terms of cooperationinvolving that structure would, someargue, reject arrangements that failedto make children in low-incomecountries as well off as they could be.Clearly, there may be more agreementabout some specific judgments of in-justice than there is on the justifica-tion for those judgments or on broad-er theoretical issues.

I shall examine briefly two ways oftrying to break the stalemate betweenstatist and cosmopolitan perspectives.One approach aims for a minimalist(albeit cosmopolitan) strategy that fo-cuses on an international obligationof justice to avoid “harming” peopleby causing “deficits” in the satisfac-tion of their human rights.43 It is aminimalist view in the sense that peo-ple may agree on negative duties notto harm even if they disagree aboutpositive duties to aid. This approachhandles some international health is-sues better than others. A morepromising (relational justice) ap-proach, which I can only briefly illus-trate, requires that we work out amore intermediary conception of jus-tice appropriate to evolving interna-tional institutions and rule-makingbodies, leaving open just how centralissues of equality would be in such acontext.44

Harms to health: a minimaliststrategy. If wealthy countries engagein a practice or policy, or impose aninstitutional order, that foreseeablymakes the health of those in poorercountries worse than it would other-wise be—specifically, making it hard-er than it would otherwise be to real-ize a human right to health or healthcare—then, according to Pogge, it isharming that population by creating a“deficit” in human rights.45 Since thisharm is defined relative to an interna-tionally recognized standard of jus-tice—the protection of humanrights—Pogge argues that imposingthe harm is unjust. Moreover, if thereis a foreseeable alternative institution-

al order that would reasonably avoidthe deficit in human rights, there isan international obligation of justiceto produce the rights-promoting al-ternative.

Some confusion remains, however,about how to specify the baselineagainst which harm is measured.When is there a “deficit” in a humanright to health? Whenever a countryfails to meet the levels of health pro-vided, say, by Japan, which has thehighest life expectancy? Or is theresome other, unspecified standard?Consider two examples.

The brain drain of health personnel.The brain drain of health personnelfrom low-income to OECD coun-tries may exemplify Pogge’s concerns.The situation is dire. Over 60 percentof doctors trained in Ghana in the1980s emigrated overseas.46 In 2002in Ghana, 47 percent of doctors’posts and 57 percent of registerednursing positions were vacant. Someseven thousand expatriate SouthAfrican nurses work in OECD coun-tries, while there are thirty-two thou-sand nursing vacancies in the publicsector in South Africa.47 Whereasthere are 188 physicians per 100,000people in the United States, there areonly one or two per 100,000 in largeparts of Africa. The brain drain ishardly the sole cause of the inequalityin health workers, but it significantlycontributes to it.

International efforts to reducepoverty, lower mortality rates, andtreat HIV/AIDS patients—the Mille-nium Development Goals agreedupon in 2000—are all threatened bythe loss of health personnel in sub-Saharan Africa. An editorial in theBulletin of the World Health Organiza-tion points out that the MDG goalsof reducing mortality rates for in-fants, mothers, and children underfive cannot be achieved without amillion additional skilled healthworkers in the region.48 The global ef-fort to scale up antiretroviral treat-ments poses a grave threat to fragilehealth systems, for its influx offunds—hardly a bad thing in itself—may drain skilled personnel away


from primary care systems that al-ready are greatly understaffed.

What about causes? There is botha “push” from poor working condi-tions and opportunities in low-in-come countries and a “pull” frommore attractive conditions elsewhere.Is this simply “the market” at work,backed by a “right to migrate”?

Pogge’s argument about an inter-national institutional order has morespecific grip than the vague appeal toa market. When economic conditionsworsened in various developing coun-tries in the 1980s, internationallenders, such as the World Bank andInternational Monetary Fund (IMF)insisted that countries severely cutback publicly funded health systemsas well as take other steps to reducedeficit spending. In Cameroon in the1990s, for example, the measures in-cluded a suspension of health workerrecruitment, mandatory retirement atfifty or fifty-five years, suspension ofpromotions, and reduction of bene-fits. The health sector budget shrankfrom 4.8 percent in 1993 to 2.4 per-cent in 1999, even while the privatehealth sector grew.49 As a result, pub-lic sector health workers migrated tothe private sector and others joinedthe international brain drain. The in-ternational institutional order in-creased the push.

