How international research might contribute to justice in global health has not been substantively addressed by bioethics. Theories of justice from political philosophy establish obligations for parties from high-income countries owed to parties from low and middle-income countries. We have developed a new framework that is based on Jennifer Ruger's health capability paradigm to strengthen the link between international clinical research and justice in global health. The ‘research for health justice’ framework provides direction on three aspects of international clinical research: (...) the research target, research capacity strengthening, and post-trial benefits. It identifies the obligations of justice owed by national governments, research funders, research sponsors, and investigators to trial participants and host communities. These obligations vary from those currently articulated in international research ethics guidelines. Ethical requirements of a different kind are needed if international clinical research is to advance global health equity. (shrink)

This latest work from one of the world's leading political philosophers will appeal to audiences from a variety of fields, including philosophy, political science, women's studies, ethnic studies, sociology, and communications studies.

The essay theorizes the responsibilities moral agents may be said to have in relation to global structural social processes that have unjust consequences. How ought moral agents, whether individual or institutional, conceptualize their responsibilities in relation to global injustice? I propose a model of responsibility from social connection as an interpretation of obligations of justice arising from structural social processes. I use the example of justice in transnational processes of production, distribution and marketing of clothing to illustrate operations of structural (...) social processes that extend widely across regions of the world. The social connection model of responsibility says that all agents who contribute by their actions to the structural processes that produce injustice have responsibilities to work to remedy these injustices. I distinguish this model from a more standard model of responsibility, which I call a liability model. I specify five features of the social connection model of responsibility that distinguish it from the liability model: it does not isolate perpetrators; it judges background conditions of action; it is more forward looking than backward looking; its responsibility is essentially shared; and it can be discharged only through collective action. The final section of the essay begins to articulate parameters of reasoning that agents can use for thinking about their own action in relation to structural injustice. a Footnotesa Thanks to David Alexander, Daniel Drezner, David Owen, and Ellen Frankel Paul for comments on an earlier version of this essay. Thanks to David Newstone for research assistance. (shrink)

: The debate over when medical research may be performed in developing countries has steered clear of the broad issues of social justice in favor of what seem more tractable, practical issues. A better approach will reframe the question of justice in international research in a way that makes explicit the links between medical research, the social determinants of health, and global justice.

Social factors have a powerful influence on human health and longevity. Yet the social dimensions of health are often obscured in public discussions due to the overwhelming focus in health policy on medical care, individual-level risk factor research, and changing individual behaviours. Likewise, in philosophical approaches to health and social justice, the debates have largely focused on rationing problems in health care and on personal responsibility. However, a range of events over the past two decades such as the study of (...) modern famines, the global experience of HIV/AIDS, the international women’s health movement, and the flourishing of social epidemiological research have drawn attention to the robust relationship between health and broad social arrangements. In Health Justice, Sridhar Venkatapuram takes up the problem of identifying what claims individuals have in regard to their health in modern societies and the globalized world. Recognizing the social bases of health and longevity, Venkatapuram extends the ‘Capabilities Approach’ of Amartya Sen and Martha Nussbaum into the domain of health and health sciences. In so doing, he formulates an inter-disciplinary argument that draws on the natural and social sciences as well as debates around social justice to argue for every human being’s moral entitlement to a capability to be healthy. An ambitious integration of the health sciences and the Capabilities Approach, Health Justice aims to provide a concrete ethical grounding for the human right to health, while advancing the field of health policy and placing health at the centre of social justice theory. With a foreword by Sir Michael Marmot, chair of the WHO Commission on the Social Determinants of Health. (shrink)

Thomas Pogge tries to explain the attitude of affluent populations to world poverty. One or two per cent of the wealth of the richer nations could help in eradicating much of the poverty and Pogge presents a powerful moral argument.

