Non‐governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non‐governmental organizations play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self‐mandating and self‐regulating. What is needed in terms of accountability is some means by which all the relevant stakeholders (...) can have their interests represented and considered. An ideally accountable decision‐making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate‐based justifications and advocacy‐based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long‐term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole. (shrink)

How should medical services be distributed within society? Who should pay for them? Is it right that large amounts should be spent on sophisticated technology and expensive operations, or would the resources be better employed in, for instance, less costly preventive measures? These and others are the questions addreses in this book. Norman Daniels examines some of the dilemmas thrown up by conflicting demands for medical attention, and goes on to advance a theory of justice in the distribution of health (...) care. The central argument is that health care, both preventive and acute, has a crucial effect on equality of opportunity, and that a principle guaranteeing equality of opportunity must underly the distribution of health-care services. Access to care, preventive measures, treatment of the elderly, and the obligations of doctors and medical administrations are fully discussed, and the theory is shown to underwrite various practical policies in the area. (shrink)

We do not live in a just world. This may be the least controversial claim one could make in political theory. But it is much less clear what, if anything, justice on a world scale might mean, or what the hope for justice should lead us to want in the domain of international or global institutions, and in the policies of states that are in a position to affect the world order. By comparison with the perplexing and undeveloped state of (...) this subject, domestic political theory is very well understood, with multiple highly developed theories offering alternative solutions to well-defined problems. By contrast, concepts and theories of global justice are in the early stages of formation, and it is not clear what the main questions are, let alone the main possible answers. I believe that the need for workable ideas about the global or international case presents political theory with its most important current task, and even perhaps with the opportunity to make a practical contribution in the long run, though perhaps only the very long run. (shrink)

This paper defends a global principle of equality of opportunity, which states that it is unfair if some have worse opportunities because of their national or civic identity. It begins by outlining the reasoning underpinning this principle. It then considers three objections to global equality of opportunity. The first argues that global equality of opportunity is an inappropriate ideal given the great cultural diversity that exists in the world. The second maintains that equality of opportunity applies only to people who (...) are interconnected in some way and infers from this that it should not be implemented at the global level. The third, inspired by Rawls's The Law of Peoples, maintains that it is inappropriate to thrust liberal ideals (like global equality of opportunity) on nonliberal peoples. Each of these challenges, I argue, is unpersuasive. (shrink)

Global economic and political inequalities are in most respects greater today than they have been for decades. From one point of view inequality is a bad thing simply because it involves a deviation from equality, which is thought to have value for its own sake. But it is controversial whether this position can be defended, and if it can, whether the egalitarian ideal on which the defense may depend applies at the global level as in individual societies. Setting aside directly (...) egalitarian reasons for concern about global inequality, this paper explores several reasons for concern that derive from nonegalitarian values – primarily those associated with poverty and material deprivation, humiliation, the impact of inequality on the capacity for self‐control and self‐government, and the unfairness of political decision‐making procedures with large economic inequalities in the background. (shrink)

This paper argues for a conception of transnational justice that provides an alternative to globalist and statist views. In light of an analysis of the transnational context of justice, a critical theory is suggested that addresses the multiple relations of injustice and domination to be found in this context. Based on a universal, individual right to reciprocal and general justification, this theory argues for justifiable social and political relations both within and between states. In both of these contexts, it distinguishes (...) between minimal and maximal justice and stresses the interdependence of domestic and transnational justice. On both levels, minimal justice calls for a discursive structure of justification, whereas maximal justice implies a fully justified basic social structure. (shrink)

Queen Mary, University of London, School of Law, Mile End Road, London E1 4NS, UK. Tel: +442078825126, Fax: +442089818733, Email: r.ashcroft{at}qmul.ac.uk ' + u + '@' + d + ' '//--> Abstract Recent doctrine in both national and international organisations concerned with public health planning and resource allocation has it that direct ethical justification of substantive decisions is so difficult as to be impossible. Instead, we should agree on criteria of procedural justice and reach decisions whose justification lies in how (...) they are arrived at, rather than any direct ethical justification on the ground of substantive moral principles. In this polemical article, I argue that this amounts to a serious dereliction of intellectual duty on the part of the bioethics community. Our role in these settings is to produce and defend the best substantive arguments we can. Failing to do this makes bioethicists at best redundant and at worst leads us to seriously defective conclusions. The argument is illustrated by analysis of the ethical frameworks for resource allocation under the UNAIDS ‘3 by 5’ programme and for pandemic influenza planning. CiteULike Connotea Del.icio.us What's this? (shrink)

Is there a limit to the legitimate demands of morality? In particular, is there a limit to people's responsibility to promote the well-being of others, either directly or via social institutions? Utilitarianism admits no such limit, and is for that reason often said to be an unacceptably demanding moral and political view. In this original new study, Murphy argues that the charge of excessive demands amounts to little more than an affirmation of the status quo. The real problem with utilitarianism (...) is that it makes unfair demands on people who comply with it in our world of nonideal compliance. Murphy shows that this unfairness does not arise on a collective understanding of our responsibility for others' well being. Thus, according to Murphy, while there is no general problem to be raised about the extent of moral demands, there is a pressing need to acknowledge the collective nature of the demands of beneficence. (shrink)

The paper discusses the problem of global distributive justice. It proposes to distinguish between principles for the domestic and for the global or intersocietal distribution of wealth. It is argued that there may be a plurality of partly diverging domestic conceptions of distributive justice, not all of which need to be liberal egalitarian conceptions. It is maintained, however, that principles regulating the intersocietal distribution of wealth have to be egalitarian principles. This claim is defended against Rawls's argument in The Law (...) of Peoples that egalitarian principles of distributive justice should not be applied globally. Moreover, it is explained in detail, why Rawls's “duty of assistance to burdened societies” cannot be an appropriate substitute for a global principle of distributive justice. (shrink)