The “pull” attracting health work-ers to OECD countries is also notjust diffuse economic demand. Tar-geted recruiting by developed coun-tries is so intensive that it has strippedwhole nursing classes away fromsome universities in the southernhemisphere. In 2000, the Labor Gov-ernment in the United Kingdom set atarget of adding twenty thousandnurses to the National Health Serviceby 2004. It achieved the goal by2002. The United Kingdom ab-sorbed thirteen thousand foreignnurses and four thousand doctors in2002 alone. Recruitment from Euro-pean Union countries was flat (manyof these countries also face shortagesin the face of aging populations), butimmigration from developing coun-tries continued despite an effort to

frame a policy of ethical recruit-ment.50 Arguably, even if there were adiffuse economic “pull,” in the ab-sence of active recruiting, the harmwould be much less.

The remedy for this harm is not aprohibition on migration, which isprotected by various human rights.The United Kingdom has recentlyannounced a tougher code to restrictrecruitment from 150 developingcountries. In addition, it has initiateda $100 million contribution to theMalawi health system aimed at creat-ing better conditions for retaininghealth personnel there. The UnitedKingdom has thus taken two stepsthat are intended to reduce both thepush and the pull behind the braindrain. Other countries have not fol-lowed suit.

International property rights and ac-cess to drugs. The minimalist strategybecomes harder to apply in a clearway to other international health is-sues. The problem of internationalproperty rights and the incentivesthey create goes beyond the issue ofaccess to existing drugs, such as the

antiretroviral cocktails that were thefocus of attention in recent years. BigPharma has long been criticized for aresearch and development biasagainst drugs needed in developingcountry markets. Indeed, it has re-sponded to existing incentives byconcentrating on “blockbuster” drugsfor wealthier markets, includingmany “me, too” drugs that marginallyimprove effectiveness or reduce sideeffects slightly. Funding the researchneeded to develop a vaccine against

malaria, for example, has fallen to pri-vate foundations.

Do intellectual property rights andthe incentive structures they supportcreate a foreseeable deficit in the rightto health that can be reasonablyavoided? Pogge argues that they do.51

Nevertheless, many drugs developedby Big Pharma under existing proper-ty right protections have filtered intowidespread use as generics on “essen-tial drug” formularies in developingcountries. Health outcomes in thosecountries are much better than theywould be absent such drugs. Sincemany of these drugs would not havebeen produced in the absence ofsome form of property right protec-tions, people are not worse off thanthey would be in a completely freemarket with no temporary monopo-lies on products.

Arguably, however, different prop-erty right protections and differentincentive schemes would make peo-ple in these poor countries with poormarkets better off than they currentlyare. Which schemes ought we to se-lect? Pogge proposes that we revise in-

centives for drug development by es-tablishing a tax-based fund in devel-oped countries that would rewarddrug companies in proportion to theimpact of their products on the glob-al burden of disease.52 For example,drugs that meet needs in poor coun-tries with very high burdens of diseasewould be rewarded with higher pay-ments from the fund, even if thedrugs were disseminated at a costclose to the marginal cost of produc-tion. The tax, he admits, would be

Though nearly all recognize some international humanitarian obligations to assist the ill wherever they are, substantial philosophical disagreement exists—even among egalitarian liberals—about whether there are also international obligations ofjustice to reduce inequality and better protect the health of thosewhose societies fail them.


hard to establish, but it would be off-set in rich countries by lower drugprices. The program could be limitedto “essential drugs,” leaving existingincentives in place for other drugproducts. Even so, the tax and thusthe incentives could vary consider-ably, presumably with consequencesof different magnitude for the globalburden of disease. How do we pickwhich alternative to use as a baselineagainst which a “deficit” in the rightto health is specified? Pogge does nottell us.

Leaving aside the problem ofvagueness, Pogge’s proposal cannot bejustified by appealing to the “noharm” principle alone. The proposedincentive fund would better help torealize human rights to health, asPogge argues, but “not optimallyhelping” is not the same as “harm-ing,” and so the justification has shift-ed. There may well be good reasonsfor an account of international justiceto consider the interests of those af-fected by current property right pro-tections more carefully than thoseagreements now do—but that takesus into more contested terrain thanthe minimalist strategy.

International harming is complexin several ways. Often, the harms arenot imposed deliberately, and some-times it may be that benefits were in-tended. Also, the harms are oftenmixed with benefits. In any case,great care must be taken to describethe baseline against which harm ismeasured. Such a complex storyabout motivations, intentions, andeffects might seem to weaken thestraightforward appeal of the mini-malist strategy, but the complexitydoes not undermine the view that wehave obligations of justice to avoidharming health.

