Peter Singer and the requirement to aid others in need

Princeton University philosopher Peter Singer writes from the perspective of consequentialism, a family of theories whose unifying element is a focus on outcomes. Consequentialists believe that consideration of outcomes forms the relevant basis for deciding which policies and practices are morally correct. Approaches differ in terms of the types of consequences taken to matter most. Some versions may specify a single good, such as pleasure or the avoidance of pain [26], while others promote the satisfaction of preferences [27], or an objective list of several goods to be promoted equally. Most forms of consequentialism focus on maximising beneficial outcomes, but this is not always the case.

Singer’s argument about our obligations to others is general, simple and, if true, profound. For Singer, every human being has the capacity for suffering and enjoyment or happiness, and is thus deserving of equal consideration [27]. Contrasting the estimated 8.8 million child deaths worldwide in 2008 due to preventable, poverty-related causes [28] with the relative comfort in which almost 1 billion people live, Singer maintains that the global rich have an obligation to alleviate the suffering of the global poor. He argues that, if we can prevent something importantly bad without sacrificing anything of comparable significance, we ought to do so. As the morbidity and premature death linked to extreme poverty is deeply bad and a significant proportion can be prevented without undue sacrifice, this ought to be done [24].

Singer’s theory addresses itself to individuals and asks that each individual moral agent give the same weight to the interests of others as to his or her own. For Singer, the moral point of view is inherently radically impartial, surmounting specific attachments to individuals, communities and countries.

Thomas Pogge on global institutions and the duty not to harm

Asking why severe poverty and inequality persist worldwide, Yale University’s Thomas Pogge focuses on structural causes. Pogge asks whether the current global institutional order—for which the governments of the rich nations (and hence their citizens) bear primary responsibility— figures as a substantial contributor to the life-threatening poverty suffered by billions in the developing world [22].

Pogge challenges us to reflect on the relationship between the persistence of severe poverty and inequality worldwide and recent decisions concerning our path of globalization [22]. While the legacy of colonialism persists, Pogge’s argument focuses primarily on events since roughly 1980. He raises two issues: first, the governments of wealthy nations “enjoy a crushing advantage in terms of bargaining power and expertise;” and second, international negotiations are based on an adversarial system in which country level representatives seek to advance the best interests of their nation. Systematic consideration of the needs of the global poor is not a part of the mandate of any of the powerful parties to the negotiation. The cumulative results are, in Pogge’s view, predictable: a grossly unfair global order in which benefits flow predominantly to the affluent [22].

What effect do these asymmetries have on the health of those in developing countries? First, decisions taken by global institutions, state actors or corporations may cause or aggravate problems in securing critical determinants of health. While severe poverty is arguably most important, climate change and environmental damage also affect health determinants such as air, water and food. Negative consequences disproportionately impact the global poor, while the benefits of development have fallen mainly to the affluent. Second, decisions have at times impeded the ability of developing country governments to provide health care to their own citizens, for example through structural adjustment or trade policies. For Pogge, a particularly important issue concerns essential medicines [29]. He believes that the global medical innovation system embodied in the World Trade Organization (WTO)’s Trade Related Intellectual Property Rights (TRIPS) agreement is unjust. An independent commission confirmed that the benefits of the current system flow disproportionately towards rich countries [30].

Pogge invokes a central element of Western morality: it is wrong severely to harm innocent people for minor gains. The duty not to harm (a so-called negative duty, as distinct from positive duties like those to render assistance) is considered a strict obligation applicable equally to fellow citizens and foreigners. If Pogge is correct about the harm caused by our global institutions, this implies that we have an immediate duty of justice to those harmed regardless of where they live [22].

There has been much debate about Pogge’s proposal and the correct baseline for determining harm. Taking a “state of nature” perspective one might perhaps argue that, in the absence of something like the current global order, the global poor would have been no worse off.

