Health Justice E-Book

Sridhar Venkatapuram

• Herausgeber: John Wiley & Sons
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 530

Veröffentlichungsjahr: 2013

Beschreibung

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.

Leseprobe

Table of Contents

Cover

Dedication

Title page

Copyright page

Acknowledgements

Foreword

Introduction

Part I

1 Health as Capability

Biostatistical theory of health (BST)

The baseline and the environment

Other environment objections

Defence mechanisms as healthy

Biological purpose

Nordenfelt’s welfare theory of health

Empty set of vital goals

Standard circumstances

Integrating Nordenfelt and Nussbaum

Practical implications

Conclusion

2 Causation and Distribution of Health

Rejecting the bio-medical model

New epidemiology and capabilities theory

Theories of disease causation and distribution

The Black Report and Whitehall studies

Causation theories and social epidemiology

Psychosocial theories

Income inequality and health

Political economy

Social capital

Life course approach

Eco-social epidemiology

Development and health

Entitlement analysis

Famines and epidemiology

Malthusian thesis and the biomedical model

Conclusion

Part II

3 The Capabilities Approach

Commodities off-target

Persistent inequalities

Recognizing diversity

Endowments and needs

Conversion skills

Welfare

Capabilities not commodities or welfare

Rawls, Sen and Nussbaum

Sen’s analytical device, quadrants, vectors

Nussbaum’s CHCs

Criticisms of the CA

Frontier issues

Conclusion

4 The Capability to be Healthy

Ethical and political justification

CH as pre-political moral entitlement

Health and CA

Capabilities and severe disability

The capability of being healthy

Structure and causal model of CH

CH and claims for research

CH and social interdependency

CH as ‘mid-fare’

CH as a ‘cluster-right’

Kamm and capabilities

Why the CH

Objections

Conclusion

Part III

5 Alternative Approaches

Health equity principles

Health and human rights

Health rights

Welfare theories and health

Resource theories and health

Daniels’ health justice

Daniels’ theory versus the CH

Luck egalitarianism

Conclusion

6 Groups and Capabilities

Ethical individualism

Health and collective action problems

Aggregation

Biology and group rights

Groups and borders

Conclusion

7 The Capability to be Healthy and Global Justice

Cosmopolitanism

CA and global justice

Health and cosmopolitan justice

Self-determination and health

Normal opportunity range

Two problems

Kingdom of capabilities

Conclusion

Conclusion

Original arguments

Limitations

References

Index

For all of my family,

especially mom and dad

Copyright © Sridhar Venkatapuram 2011

The right of Sridhar Venkatapuram to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

First published in 2011 by Polity Press

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ISBN-13: 978-0-7456-5034-0 (hardback)

ISBN-13: 978-0-7456-5035-7 (paperback)

ISBN-13: 978-0-7456-3750-1 (Multi-user ebook)

ISBN-13: 978-0-7456-3751-8 (Single-user ebook)

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Acknowledgements

I can still remember the awkwardness and sniggering in a Harvard graduate philosophy seminar on social justice when I brought up issues such as HIV/AIDS, the rights and health of poor girls and women, or global inequalities. My curiosity and righteous indignation seemed totally out of place in the context of abstract discussions on equality, rights, well-being and social justice. Until very recently, the most well-known contemporary philosophers and thus most philosophy graduate students did not think the issues I was concerned with were relevant to thinking about social justice. Most of the world’s human beings and the concerns of their daily lives were literally relegated to the footnotes in discussions about justice. Justice as an ethical concept simply ‘did not apply’ to most of the world’s humanity and instead, charity was thought to be the relevant concept. Of course, this is a broad generalization and certainly not true of the work of philosophers such as Martha Nussbaum, Onora O’Neill, Thomas Pogge, Henry Shue, Peter Singer, Amartya Sen and others. But then these philosophers have only relatively recently become widely recognized as being leading philosophers rather than as individuals working on ‘special topics’. One of the greatest achievements in philosophy in this new millennium, I think, is that these philosophers have brought all human beings within the scope of justice. I know for a fact that I would not be interested in philosophy, or have pursued the argument presented in this book, were it not for these individuals. I am particularly indebted to Martha Nussbaum, as she was my first philosophy teacher and to Amartya Sen, who captured my attention in the very first semester of college with his talk on famines. I also owe much to Onora O’Neill, as her work on global inequality and public health initially drew me to Cambridge.

Aside from acknowledging my intellectual debts, I must express my deep gratitude for the great material and moral support provided to me by my parents over the years, particularly after my graduation from college. What was supposed to be one or two years of public service work has turned into an intellectual journey and career largely made possible by my parents. All my human rights work, graduate education, research fellowships and the writing of this book have been underwritten by my parents, who were expecting and surely deserve a completely different scenario.

I am also grateful to many individuals in Cambridge, especially Melissa Lane, my PhD supervisor and mentor. I owe much thanks to Maria De La Riva, Bill Burgwinkle, Richard Lloyd Morgan and many others at King’s College for providing me with a safe, comfortable and supportive home for a number of years. Thanks also to Bryan Turner and Darin Weinberg for bringing me to Cambridge as well as to David Lehman and Larry King for providing opportunities and encouragement to teach.