In any case, international harmingis only one of three causes of interna-tional health inequalities. Interna-tional health inequalities are also theresult of (a) domestic failures to pro-mote population health adequately orfairly; and (b) differences across coun-tries in levels of human and naturalresources and in the natural condi-

tions that contribute to the preva-lence of disease (such as malaria).Thus the minimalist strategy fails toaddress many inequalities that somebelieve raise questions of internation-al justice.

The new terrain of global justice:where the action is. Although I notedthe strong pull of the cosmopolitanintuition about the unfairness of in-ternational health inequalities, thereis also a strong intuition that obliga-tions of justice arise only when peoplestand in certain specified relations toeach other (“relational justice”). If weabandon the idea that such relationscan arise only within states, we mayfind attractive the view argued byCohen and Sabel.53 They sketch threetypes of international relationshipsthat might give rise to obligations ofjustice going beyond humanitarianconcerns: international agenciescharged with distributing a specificgood, cooperative schemes, and somekinds of interdependency. Each maygive rise to obligations of justice, suchas concerns about inclusion. Thesemay range from an obligation to givemore weight to the interests of thosewho are worse off if it can be done atlittle cost to others to obligations ofequal concern, perhaps yielding farmore egalitarian obligations. I shall il-lustrate each of these relationshipsand the obligations to which theygive rise with examples focused onkey issues of global health.

WHO plausibly illustrates the ideathat institutions charged with distrib-uting a particular, important good,such as public health expertise andtechnology, must show equal concernin the distribution of that good. Theorganization would be acting unfairlyif it ignored the health of some andattended more to the health of others.This point about showing equal con-cern arises in other debates about themethodologies WHO employs. Wesaw that cost-effectiveness analysis ig-nores issues of equity in the distribu-tion of health and health care.54

These criticisms of cost-effectivenessanalysis thus challenge its uncon-strained use by WHO, whether

WHO is using it to determine healthpolicy within a specific country oracross countries. WHO is con-strained by its mission of improvingworld health to consider equity indistribution in all contexts in which itworks—within and across countries.

Concerns about equity show up inprogrammatic discussions as well.WHO paid attention to equity in thedistribution of antiretroviral treat-ments for HIV/AIDS. I noted earlierWHO’s sponsorship of a Commis-sion on the Social Determinants ofHealth, with its focus on equity. Bothof these examples illustrate behaviorcompatible with and required by theinstitutional charge to WHO. Eitherthis is a misguided focus of energy forWHO, as seems to be implied byNagel’s strong statist view, or it is animplication of the obligation to showequal concern that arises within insti-tutions charged with delivering animportant good—whether they oper-ate within states or across them.

Consider now the internationalbodies that establish rules governingintellectual property rights, includingthose that are key to creating tempo-rary monopolies over new drugs.Such a scheme is “consequential” inthat it increases the level of coopera-tion in production of an importantcollective good—the research and de-velopment of drugs—and it does soin a way that has normatively relevantconsequences.55 Suppose we concludethat this mutually cooperative schemegenerates considerations of equal con-cern, or at least that it must be gov-erned by a principle of inclusion.Then we might view quite favorablyPogge’s suggestion about structuringdrug development incentives so thatthey better addressed the global bur-den of disease. Earlier, I said Pogge’sproposal could not be defended onthe minimalist grounds that it avoid-ed doing harm because of the prob-lem of specifying the relevant humanrights baseline. Now, however, wehave a new basis on which to defendthe justice of Pogge-style incentives.Such an incentive scheme, supple-menting existing property rights or


modifying them appropriately, wouldgreatly enhance the benefits to thosewho are largely excluded from benefitfor a significant period of time, and itwould do so at only modest cost tothose profiting from the endeavor.Minimally, it illustrates what a moreinclusive policy should include; onecan build into it even stronger egali-tarian considerations, if the coopera-tive scheme gives rise to concernsabout equality and not simply inclu-sion. Exactly what form the policywould take, and the justification for it(deriving from the form of coopera-tive scheme involved), remain tasksfor further work. With these issuesworked out, we might then supportPogge’s incentive schemes as a way ofmoving some countries closer to satis-faction of a right to health, connect-ing the effort to human rights goals ashe does.

