Just Health by Norman Daniels - Dissertation Example

In ‘Just Health’ by Norman Daniels, the poses “Three Questions of Justice” as an alternative to the most common query into the issue of whether or not society is obligated to protect and promote health in the community and to be a safety-net for public health assistance to individuals and families who cannot provide for these services themselves physically or economically. (Daniels, 2008) Daniels three questions go further to establish the dimensions and context of the subject by asking: 1. "Is health, and therefore health care and other factors that affect health, of special moral importance?" 2. "When are health inequalities unjust? 3. “How can we meet health needs fairly under resource restraints?" (Daniels, 2008) Though Daniels generally defines healthcare as relating to “modern medicine” and the facilities, pharmaceuticals, and surgical operations that are credited with prolonging the lifespan and life-quality of modern, wealthy people in the West, this essay will explore the question more broadly by inquiring into the degree that access to food resources are to be included in a definition of health and how the social justice issues posed by Daniels, Amartya Sen, Dworkin, and other modern philosophers and scholars relate to global hunger. “Abraham Maslow (1954) attempted to synthesize a large body of research related to human motivation. Prior to Maslow, researchers generally focused separately on such factors as biology, achievement, or power to explain what energizes, directs, and sustains human behavior. Maslow posited a hierarchy of human needs based on two groupings: deficiency needs and growth needs. Within the deficiency needs, each lower need must be met before moving to the next higher level. Once each of these needs has been satisfied, if at some future time a deficiency is detected, the individual will act to remove the deficiency. The first four levels are: 1) Physiological: hunger, thirst, bodily comforts, etc.; 2) Safety/security: out of danger; 3) Belongingness and Love: affiliate with others, be accepted; and 4) Esteem: to achieve, be competent, gain approval and recognition. According to Maslow, an individual is ready to act upon the growth needs if and only if the deficiency needs are met.” (Huitt, 2007) Abraham Maslow’s “Hierarchy of Human Needs” is widely accepted across humanistic sectors of society and is central to the worldview that asserts that society should provide the basic services of health and even food sources to the poorest of the poor and the people who cannot care for themselves in the community. Following Maslow, the individual must have the most basic human needs of food and water in order to develop higher states of consciousness, awareness, and culture. Yet, in looking at Maslow’s hierarchy, it is evident that he is not relating healthcare to the question of human development in the same manner that Norman Daniels does in his work, perhaps because the medical industry and the associated costs had not fully developed as a dividing political and social issue when he was writing in the 1950’s. Historically considered, the same issues of inequality in access to proper healthcare were found in minority communities during this period, but Maslow is not clear in relating the issue of equality in healthcare explicitly to “lower” states or needs on the hierarchy, for to do so would prohibit those with illness from attaining higher states of self-actualization or transcendence, something which is clearly not the case in practice psychologically. Thus, it must be concluded from Maslow that there is no direct correlation between healthcare access and higher states of personal development in the same manner that this problem exists for him with relation to hunger and thirst, but that health is an obvious requisite for basic enjoyment of various types of happiness. Further continuing this argument, the case can be made then that hunger and thirst are more primal or of deeper importance to the human being than even most forms of healthcare. Yet, this position itself is not without criticism, for some forms of disease can cause death even faster than the lack of adequate access to food or water. From a comparative analysis of the basis of both appeals, it becomes evident that death, human suffering, and illness form a type of continuum of negative situations which humans seek to avoid with ever more severe consequences. The immediacy of death can be swift and accidental, or gradual, structural, chronic, and endemic, but the subjectivity of the perception of gravity in each of the situations will be unique and individual in every example, like the threshold or tolerance for pain, making it difficult to build a general rule for social application in policy or legislation. This is seen further when relating the importance of diet to health. There are innumerable opinions as to what a healthy diet consists of, and no one would be particularly comfortable with another person or institution fixing their dietary choices or restricting the intake of food based on publicly-defined health concerns. Nevertheless, in principle the same type of restriction occurs in society when regulating other substances such as alcohol, illegal drugs, or firearms, with the legal framework based on the greater need to protect both society and the individual from the potentially harmful, unhealthy, or deadly substances. The degree that the principles fluctuate with subjectivity in direct application makes it evident that there is indeed a problem in properly understanding and constructing