Although rationing by clinical judgment is controversial, its acceptability partly depends on how it is practiced. In this paper, rationing by clinical judgment is defined in three different circumstances that represent increasingly wider circles of resource pools in which the rationing decision takes place: triage during acute shortage, comparison to other potential patients in a context of limited but not immediately strained resources, and determination of whether expected benefit of an intervention is deemed sufficient to warrant its cost by reference (...) to published population based thresholds. Notions of procedural justice are applied along with an analytical framework of six minimal requisites in order to facilitate fair bedside rationing: (1) a closed system that offers reciprocity, (2) attention to general concerns of justice, (3) respect for individual variations, (4) application of a consistent process, (5) explicitness, and (6) review of decisions. The process could be monitored for its applicability and appropriateness. (shrink)

Accounts of international or global justice often focus primarily on the rights or goods to be enjoyed by all human beings, rather than on the obligations that will realise and secure those rights and goods, or on the agents and agencies for whose action obligations of justice are to be prescriptive. In the background of these approaches to international or global justice there are often implicit assumptions that the primary agents of justice are states, and that all other agents and (...) agencies are secondary agents of justice, whose main contribution to justice will be achieved by conforming to the just requirements of states. This background picture runs into difficulties when states are either unjust or weak. The problems posed by unjust states have been widely noted, but the distinctive problems weak states create are less commonly discussed. In this paper I shall consider some reasons for and against viewing states as primary agents of justice, and will focus in particular on the importance of recognising the contribution to justice that other agents and agencies can make when states are weak. (shrink)

In a democratic society, the social rules are imposed by all upon each. As “recipients” of the rules, we tend to think that they should be designed to engender the best attainable distribution of goods and ills or quality of life. We are inclined to assess social institutions by how they affect their participants. But there is another, oft-neglected perspective which the topic of health equity raises with special clarity: As imposers of the rules, we are inclined to think that (...) harms we inflict through the rules have greater moral weight than like harms we merely fail to prevent or to mitigate. What matters morally is not merely how we affect people, but how we treat them through the rules we impose. While current (consequentialist and Rawlsian) theorizing is dominated by the first perspective and thus supports purely recipient-oriented moral conceptions, an adequate approach to social justice requires a balancing of both. Such balancing results in a relational conception of justice, which distinguishes various ways in which an institutional scheme may causally affect the quality of life of its participants.This essay argues that the strength of our moral reason to prevent or mitigate particular medical conditions depends not only on what one might call distributional factors, such as how badly off the people affected by these conditions are in absolute and relative terms, how costly prevention or treatment would be, and how much patients would benefit from given treatment. Rather, it depends also on relational factors, that is, on how we are related to the medical conditions they suffer. It then discusses some implications of this view for understanding responsibilities for international health outcomes. (shrink)

Adds to the debate on priority setting by looking at experience from other countries.

Some people believe that the demands of morality coincide with the requirements of an enlightened self-interest. Others believe that morality is diametrically opposed to considerations of self-interest. This book argues that there is another position, intermediate between these extremes, which makes better sense of the totality of our moral thought and practice. Scheffler elaborates this position via an examination of morality's content, scope, authority, and deliberative role. Although conflicts between morality and self-interest do arise, according to this position, nevertheless morality (...) is fundamentally a reasonable and humane phenomenon. Moreover, the psychological bases of effective moral motivation have sources deep within the self, and morally motivated individuals try to shape their own interests so as to avoid conflict with morality. Since human practices and institutions help to determine the prevalence of these motives, and since in this and other ways they influence the degree to which conflicts between morality and self-interest actually occur, the extent of such conflict is not fixed or immutable, and is in part a social and political issue. (shrink)

This paper describes the interventions by the International Committee of the Red Cross to support a hospital in Afghanistan during the mid 1990s. We present elements of the interventions introduced in Ghazni, Afghanistan, and consider a number of ethical issues stimulated by this analysis. Ethical challenges arise whenever humanitarian interventions to deal with complex political emergencies are undertaken: among those related to the case study presented are questions concerning: a) whether humanitarian support runs the risk of propping up repressive and (...) irresponsible governments; b) whether humanitarian relief activities can legitimately focus on a narrow range of interventions, or need to broaden to address the range of challenges facing the health system; and c) whether sustainability and quality of care should be routinely considered in such settings. The paper concludes by highlighting the value of case studies, suggesting mechanisms for extending transparency and accountability in humanitarian health interventions, and highlighting the need of contextualising humanitarian work if the interventions are to be successful. (shrink)

This paper describes the interventions by the International Committee of the Red Cross to support a hospital in Afghanistan during the mid–1990s. We present elements of the interventions introduced in Ghazni, Afghanistan, and consider a number of ethical issues stimulated by this analysis. Ethical challenges arise wherever humanitarian interventions to deal with complex political emergencies are undertaken: among those related to the case study presented are questions concerning: a) whether humanitarian support runs the risk of propping up repressive and irresponsible (...) governments; b) whether humanitarian relief activities can legitimately focus on a narrow range of interventions, or need to broaden to address the range of challenges facing the health system; and c) whether sustainability and quality of care should be routinely considered in such settings. The paper concludes by highlighting the value of case studies, suggesting mechanisms for extending transparency and accountability in humanitarian health interventions, and highlighting the need for contextualising humanitarian work if the interventions are to be successful. (shrink)