Consider again the example of thebrain drain of health personnel fromlow and middle income countries towealthier ones. Nagel notes that na-tions generally have “immunity fromthe need to justify to outsiders thelimits on access to its territory,”56 al-though this immunity is not absolute,since the human rights of asylumseekers act as a constraint. Still, thedecisions different countries makeabout training health personnel andabout access to their territories havegreat mutual impact on them. Thereis an important interdependency af-fecting their wellbeing—specifically,the health of the populations con-tributing and receiving health person-nel. The British decision in 2000 torecruit thirty thousand new nursesfrom developing countries rather thantry to train more greatly affected thefate of people being served by healthsystems in southern Africa. The un-derfunding of salaries for Africannurses and doctors—in part a legacyof Structural Reform Programs im-posed by the IMF and World Bankbut clearly continued by local govern-ments—helps create the “push” factordriving these workers abroad. Ar-guably, this interdependence bringsinto play obligations of inclusion,

even those of equal concern; in anycase, they go beyond humanitarianconsiderations. In addition to Pogge’s“no harm” or minimalist approach,we thus have available obligations ofinclusion requiring us to consider theinterests of all those in the interde-pendent relationship. These obliga-tions can be translated into variouspolicy options that address the braindrain: it may be necessary to restrictthe terms of employment in receivingcountries of health workers from vul-nerable countries; it may be necessaryto seek compensation for lost trainingcosts of these workers; it may be im-portant to give aid to contributingcountries aimed at reducing the push

factors; it may be necessary to prohib-it active recruitment from vulnerablecountries.

We might combine this interde-pendence with the relationships andobligations that arise from coopera-tive schemes. The International Orga-nization for Migration, established in1951 to help resettle displaced per-sons from World War II, now has 112member states and twenty-three ob-server states. It “manages” various as-pects of migration, providing infor-mation and technical advice, and ar-guably goes beyond its initial human-itarian mission. Suppose it took onthe task of developing a policy thathelped to coordinate or manage thefrightening health personnel braindrain. Minimally, it might seek inter-nationally acceptable standards formanaging the flow—standards for re-cruitment, compensation, and termsof work. More ambitiously, it mightseek actual treaties that balancedrights to migrate with costs to thecontributing countries, countering atleast some of the pull factors and even

providing funds that might alleviatesome of the push factors underlyingthe brain drain. In seeking these, itmight work together with the Inter-national Labour Organization, withthe World Trade Organization, withWHO, and with the United Nations.Such a cooperative endeavor wouldreflect the common interest in allcountries in having adequate healthpersonnel—and thus being able to as-sure citizens a right to health andhealth care—as well as the commoninterest in protecting human rights todignified migration.

The fuller development of a plau-sible account of justice in these inter-mediary institutions is a task for the

expanded bioethics agenda I havebeen charting. Bioethicists must:

10) assess the implications of theobligation not to harm for reduc-ing health inequalities interna-tionally;

11) develop an account of justicefor the evolving international in-stitutions and rule-making bod-ies that have an impact on inter-national health inequalities; and

12) examine Promethean chal-lenges from the perspective oftheir impact on internationalhealth inequalities and obliga-tions of justice regarding them.

Preparing the Field

The broader bioethics agenda Ihave described poses two distinct

and significant challenges to the field.The first challenge is one of training.Many of the problems take us outsidethe more familiar domain of ethics

In order to broaden its agenda to meet these challenges, the field ofbioethics would have to expand its focus beyond ethics and the clinical practice of medicine to the far less familiar terrain of political philosophy and the social sciences.


and the clinical practice of medicineinto the far less familiar terrain of po-litical philosophy and a wide range ofsocial sciences. The relevant philo-sophical literature is less familiar tomany in the field, and it would haveto be mastered by both those whoteach bioethics and those who engagein it. Some training programs inbioethics already include some of thismaterial, but many would have to ex-pand their focus.

The second challenge is political.An implication of my earlier argu-ment is that social justice is good forpopulation health and is essential toits fair distribution. But engaging inthe pursuit of social justice and notsimply justice in health care can bedivisive in a novel way. Many peoplealready agree that we have socialobligations to give people equal accessto an appropriate array of health careinterventions. Perhaps this is becausethey see the threat of disease and dis-ability as a part of the struggle of hu-mans against nature. In that battle,we are united in our vulnerability. Wehope that technology will rescue all ofus. The Promethean battle of humansagainst nature—and our own humanweaknesses—is in a certain sense uni-fying.