My heartfelt thanks to Amartya Sen and Tania Burchardt from the LSE for their time and energy in serving as my doctoral dissertation examiners.

In London, at UCL, I am deeply indebted to Sir Michael Marmot for his tutelage and support in many forms. And to Mel Bartely, my thanks for giving me the idea to come to UCL and helping me get there. My thanks to Jo Wolff for providing many opportunities and continued guidance. Many thanks also to the folks at the Centre for Philosophy, Justice and Health, including James Wilson, Shepley Orr and Sarah Edwards for their help in various ways.

I wish to thank a number of institutions for financial and material support starting with the Fellows of King’s College, the Cambridge Overseas Trust and the Cambridge University Board of Graduate Studies. The ESRC-DFID Joint Scheme for Research on International Development supported my joint research with Sir Michael for three years, when much of this book was written. And my thanks to the Wellcome Trust for helping me complete the book and supporting the next stage of research. Also, thanks to the Brocher Foundation and the Harvard Program in Ethics and Health for an illuminating week in Geneva. In particular, thanks to Nir Eyal, Samia Hurst, Dan Wikler and Dan Brock. My thanks also to Niels Weidtmann and Bilal Hawa at the Forum Scientiarum, University of Tübingen, for arranging a spectacular week with Martha Nussbaum. My sincere thanks to the attendees of the workshop for a great learning experience. Especially, thanks to Tom Wells, Shaun Oon and Lyn Tjon Soei Len for their time and comments on the book draft. Thanks also to Kaveri Gill, Hans-Joerg Ehni and Lennart Nordenfelt for their time reading and commenting on earlier drafts.

The argument in this book has taken shape over fifteen years. During those years I have been very lucky to have been supported by a number of friends, teachers and colleagues in moving this argument from idea to academic research to book. I must thank Makau Mutua, Robert Kushen, Anjali Nayyar, Sagri Singh, Sarah Zaidi, Tarani Chandola, Sumant Jayakrishnan, Kaveri Gill, Zeynep Gurtin, Alex Broadbent, Dennis Novy, David Kalal, Eleana Kim, Suchi Reddy, Heidie Joo, Anjali Singh and Robert Glick. David Rohlfing, Jeff Perkins, Jeffrey Trask, John Bjornen, Charles O’Byrne, Mark DeMuro and Sean Cross also provided a helping hand in getting this argument out into the world.

Finally, my thanks to all the individuals involved at Polity Press. This book would not be in its current form were it not for Emma Hutchinson, the ablest of editors, and David Winters, Neil de Cort, Susan Beer and many others at Polity. I take sole responsibility for any errors. All corrections and constructive criticism will be gratefully received. They can be sent to [email protected].

Foreword

Some time, last millennium, I attended a seminar of philosophers, economists and health people to discuss approaches to health equity. The philosophers took no prisoners. The fact that there may be people in the room who thought that rawls were to do with building sites and had not knowingly come across consequentialist reasoning, nor yet be unclear why it was beyond the pale, appeared to be of little moment to these distinguished thinkers. They were too busy supposing what justice would mean if one were transposed to an island … Finally, in an effort to understand the conversation and bring it to bear on some real-life concerns, I said I was interested in outcomes. For example, the fact that children from different socio-economic groups went through an educational system that appeared to be fair in so far as there were equal inputs, but came out with most unequal outcomes, in terms of educational knowledge, meant that we had not solved the problem of equity. Outcomes matter. A philosopher looked at me, witheringly, as if I’d wandered into the National Gallery and said: ‘I don’t know much about art, but I know what I like’ and dismissed me with a vague mumble about the educational differences probably being genetic and went back to the real business of talking to people worth talking to – i.e. other philosophers.

I was more mystified than annoyed. First, why did this philosopher feel no need to engage with a non-philosopher? Why come to an interdisciplinary meeting if the perspectives of other disciplines were too ill-informed, too worthy of contempt, to be of interest? Second, why did he not think that a real-life problem was of interest – he seemed to be engaged in highly theoretical discussion that engaged not at all with the real world? Third, how could he be so ignorant of the evidence on education? Simply to dismiss educational differences between socio-economic groups as ‘probably genetic’ was worse than ignorant. What if they weren’t? If knowledge of how the real world worked was irrelevant to his philosophy, might the converse be true: that his philosophy was irrelevant to the real world? This is not to say my view was correct – I didn’t really have a worked-out view – but that I wanted a philosopher to engage with real-life concern.

I came back from this meeting and said to a philosopher friend – one who did engage with the real world – I think I’m a consequentialist.

‘I don’t think you are’, said my friend.

But I’m a doctor and the evidence shows that health is the consequence of the conditions in which people live. I am, therefore, interested in outcomes, in consequences.

‘Of course you are’, said my friend, ‘that’s just common sense.’