Poverty, inequality, violence, environmental degradation, and tyranny continue to afflict the world. Ethics of Global Development offers a moral reflection on the ends and means of local, national, and global efforts to overcome these five scourges. After emphasizing the role of ethics in development studies, policy-making, and practice, David A. Crocker analyzes and evaluates Amartya Sen's philosophy of development in relation to alternative ethical outlooks. He argues that Sen's turn to robust ideals of human agency and democracy improves on both (...) Sen's earlier emphasis on 'capabilities and functionings' and Martha Nussbaum's version of the capability orientation. This agency-focused capability approach is then extended and strengthened by applying it to the challenges of consumerism and hunger, the development responsibilities of affluent individuals and nations, and the dilemmas of globalization. Throughout the book the author argues for the importance of more inclusive and deliberative democratic institutions. (shrink)

In this major book Martha Nussbaum, one of the most innovative and influential philosophical voices of our time, proposes a kind of feminism that is genuinely international, argues for an ethical underpinning to all thought about development planning and public policy, and dramatically moves beyond the abstractions of economists and philosophers to embed thought about justice in the concrete reality of the struggles of poor women. Nussbaum argues that international political and economic thought must be sensitive to gender difference as (...) a problem of justice, and that feminist thought must begin to focus on the problems of women in the third world. Taking as her point of departure the predicament of poor women in India, she shows how philosophy should undergird basic constitutional principles that should be respected and implemented by all governments, and used as a comparative measure of quality of life across nations. (shrink)

Scholarship focusing on how international research can contribute to justice in global health has primarily explored requirements for the conduct of clinical trials. Yet health systems research in low- and middle-income countries has increasingly been identified as vital to the reduction of health disparities between and within countries. This paper expands an existing ethical framework based on the health capability paradigm – research for health justice – to externally-funded health systems research in LMICs. It argues that a specific form of (...) health systems research in LMICs is required if the enterprise is to advance global health equity. “Research for health justice” requirements for priority setting, research capacity strengthening, and post-study benefits in health systems research are derived in light of the field's distinctive characteristics. Specific obligations are established for external research actors, including governments, funders, sponsors, and investigators. How these framework requirements differ from those for international clinical research is discussed. (shrink)

In bioethics, discussions of justice have tended to focus on questions of fairness in access to health care: is there a right to medical treatment, and how should priorities be set when medical resources are scarce. But health care is only one of many factors that determine the extent to which people live healthy lives, and fairness is not the only consideration in determining whether a health policy is just. In this pathbreaking book, senior bioethicists Powers and Faden confront foundational (...) issues about health and justice. How much inequality in health can a just society tolerate. The audience for the book is scholars and students of bioethics and moral and political philosophy, as well as anyone interested in public health and health policy. (shrink)

What are the respective roles and responsibilities of global, national, and local communities as well as individuals themselves to address health deprivations and avert health threats? This article offers the beginnings of a theory of global health justice, arguing for universal ethical norms (general duty) with shared global and domestic responsibility (specific duties) for health. It offers a global minimalist view I call ‘ provincial globalism ’ as a mean between nationalism and cosmopolitanism, in which a provincial consensus must accompany (...) a global consensus on health morality. This minimalist account asserts global and national duties to promote human flourishing and, more specifically, individuals’ central health capabilities. In this view, justice requires prioritizing responsibilities through shared health governance to reduce shortfall inequalities in central health capabilities — a general duty to reduce premature mortality and escapable morbidity. It examines the difficulties presented by the philosophical principles of connectedness, causality, remediation, partiality, and capacity in the allocation of responsibility for global health. It offers a theory of responsibility allocation based on a functional, health agency centered and homeostatic balanced understanding of the analytical components required to solve global health problems and parcels out roles and responsibilities at the global, national, local, and individual levels accordingly. Allocations of responsibility rest on the effectiveness and special obligations of different actors, respecting self-determination by groups and individuals and seeking voluntary commitments . This view understands that the remedy for global health problems must be sustainable to take nations and the global health community to a new global health equilibrium that remedies current problems and prepares for new health threats to come. (shrink)