Many fewer people, however, un-derstand the broad ways in which thedistribution of other goods affecthealth inequalities, let alone agreeabout how to distribute those goods.Indeed, this is a context in which wecannot all easily unite against nature.Rather, there are divisions of interestand perspective among all of us, in-cluding across nations. Shifting abioethics agenda to address the causesof health inequality can thus be polit-ically divisive, both domestically andinternationally.

Acknowledgments

This article is adapted from a lecturedelivered to the Nuffield Council inMay 2005. It also draws on materialfrom a new book, Just Health: A Popu-lation View (Cambridge UniversityPress, forthcoming).

References

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2. Preamble to Constitution of WHO,adopted by International Health Confer-ence, New York, June 19-22, 1946; enteredinto force April 7, 1948, never amended.

3. I sidestep a debate about whether tomeasure all individual variation in health,later factoring in information about demo-graphic subgroups (compare this to E.E.Gakidou, C.J.L. Murray, and J. Frenk,“Defining and Measuring Health Inequali-ty,” Bulletin of the World Health Organiza-tion 78 [2000]: 42–54), or to focus onhealth inequalities across important sub-groups, such as by class or race or ethnicity(P. Braveman, B. Starfield, and H.J. Geiger,“World Health Report 2000: How It Re-moves Equity from the Agenda for PublicHealth Monitoring and Policy,” BritishMedical Journal 323 [2002]: 678-81).

4. Rawls’s social contract situation in-volves a simplifying assumption that all peo-ple are fully functional over a normal lifes-pan. We might take this to be an egalitariandefault position. See J. Rawls, A Theory ofJustice (Cambridge, Mass.: Harvard Univer-sity Press, 1971).

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10. Because these additional social factorsso crucially affect population health and itsdistribution, the distinction that labelshealth as a natural rather than as a socialgood, as in Rawls or Nagel, is less clear. SeeRawls, A Theory of Justice; T. Nagel, “Justiceand Nature,” Oxford Journal of Legal Studies17, no. 2 (1997): 303-21.

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12. Daniels, Kennedy, and Kawachi,“Why Justice Is Good for Your Health.”

13. Ibid.14. Suppose we flatten SES gradients of

health as much as the principles of justicewould seem to require us to, but socioeco-nomic inequalities remain that induce somehealth inequalities. Are these residual healthinequalities just? Or must we eliminate allsocial and economic inequalities that con-tribute to health inequalities? Some mightinterpret the priority Rawls gives to oppor-tunity as requiring this response. Then,Rawls’s theory becomes more egalitarianthan was supposed. Alternatively, we mightcome to understand the mechanismsthrough which health inequalities are pro-


duced by other inequalities and intervene toreduce them without having to reduce oth-erwise justifiable inequalities. On anotherreading, Rawls’s theory may not specificallyanswer this question about residual healthinequalities. See Daniels, Kennedy,Kawachi, “Why Justice Is Good for YourHealth.”

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18. N. Daniels, “Fair Process in PatientSelection for Antiretroviral Treatment forHIV/AIDS in WHO’s 3 by 5 program,”The Lancet 366 (2005): 169-71.

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21. Kotlikoff and Burns, The ComingGenerational Storm.

22. Peterson, Gray Dawn, citing 1996census figures.

23. Center for Strategic and Internation-al Studies, Meeting the Challenge of GlobalAging (Washington, D.C.: Center for Strate-gic and International Studies, 2002), avail-able at http://www.csis.org/gai.

24. R. Jackson and N. Howe, GlobalAging: The Challenge of the New Millennium(Washington, D.C.: Center for Strategicand International Studies and WatsonWyatt Worldwide, 1999), at http://www.csis.org/component/option,com_csis_pubs/task,view/id,892/type,1/.

25. Ibid.26. “Aging on the World Stage,” Interna-

tional Center for Longevity, May 2006 ath t t p : / / w w w. i l c u s a . o r g / _ l i b / p d f /madrid2002.pdf.

27. Center for Strategic and Internation-al Studies, Meeting the Challenge of GlobalAging, chapter 3.

28. B.L. Neugarten, Age or Need? PublicPolicies for Older People (Beverly Hills,Calif.: Sage Publications, 1982).

29. M. Gillick, “Medicare Coverage forTechnological Innovations: Time for New

Criteria?” New England Journal of Medicine350 (2004): 2199-2203.

