Philosophy, Global Health, and Ethics: An Attempt to Understand How We “Do” Global Health
Ethics can be understood as the philosophical study of morality — the social rules, principles, and norms that are intended to guide the conduct of people in a society. A part of global health ethics is bioethics, which has to do with the moral appraisal of actions affecting lives and communities. Bioethics is the consideration of what ought to be done to secure health goals.
Numerous ethical dilemmas arise in global public health. Practitioners are often tasked with the difficult responsibility of deciding whose life to save. Global health initiatives often come with a risk that has to be negotiated and appraised. Ethical concerns are always an issue with research that involves human subjects.
For example, the decision of some global health institutions to focus their efforts on HIV and AIDS prevention rather than treatment because it is more cost-efficient poses an ethical dilemma, because it affords fewer resources to those who are already living with the virus. Similarly, pharmaceutical companies donating drugs to low- and middle-income countries but setting high prices which act as an initial barrier to care poses another ethical dilemma. As publicly owned for-profit enterprises, the primary responsibility of drug manufacturers is to stockholders as opposed to those who desperately need their drugs to continue living. As a result of dilemmas such as these, notions of culpability and fault often accompany global health ethics and initiatives.
Additionally, if promoting global health is an activity that takes time and money, it follows that it is guided and directed by those who have control over both. As Benatar and Brock point out, since people earn their living by “doing global health,” the consequence is that the dominant social and economic forces or countries in society determine to a large extent what global health is about and how it is pursued. This begs the question — is global health really global? If the agenda setters or those who define the principles of global health are limited to academics, scientists, and others in wealthy countries, and not those whose lives and health are adversely affected by injustices driven by economic policies, how global are global health initiatives? Those with control of money and time inadvertently decide who dies and who gets to live.
This begs the question — is global health really global? If the agenda setters or those who define the principles of global health are limited to academics, scientists, and others in wealthy countries, and not those whose lives and health are adversely affected by injustices driven by economic policies, how global are global health initiatives? Those with control of money and time inadvertently decide who dies and who gets to live.
One could argue that there are universal fundamental norms, values, and moral principles that guide global health action. While we can point to recent trends in a widening acceptance of imperatives such as human rights and how that has enabled a growing number of individual actors to mobilize in defense and pursuit of global health, the question of whether or not global health is truly global still remains.
Who is responsible for establishing global health policy? Whose values should guide the process of setting objectives and making policy? Who has the right to modify whose behavior? Is there a line between coercion and incentives, education and manipulation? What ethical principles ought to guide policymakers when making government policy about personal behavior and health? These are a few of the types of questions policymakers and those involved with global health must wrestle with. In trying to address these issues, we run into the reality and challenge of trying to orchestrate a solution that takes into account multiple lived realities.
Attempts to address ethical issues in global health are complicated by what global philosopher Ashok Gangadean decribes as the “cultural lens” we bring to the work we do. As a logician, ontologist, and philosopher of language, Gangadean explains that most of us develop “a personal cultural lens” that we are not sufficiently aware of. He points out that this cultural lens “both conditions and allows our world or living realities to appear in our experience.” In one of his essays he goes on to acknowledge that:
Of course this “lens” can be, and often is, complex and cultivated to process multiple diverse worlds, cultures, ideologies and forms of life. Nevertheless, even in this kaleidoscopic multiplicity of [lenses] most of us live our lives, both personal and professional, uncritically lodged within the relatively local and “tribal” literacy of our worldview, culture, discipline or ideology practice.”
When this claim is applied to global health, it essentially reveals how global health work is a social institution completely integrated into and influenced by the structure of other institutions. In other words, those who work in global health view the topic through a lens that has been shaped by their social experience.
What other insights do we gain from applying these notions to global health? First, we must understand what global health itself is. As a movement or terminology that came into prominence between 1948 and 1998, global health is anything and everything that has to do with promoting all aspects of health through organized global effort. In their exploration of global health ethics, Benatar and Brock explain that global health, as it exists today, has no clear-cut definition. It can be understood as:
- a medically defined state of affairs that involves measuring health status
- an activist agenda or assertion about the state of health for all
- an extended biomedical approach to health, making medical treatment available globally
- a governance of health issues, describing how health services should be or are structured
- a global social justice issue, concerned with how to improve health disparities world-wide
- environmental health
- a new term for international health
Analyzing global health through the perspectives provided by Gangadean, Benatar, and Brock highlight how global health institutions are made up of multiple predicates that potentially objectify, create dualities and fragmentation, and ultimately lead to violence. Take for instance anthropologist Johanna Crane’s concept of valuable inequalities. In her ethnographic account of HIV/AIDS care in Uganda, Crane describes how Uganda and many African countries went from being excluded from the advancement of HIV treatment to being an area of central concern and production of knowledge within the increasingly popular field of “global health science.” There was essentially a shift away from understanding Africa as a place of “anti-retroviral anarchy” and a “petri-dish for new treatment resistant strains” to Africa being “in vogue.” African countries became increasingly courted by prestigious research universities who were scrambling to find resource-poor hospitals to base their international HIV research and global health programs.
In her critical analysis of this phenomenon, Crane explains that AIDS in Africa has not only been a source of tragic misfortune and death but also a generator of profound institutional and intellectual opportunities — opportunities that are allocated unevenly and produce new inequalities. Benefits gained from research endeavors in Africa are attained within what Crane calls an “uncomfortable mix of preventable suffering [inequity] and scientific productivity.” She points to the rise of global health science and how it paradoxically embodies and even benefits from the very inequalities it aspires to resolve. “Resource-poor” settings become the sites of “global” research and educational opportunities unavailable in “resource-rich” settings creating what can be understood as valuable inequalities. From Crane’s analysis of valuable inequalities, it is easy to see how global health science both generates and relies upon inequalities. It also highlights how good intentions and compassionate action are not immune to the power imbalances between actors involved.
With varying perceptions of global health as foreign policy, security, charity, investment, public health, or opportunities for scientific discovery, what effect do these multiple lenses of global health have on how global health work is carried out? What happens when there is a lack of real dialogue among all global health actors?
For global health efforts to lead to positive outcomes and an improved state of health across the globe, we have to move beyond the confines of our ideology. We have to step away from privileging our own lens and make room for different perspectives and real dialogue among all global health actors. While global health ethics and fundamental values like human rights might transcend boundaries and borders, the case seems to be that global health, as it exists today, strives to function within a normative framework but fails to accomplish this in practice or reality. It is important to always reflect on the motives behind initiatives and take the time to consider the intended and unintended consequences of our actions. Only in this way can innovations and equitable progress be made.
Tobi Alliyu was a 2016–2017 Global Health Corps fellow.