That’s not a bad starting point: a philosophy that engages with the real world and makes sense. As a non-philosopher, I’m bound to add – and makes sense to non-philosophers.

Central to Sridhar Venkatapuram’s philosophy is how the real world works. His starting point is that Rawls doesn’t engage with health. Parenthetically, I do now know the difference between ‘rawls’ and Rawls – and Rawls does ‘make sense’ to a non-philosopher. But, as Venkatapuram points out: Rawls believed that human health is a ‘natural good’ and subject to random luck over the life course; he sees health as something that is not significantly or directly socially produced so it does not even come within the scope of social justice, let alone that it is central to it.

The Commission on Social Determinants of Health (CSDH) argued that health and the social distribution of health, function as a kind of social accountant. So intimate is the connection between our set of social arrangements and health that we can use the degree of health inequalities to tell us about social progress in meeting basic human needs. The CSDH argued that action on the social determinants of health, to promote health equity, was dictated by a concern with social justice. The passion of the CSDH about social justice was perhaps not matched by the depths of our analysis of what we meant by it. We were influenced by Amartya Sen’s ideas on capabilities and human flourishing. But, as chair of the CSDH, I felt the need for a better articulation of the philosophical underpinnings: why are avoidable inequalities in health unjust?

Venkatapuram provides such an analysis. He roots his philosophical approach in the empirical evidence that health is indeed influenced (determined in the language of the CSDH) by the conditions in which people are born, grow, live, work and age. That is the basis for his move into the moral sphere: So the central aim of this book is to present an argument that every human being has a moral entitlement to a capability to be healthy (CH) and to a level that is commensurate with equal human dignity in the contemporary world. The moral claim is to the capability and not directly to certain ‘health outcomes’ or particular biological and mental functionings. And, more specifically, the entitlement is to the social bases of the CH.

In contrast to an economic view that sees health as instrumental to something else such as achieving higher income, the CSDH emphasized the intrinsic value of good health. Venkatapuram sees health as both intrinsically valuable and instrumental: Being alive and unimpaired directly constitutes a person’s well-being and being alive and unimpaired enables individuals to pursue projects.

For those of us committed to taking action in the service of health equity, what this book represents is a theoretical justification for the emphasis on social justice. It is a theoretical justification but one firmly grounded in the evidence linking social conditions to health. It is a most welcome achievement.

Michael Marmot

Director, International Institute of Society and Health, UCL

Introduction

I am going to skip the usual graphic story describing the wretched life of some poor girl or woman in some poor country. I am also going to skip over the mind-boggling statistics on the millions of avoidable deaths and cases of serious disease and disability occurring every year. Nor will I dwell on their conspicuous social distribution patterns within every country and across countries.1 I am assuming that anyone interested in reading a book titled ‘health justice’ has some intuitions or ‘pre-theoretical’ notions about the important value we human beings give to being healthy and living a long life. I am also assuming that readers have at least some minimal sense of discomfort about either the causes, distribution patterns, or consequences of avoidable illnesses and premature mortality across modern human societies.

So I begin, instead, by making the rather mundane observation that for human beings to be able to live a full lifespan and experience as few avoidable physical and mental impairments as possible they need to be surrounded by a supportive environment. That is to say, for human beings to live a long and healthy life requires not only having access to clinical medical care when they need it, but also having other things ranging from emotional nurturing as well as cognitive and physical stimulation when they are infants to adequate nutrition, shelter, clothing, access to information, protection from physical, psychological and sexual abuse, and so forth throughout their life.

However, even if and when fully supportive physical and social environments are externally present, the health and longevity of a person are profoundly influenced by her internal biological endowments and needs that change over the life cycle as well as her individual behaviours. So, putting it all together, every human being experiences different types and durations of physical and mental impairments, or different periods of health and illness, and lives for varying lengths of time due to the combined interactions of her internal biological endowments and needs, behaviours, external physical environment and social conditions (Lalonde, 1974; Evans and Stoddart, 1990).2

While these are the breadth of determinants of human health and longevity, individuals can have influence or control over some factors, and to varying degrees, in each category. Social institutions can influence some of the determinants and to varying degrees. And, importantly, neither individuals nor social institutions can influence some causal factors. So far, so good.

The centrality of human health and longevity to social justice is so patently obvious to some people that they simply take it as a starting point. This is particularly apparent in the remarkable history of physicians becoming social and political reformers, and even armed revolutionaries because of their understanding of manifest injustice in such aspects as the causes, consequences, persistence through generations, or distribution patterns of preventable ill-health and premature mortality in a population. But such an understanding is not limited only to physicians or to those who work in the front lines of healthcare and public health. For example, Amartya Sen, the economist and philosopher, begins a lecture by stating, ‘In any discussion of social equity and justice, illness and health must figure as a major concern. I take that as my point of departure.’ He then continues, ‘… and begin by noting that health equity cannot but be a central feature of the justice of social arrangements in general’ (Sen, 2002c, p. 659).