society’s role as a solution to these problems publicly. "My working assumption in this book is that the appeal to a right to health or to health care is not an appropriate starting point for an inquiry into just health or just health care. Rights are not moral fruits that spring up from bare earth, fully ripened, without cultivation. Rather, we may claim a right to health or health care only if it can be harvested from an acceptable general theory of distributed justice or from a more particular theory of justice for health and health care. Such a theory would tell us which kinds of right claims are legitimate. It would also help us specify the scope and limits of justified right claims.... To answer the difficult questions of what a right to health care or a right to health may include, we need a systematic theory of distributive justice for health-related needs." (Daniels, 2008) The closest document civil society has internationally to this systematic theory of justice is the United Nations’ Universal Declaration of Human Rights, yet Daniels is fundamentally skeptical of this political approach. The UDHR is generally concerned with political rights such as life, liberty, and personal freedoms, yet in Articles 25 it states: “(1) Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control. (2) Motherhood and childhood are entitled to special care and assistance. All children, whether born in or out of wedlock, shall enjoy the same social protection.” (UDHR, 1948) It would seem that if the Universal Declaration of Human Rights and similar rights documents of international law provide a framework and foundation for a conceptualization of these rights universally, they provide no funding or means of organization to implement them. This is one reason that Daniels is fundamentally skeptical of this approach. Yet, while he and many academics agree on the immensity of the issue and its vital importance, the biggest obstacle is in the budgetary allocation of collective social resources to meet the needs of humanity’s poorest people. Statistics published by the United Nations and World Food Program (WFP) state: “925 million people do not have enough to eat - more than the populations of USA, Canada and the European Union;” (Source: FAO news release, 14 September 2010) “98 percent of the worlds hungry live in developing countries;” (Source: FAO news release, 2010) “More than 70 percent of the worlds 146 million underweight children under age five years live in just 10 countries, with more than 50 per cent located in South Asia alone;” (Source: Progress for Children: A Report Card on Nutrition, UNICEF, 2006) “10.9 million children under five die in developing countries each year. Malnutrition and hunger-related diseases cause 60 percent of the deaths;” (Source: The State of the Worlds Children, UNICEF, 2007) In analysis, the developing countries do not have enough public and private resource capital available to provide for their citizens in the same manner that Western or developed nations have established as a basic standard of living. Outside of the developed economies, billions of human beings live without adequate access to food, clean drinking water, healthcare, and other basics that Maslow and others would characterize as fundamental to human life. There simply is not adequate capital allocated for these communities by the domestic governments, local economies, and international aid organizations to address the problem. International organizations have sought, for example through the Millennium Goals, to increase the percentage of GDP that developed nations donate to developing nations to provide for these services, but the allocators of budgets and administrators of service projects often live far from the communities that they are declared to serve or care about. The bottom line is that millions of children die each year due to starvation and lack of basic healthcare, and the international community has resources in abundance to meet these needs that are not properly distributed due to the economic system. The larger question is whether or not society has an obligation to help such people who cannot provide for themselves or to change the economic system itself. Most would agree that the moral obligation to help others in these dire situations is critical, but that the actuality of the problem is that it is too large and grave to be addressed quickly. Yet, this only glosses a political debate that goes to the heart of the debate between the developing nations and the global economic powers. Harry Brighouse and Ingrid Robeyns identify two main schools of thought among contemporary theorists regarding the question of social justice and the distribution of resources: the ‘Social Primary Goods Approach’ as promoted by Rawls and others, and the ‘Capability Approach’ as advocated by Amartya Sen. In “Measuring Justice: Primary Goods and Capabilities,” the authors write: "Social primary goods are, according to Rawls, those goods that anyone would want regardless of whatever else they wanted. They are means, or resources (broadly conceived), and this approach says that we should compare holdings of such resources, without looking closely at what individuals, possessed of heterogeneous abilities and preferences, can do with them.” (Brighouse & Robeyns, 2010) Rawls in many ways mirrors the structure and hierarchy of Maslow in his theory of Social Primary Goods, however he does not emphasize the activist elements of social justice relating to global hunger, healthcare access, and developing nations or minorities as does Daniels in “Just Health”. Where