This objection misconstrues Pogge’s claim. Pogge proposes that we appeal to human rights as a minimum standard for judging the adequacy of institutions. Inspired by the 1948 Universal Declaration of Human Rights which states: “Everyone is entitled to a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized,” [31] he argues that any justifiable international order must be designed insofar as reasonably possible to guarantee human rights including basic freedoms of participation, subsistence, education and health care. Pogge argues that the attribution of harm implicitly involves a “subjunctive” (as opposed to an historical) comparison, and that the correct subjunctive comparison would be the possibility of a feasible alternative institutional order in which fewer human rights deficits would be produced [21, 22, 25].

In sum, for Pogge, a set of global institutional arrangements is unjust if it foreseeably perpetuates large-scale human rights deficits that could reasonably be avoided through feasible institutional modifications. He amasses empirical evidence to demonstrate that the citizens of wealthy nations via their elected governments contribute to the perpetuation of global poverty and ill health. If Pogge’s analysis is correct, we have a strict obligation of justice, grounded in the duty not to cause harm, to change our institutions and take concrete compensatory actions [22].

Henry Shue on “basic rights”

Oxford University’s Henry Shue focusses on the role of human rights, especially economic rights, in international affairs. Discussions of human rights in the West have generally distinguished “civil and political” from “social, economic and cultural” rights and given priority to the former. Shue argues that the most fundamental core of the economic rights, which he calls “subsistence rights,” ought also to receive priority [23].

What does Shue’s thesis about “basic rights” imply about transnational duties towards health? His response is somewhat ambivalent and falls short of asserting universal duties towards all those deprived of their basic rights. A particularly important challenge comes from an interlocutor who accepts the notion of universal subsistence rights, but argues that responsibility for their fulfilment rests with the nation of the bearer of the duty [23]. For Shue, duties beyond borders figure principally as “a back-up arrangement for the failure of so-called national governments” and come into play “where the state with the primary duty to protect rights fails – for lack of will or lack of capacity – to fulfill its duty”.[23] In essence, to the extent that liberal democracies accept that basic rights are fundamental to domestic justice, Shue argues that a principle of consistency requires that they also respect and promote basic rights through foreign policy in countries where appropriate institutional provisions are absent or incomplete. Therefore, even if national boundaries legitimately delimit political communities whose members share strong ties and obligations, states espousing liberal democratic values have a duty to adopt foreign policies consistent with basic rights.

The right to subsistence aims to guarantee every human being worldwide a decent chance at living a long and healthy life, and includes protection from extreme poverty and guarantees related to the social determinants of health, as well as elementary health care [23].

John Rawls and the duty of assistance

Perhaps the most influential analyst of international responsibilities from a liberal perspective, the late Harvard philosopher John Rawls addressed the question of how reasonable citizens and peoples might live together peacefully in a just world. His work is animated by the belief that the greatest evils of human history—including war, persecution, starvation and poverty—are the consequence of political injustice, and the removal of such injustice the key to their resolution [32]. For Rawls, the fundamental subjects of international law are political societies or “peoples”, collective entities with specific concepts of right and justice whose territory is bounded by borders. The diversity of values and cultures among peoples is the result of legitimate free exercise of human reason, and tolerance requires that we refrain from imposition of a supposedly universal conception of human rights and liberal democracy at the international level.

Rawls’s description of a just international community is based on his description of justice at the national level [33]. Speaking of modern constitutional democracies, Rawls argues that a just state must structure economic opportunities and social conditions so as to guarantee “fair equality of opportunity” in terms of life chances of the members of different sectors of society. Within a framework of guaranteed rights and liberties, Rawls proposes that social and economic inequalities be permitted only to the extent that they are of greatest benefit to the least advantaged. He argues that these principles of social cooperation reflect the notion of “reciprocity,” or what it would be reasonable for free and equal persons ignorant of their specific future roles to accept in an ideal form of social contract [33].

At the international level Rawls envisages a similar hypothetical social contract. The representatives of peoples come together in a context of reciprocity, characterised by symmetry, freedom and equality of the parties. In a situation that masks specific knowledge of features such as country size, wealth and history, Rawls claims that the representatives would define eight principles of mutual governance, including a duty to “assist other peoples living under unfavourable conditions that prevent their having a just or decent political and social regime” [32].