30. N. Daniels, Am I My Parents’ Keeper?An Essay on Justice between the Young and theOld (New York: Oxford University Press,1988).

31. Ibid.32. A. Williams, “Intergenerational Equi-

ty: An Exploration of the Fair Innings Argu-ment,” Health Economics 6 (1997): 117-32.

33. F. Kamm, Morality, Mortality.34. K. Shepsle and E. Dickson, “Working

and Shirking: Equilibrium in Public GoodsGames with Overlapping Generations ofPlayers,” Journal of Law, Economics, and Or-ganization 17 (2001): 285-318.

35. Privatization strategies do not solvethe problem; they just represent one conclu-sion about what such equity requires, andthey do so without allowing us to use ascheme that addresses the age group prob-lem at the same time. In addition, privatiza-tion is not even a starter for lifespan healthsystems the way it is for income support.

36. The UN Commission on HumanRights “urges States to take steps, individu-ally and through international assistanceand cooperation, especially economic andtechnical, to the maximum of their availableresources, with a view to achieving progres-sively the full realization of the right ofeveryone to the enjoyment of the highest at-tainable standard of physical and mentalhealth by all appropriate means, includingparticularly the adoption of legislative mea-sures.” UN Commission on Human Rights,“The Right of Everyone to the Enjoymentof the Highest Attainable Standard of Phys-ical and Mental Health,” Commission onHuman Rights Resolution 2003/28.

37. T. Nagel, “The Problem of GlobalJustice,” Philosophy and Public Affairs 33,no. 2 (2005): 113-47.

38. J. Rawls, The Law of Peoples (Cam-bridge, Mass.: Harvard University Press,1999).

39. Forty years versus more than eightyyears; “People Facts and Figures,” athttp://www.os-connect.com/pop/p1.asp?whichpage=10&pagesize=20&sort=Coun-try, accessed May 5, 2006.

40. UNICEF, “The State of the World’sChildren,” at http://www.unicef.org/sowc00/stat2.htm, accessed August 23,2005.

41. WHO/UNICEF/UNFPA, “Mater-nal Mortality in 2000: Estimates Developedby WHO, UNICEF, and UNFPA,” athttp://childinfo.org/areas/maternalmortali-ty/, accessed May 5, 2006.

42. C. Beitz, “Rawls’s Law of Peoples,”Ethics 110 (2000): 669-96.

43. T.W. Pogge, World Poverty andHuman Rights: Cosmopolitan Responsibilities

and Reforms (Cambridge, U.K.: BlackwellPublishers, 2002); T.W. Pogge, “HumanRights and Global Health: A Research Pro-gram,” Metaphilosophy 36, nos. 1-2 (2005):182-209.

44. J. Cohen and C. Sabel, “Extra Rem-publicam Nulla Justitia,” Philosophy & Pub-lic Affairs 34, no. 2 (2006): 147-75.

45. T. Pogge, “Severe Poverty as a Viola-tion of Negative Duties,” Ethics and Interna-tional Affairs 19, no. 1 (2005): 55-83.

46. World Health Organization, Interna-tional Migration, Health, and Human Rights(Geneva, Switzerland: World Health Orga-nization, 2003), 13.

47. S. Alkire and L. Chen Alkire, “‘Med-ical Exceptionalism’ in International Migra-tion: Should Doctors and Nurses Be TreatedDifferently?” JLI Working Paper 7-3(2004): 1-10.

48. L. Chen and P. Hanvoravonchai,“HIV/AIDS and Human Resources,” Bul-letin of the World Health Organization 83(2005): 143-44.

49. B. Liese, N. Blanchet, and G. Dus-sault, “The Human Resource Crisis inHealth Services in Sub-Saharan Africa,”background paper prepared for the WorldDevelopment Report 2004, Making ServicesWork for Poor People (Washington, D.C.:The World Bank, 2004).

50. C. Deeming, “Policy Targets and Eth-ical Tensions: UK Nurse Recruitment,” So-cial Policy and Administration 38, no. 7(2004): 227-92.

51. Pogge, “Human Rights and GlobalHealth: A Research Program.”

52. Ibid.53. Cohen and Sabel, “Extra Rempubli-

cam Nulla Justita.”54. Daniels and Sabin, Setting Limits

Fairly.55. Cohen and Sabel, “Extra Rempubli-

cam Nulla Justita.”56. Nagel, “Global Justice,” 130.

equity and population health: toward a broader bioethics agenda

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