Maslow’s argumentation is more aligned with Socialist theory of government, Rawls seems to be positing a more Libertarian Capitalist viewpoint, though some critics reject this as extreme by pointing to his discussion of political systems in “A Theory of Justice”. As Michael Green writes: “Rawls presents four systems as a way of explaining how to interpret the second of his two principles of justice. We get four systems because there are two phrases in the principle that could each have two different meanings. What follows is his thinking about these four systems. It’s why he chose the particular interpretation of his second principle that he did. The system closest to a version of libertarianism like Nozick’s, the System of Natural Liberty, is consistent but wrong. It does nothing to correct or compensate for what Rawls regards as morally arbitrary influences on the distribution of goods. These influences are social or natural and the idea is that it’s unfair for your course in life to be determined by your family’s social class or your natural abilities. Two of the systems make partial attempts to deal with the problem of morally arbitrary influences, Liberal Equality and Natural Aristocracy. But since they only go part way, they are unstable. If you’re convinced that the distribution of goods should not be influenced by morally arbitrary factors, why address only some of them? ...The line of thinking that leads to these systems also leads beyond them. Only Democratic Equality is both consistent and correct.” (Green, 2008) The result of this is the establishment of “Democratic Equality” as the preferred moral, political, and aesthetic choice for defining Justice in a society, and with it the theory that this is the best process with which to negotiate the public issues of governance that relate to resource distribution and economic development in civil society both domestically and internationally. Rawls’ theory is not out of line with Churchill’s reasoning that democracy was but the best of many flawed and undesirable systems of government, problematic, but the lesser of evils. Rawls makes certain to append “equality” to democracy, as considerable attention has been drawn through progressive reform and civil rights movements to highlight the exclusionary, segregationist, and unequal aspects of democracy, especially those where vote is restricted by sex, religion, race, or other arbitrary reasons and monetary interests control dialog through access to means of mass-communication. This “Democratic Equality” is thus preferable and an ideal born of recognitions of the shortcomings of the democratic system itself. His arrangement of social primary goods is more of an interrelated union of causes and effects than the deterministic and pyramid-type of system of causality that Maslow proposed. “Rawls (2001, pp. 58-61) specifies the social primary goods in a list as follows: i) The basic liberties (freedom of thought and liberty of conscience, etc.) are the background institutions necessary to decide upon and revise, and rationally to pursue, a conception of the good. Similarly, these liberties allow for the development and exercise of the sense of right and justice under political and social conditions that are free. ii) Freedom of movement and free choice of occupation against a background of diverse opportunities are required for the pursuit of final ends as well as to give effect to a decision to revise and change them, if one so desires. iii) Powers and prerogatives of offices of responsibility are needed to give scope to various self-governing and social capacities of the self. iv) Income and wealth, understood broadly as they must be, are all-purpose means (having an exchange value) for achieving directly or indirectly a wide range of ends, whatever they happen to be. v) The social basis of self-respect are those aspects of basic institutions that are normally essential if citizens are to have a lively sense of their own worth as moral persons and to be able to realise their highest order interests and advance their ends with self confidence.” (Brighouse & Robeyns, 2010) Rawls’ Theory of Social Primary Goods shows the interrelation between the social, economic, and political, as well as how psychological factors of human nature self-define their own activities, goals, and beliefs through freedom in life. As such, it is an optimistic and hopeful vision which realistically recognizes the need to re-organize society to address income and wealth misallocations that are based on socially defined problems and issues. That the collective conscience may lag in recognition of its own atrocities and that majority rule through democratic systems can proceed tyrannically against minority interests in culture, religion, and race is part of the reason that Rawls emphasizes “Democratic Equality”. There may be numerous solutions that address the same basic problems chosen for application according to cultural preferences and tastes. What is problematic is if the collective conscience is unwilling to recognize problems that are occurring or unwilling to undertake the sacrifices required to solve them, as in developing nations, global poverty, and access to healthcare. The strength of Rawls theory is that it can be used to show the pressure points and breakdowns of the system, such as when social division leads to war or civil war in a society. The negotiations between nations can be related to the brokering between individuals for support in positions, trading interests and votes in a manner similar to a marketplace, or the cultural singularity of the