The final question of the MacLean Center for Clinical Medical Ethics seminar series on health disparities was a seemingly obvious query that had gone unasked and unanswered the entire year: who is responsible for fixing the problem? For the self-selecting audience that had attended the lectures all year, the question may have seemed irrelevant – many in attendance are already working on research and interventions to reduce disparities at home and abroad. But for Dan Brock, the director of medical ethics at Harvard Medical School, the question was worth approaching from a philosophical perspective, if only for the purpose of preaching beyond the choir assembled each week at the seminar series.
The statistics about disparities between developed and undeveloped countries are not in question: the threefold difference in life expectancy, the millions of children who die each year from preventable disease and malnutrition, the large discrepancies in health care spending. But who has the moral responsibility to try and remedy these enormous global health gaps? Is it the obligation of rich individuals, or organizations and institutions, or governments, or (as a libertarian might say) of nobody at all? Brock said that philosophical theories of global justice are too new to offer answers for such questions. Arguments have been made for centuries about helping the unfortunate you can see, or even the unfortunate of your own tribe, city, state, or country. But stretched to a global scale, these theories have not yet matured, on issues such as how to take care of a nation’s own needy while still assisting the “foreign” needy thousands of miles away.
To address this shortcoming, Brock suggested three other scaffolds upon which an argument for fighting global disparities could be argued. The first was an economic proposition: as he stated, “if you can prevent great harms at little risk, you are obligated to do so.” Fifteen cents worth of rehydration salts can save a child from dying of dehydrating diarrhea, ten dollars (the cost of a movie) given to a charity can buy minimum essential medicines and more – an argument for sacrifice.
“One can’t make a plausible case that more good comes from me going to a movie then would be done in the world if I had gave that money to OxFam instead,” Brock said.
One obstacle to these small acts of charity is the “out of sight, out of mind” phenomenon – as Brock said, almost everyone would give part of their sandwich to a starving African child sitting next to them, but the concept of millions of starving African children is more abstract. But in a time of increased connectivity, where news organizations and social media can instantaneously spread images around the world from even the most remote locales, this detachment will no longer be an excuse, he said.
Brock’ s second argument that the well-off are obligated to help the needy was a harder pill to swallow: Guilt. The prosperity of the developed world is not independent from the poverty of the undeveloped, Brock argued; it was built upon a history of slavery and colonialism that has continued to handicap Africa and Asia long after such policies (officially) ceased. Even today, the exportation of natural resources such as oil from Africa and the Middle East to the developed world perpetuates oppressive governments, inequalities, and poverty in those countries. That complicity in the suffering of others gives the developed world a special responsibility to help, Brock said.
“Our failure to act isn’t just a failure of beneficence, a failure to help others that are needy, because we are in significant respects causally responsible for their need and in turn morally responsible for their suffering,” Brock said. “If I was the one who drove into your car and wrecked it, then I have a special obligation to help you, because I caused your need.”
The third basis for fighting global health disparities came from the 1948 Universal Declaration of Human Rights: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.” As laid out by the United Nations, these rights cut across borders and are bestowed to a person at birth, simply for being a person. Most countries in the world have committed themselves to these standards, Brock said, but they remain ill-defined in practice: is it a right to health or a right to health care? And what about social determinants that affect health, such as education and employment?
With all of these very cogent arguments for intervening in global health disparities, Brock’s talk couldn’t help but leave a sour feeling, even in a room of physicians and scientists who do more than most to take care of the world’s needy and sick. Brock offered no easy medicine, saying that all of us fortunate enough to have our health are obligated to do what we can – and maybe a little bit more – to assist those without around the world.
“I can’t give you a precise amount each of us should be giving based on your resources,” Brock said. “I’m confident almost all of us do much less than we should. The first thing you should do is feel guilty.”
[Each academic year, the MacLean Center for Clinical Medical Ethics organizes a series of lunchtime seminars by physicians, biologists, economists, social scientists and other experts covering the biggest questions in health care and ethics. This year’s theme is “Health Disparities: Local, National, Global,” and the series was put together with the Urban Health Initiative, the Global Health Initiative, and Finding Answers. ScienceLife will carry regular coverage of this unique series, and video of the lectures will be posted when available.]