Theories of social justice are necessarily abstract, reaching beyond the particular and the immediate to the general and the timeless. Yet such theories, addressing the world and its problems, must respond to the real and changing dilemmas of the day. A brilliant work of practical philosophy, Frontiers of Justice is dedicated to this proposition. Taking up three urgent problems of social justice neglected by current theories and thus harder to tackle in practical terms and everyday life, Martha Nussbaum seeks a (...) theory of social justice that can guide us to a richer, more responsive approach to social cooperation. The idea of the social contract--especially as developed in the work of John Rawls--is one of the most powerful approaches to social justice in the Western tradition. But as Nussbaum demonstrates, even Rawls's theory, suggesting a contract for mutual advantage among approximate equals, cannot address questions of social justice posed by unequal parties. How, for instance, can we extend the equal rights of citizenship--education, health care, political rights and liberties--to those with physical and mental disabilities? How can we extend justice and dignified life conditions to all citizens of the world? And how, finally, can we bring our treatment of nonhuman animals into our notions of social justice? Exploring the limitations of the social contract in these three areas, Nussbaum devises an alternative theory based on the idea of capabilities. She helps us to think more clearly about the purposes of political cooperation and the nature of political principles--and to look to a future of greater justice for all. (shrink)

In this book by the award-winning author of Just Healthcare, Norman Daniels develops a comprehensive theory of justice for health that answers three key questions: what is the special moral importance of health? When are health inequalities unjust? How can we meet health needs fairly when we cannot meet them all? Daniels' theory has implications for national and global health policy: can we meet health needs fairly in ageing societies? Or protect health in the workplace while respecting individual liberty? Or (...) meet professional obligations and obligations of justice without conflict? When is an effort to reduce health disparities, or to set priorities in realising a human right to health, fair? What do richer, healthier societies owe poorer, sicker societies? Just Health: Meeting Health Needs Fairly explores the many ways that social justice is good for the health of populations in developed and developing countries. (shrink)

This article investigates whether or not theories of justice from political philosophy, first, support the position that health research should contribute to justice in global health, and second, provide guidance about what is owed by international clinical research (ICR) actors to parties in low- and middle-income countries. Four theories—John Rawls's theory of justice, the rights-based cosmopolitan theories of Thomas Pogge and Henry Shue, and Jennifer Ruger's health capability paradigm—are evaluated. The article shows that three of the four theories require the (...) conduct of health research for justice in global health. The theories help identify the ends of justice to which ICR is to contribute, but they cannot tell us how to organize ICR to promote these ends. Aside from Ruger's health capability paradigm, the theories also lack an allocative principle for assigning specific duties to specific actors. This creates difficulties for establishing obligations for certain types of ICR actors. (shrink)

The debate over when medical research may be performed in developing countries has steered clear of the broad issues of social justice in favor of what seem more tractable, practical issues. A better approach will reframe the question of justice in international research in a way that makes explicit the links between medical research, the social determinants of health, and global justice.

There is no cure or vaccine for HIV/AIDS. The only life-prolonging treatment available is antiretroviral (ARV) therapy. WHO estimates, however, that less than 5 percent of those who require treatment in developing countries currently enjoy access to these medicines. In Africa fewer than 50,000 people–less than 2 percent of the people in need–currently receive ARV therapy. These facts have elicited strongly divergent reactions, and views about the appropriate response to this crisis have varied widely.The intensity of the debate concerning access (...) to life-prolonging medicines for the treatment of HIV/AIDS, and the heated rhetoric with which they are often conducted, suggest that these disagreements may be rooted in deeper disagreements of value. It is not obvious, however, what disagreements of value are at stake in this debate. By analyzing the statements of scholars, public officials, activist organizations, and private sector representatives, each of whom may endorse very different policy recommendations on access to HIV/AIDS drugs, we have identified and created a typology of the different sources of disagreement in the debate. We conclude that the central disagreements concerning access to medicines arise from competing understandings of how responsibilities for bringing remedy to hardships should be allocated to different agents and institutions. A central lesson that emerges from our analysis is that thinking about “health equity” must extend beyond the explanation and justification of goals, values, and ideals, and engage more honestly with the difficult question of how responsibilities for bringing remedy to health crises should be allocated in complex social contexts. (shrink)

Recent scholarship has considered what, if anything, rich people owe to poor people to achieve justice in global health and the implications of this for international research. Yet this work has primarily focused on international clinical research. Health systems research is increasingly being performed in low and middle income countries and is essential to reducing global health disparities. This paper provides an initial description of the ethical issues related to priority setting, capacity-building, and the provision of post-study benefits that arise (...) during the conduct of such research. It presents a selection of issues discussed in the health systems research literature and argues that they constitute ethical concerns based on their being inconsistent with a particular theory of global justice (the health capability paradigm). Issues identified include the fact that priority setting for health systems research at the global level is often not driven by national priorities and that capacity-building efforts frequently utilize one-size-fits-all approaches. (shrink)

How international research might contribute to justice in global health has not been substantively addressed by bioethics. Theories of justice from political philosophy establish obligations for parties from high‐income countries owed to parties from low and middle‐income countries. We have developed a new framework that is based on Jennifer Ruger's health capability paradigm to strengthen the link between international clinical research and justice in global health. The ‘research for health justice’ framework provides direction on three aspects of international clinical research: (...) the research target, research capacity strengthening, and post‐trial benefits. It identifies the obligations of justice owed by national governments, research funders, research sponsors, and investigators to trial participants and host communities. These obligations vary from those currently articulated in international research ethics guidelines. Ethical requirements of a different kind are needed if international clinical research is to advance global health equity. (shrink)

Revisioning macro-democratic processes in light of the processes and promise of micro-deliberation, Innovating Democracy provides an integrated perspective on democratic theory and practice after the deliberative turn.

Health and Social Justice (Ruger 2009a) developed the ?health capability paradigm,? a conception of justice and health in domestic societies. This idea undergirds an alternative framework of social cooperation called ?shared health governance? (SHG). SHG puts forth a set of moral responsibilities, motivational aspirations, and institutional arrangements, and apportions roles for implementation in striving for health justice. This article develops further the SHG framework and explains its importance and implications for governing health domestically.

The dissertation Aristotelian Justice and Health Policy: Capability and Incompletely Theorized Agreements , Jerry Green, and Joseph Newhouse) focuses on the implications for health policy of Aristotelian/Capability lines of reasoning to social justice and efficiency. The monograph draws on philosophical and economic analysis and social choice theory in the examination of health capabilities as: a central focal variable for the assessment of equality and efficiency in health policy; the product of health and other public policies; and the object of social (...) choice. Drawing on moral and political philosophy, the Aristotelian/Capability lines of reasoning provide the basis for the special moral importance of health capabilities as the central focal variable for assessing equality and efficiency in health policy. These lines of thought take a universal view of humans' capability to flourish as an end of political activity and provide an analytical framework to address questions of justice and efficiency in public policy in a way that other philosophical schools do not. Drawing on economic analysis, the monograph makes a case for focusing attention in health economics and health policy on the economics of health, per se, as differentiated from the economics of medical care, and as such emphasizes the analysis of empirical evidence on the instrumental effectiveness and cost-effectiveness of the various determinants of health and the public policies associated with these determinants. Further investigations of the determinants and consequences of variations in health capabilities is necessary to fully understand the patterns and public policies associated with health production. And finally, drawing on social choice literature, this monograph identifies and defends a particular approach to collective decision making in public policy--incompletely theorized agreements . In matters of social decision making about health capabilities in health policy, the ICTA framework is particularly useful and complementary to the capability approach. Health, and thus health capabilities, is a multidimensional concept about which different people have different, and sometimes conflicting, views. Since no unique view of health capabilities exists and is ideal for all evaluative purposes, the pragmatism of both the incomplete ordering of the capability approach and the incompletely theorized agreement on that ordering of the ICTA approach allow for reasoned public policy decision making and analysis in particular situations in the face of plural goods and different, even conflicting, views. (shrink)