expression as a product of the contemporary worldview and practice. “The other approach, developed most prominently by Amartya Sen, and more recently also by Martha Nussbaum, is known as the capability approach. Instead of looking at peoples holdings of, or prospects for holding, external goods, we look at what kind of functionings they are able to achieve. As Sen puts it, in a good theory of well-being, account would have to be taken not only of the primary goods the persons respectively hold, but also of the relevant personal characteristics that govern the conversion of primary goods into the persons ability to promote her ends. What matters to people is that they are able to achieve actual functionings, that is the actual living that people manage to achieve. (Sen, 1999, p.74)" (Brighouse & Robeyns, 2010) The Capability Approach is consistent with Maslow’s Hierarchy of Human Needs, and the ‘functionings’ can be seen as the forces integrating the individual psychologically and socially at each level of personal development. For example, when the need for food and water is met, the efficiency of the system is validated empirically. When the same fundamental needs of the individual are unmet, as in global hunger or access to education and healthcare in developing nations, both the system and the individual are considered to be non-functional. Thus, there is a very direct way of analyzing needs and the application of social solutions through multiple processes including democracy, but not limited to it as such. Sen’s view can be potentially more revolutionary, as it matches with the “by any means necessary” credo of Malcolm X and other social liberationist who seek to advance society to address injustice. Ultimately, the revolutionary act is the dissolving of the social contract that establishes the system of primary goods as posited by Rawls. Dworkin deconstructs the practice of equality in democratic and undemocratic systems by discussing the different aspects of the questions in a series of essays. The equality of welfare, the equality of resources, and other moral questions of political and economic systems are engaged with a critical view to highlight the problems of practical application of progressive ideals. The most obvious problem is that resources both within local environments and globally are finite, and ownership is centralized and concentrated into the hands of a relative few. When these same economic minorities control political institutions, they may prevent progressive reform or recognition of the rights of minorities, as in America with slavery, women’s rights, and the Native American genocide. When idealized, the principals are apparently different than when applied. The same can be concluded from religion, for charity and compassion have failed to provide for an equal society where the needs of all were met and none suffered unjustly due to the position of their birth. The relationship between the sovereign State of the most developed nations and the military is mediated by the economic condition of society and tax revenue. Yet, the same forces may coerce other interests in society, and prevent the equal distribution of goods and services, or even the equal enjoyment of rights. For Dworkin, like Rawls and Sen, the moral conscience of the individual is the a priori of most importance, for it allows the judgment that precedes even the binding into groups of interest and political identity. Yet, the moral conscience is educated and not altogether altruistic in engaging in issues dispassionately or free from subjective bias. As such, it is the statistical generalization of the moral conscience, and the social feedback of the education process that builds the cohesion of larger social movements of reform within the democratic process towards the goal of equality. Dworkin writes in Part One of “What is Equality”: “Equality is a popular but mysterious political ideal. People can become equal (or at least more equal) in one way with consequence that they become unequal (or more unequal) in others. If people have equal income, for example, they will almost certainly differ in the amount of satisfaction they find in their lives, and vice versa. It does not follow, that equality is worthless as an ideal. But it is necessary to state, more exactly than commonly done, what form of equality is finally important.” (Dworkin, 1981) For Rawls, this is “Democratic Equality” and not specifically the process through which truth is established scientifically, as these two systems may proceed on fundamentally different principles. In the epistemology of science, the empirical, statistical, and replicable are determined as fundamental to accepting a hypothesis as true or verified. In moral epistemology, the subjective is repeated on the common basis of humanity, making a shared subjectivity and consensual reality possible. Yet, ultimately the individual should in all systems be able to make independent judgments on the validity of even the decision making process as an a priori to membership in civil society, and this may be a cultural bias rooted in a particular form of education psychologically. As an internalized political and economic system, a society can reproduce its values through education which may lead to a limiting rather than an opening of truth. The possibility exists, and as such, should be considered as an aspect of risk management in a democracy, for as a fundamental decision-making process it is entrusted with protecting the very basic rights and liberties of a society, but also the life of the citizens. Nevertheless, history teaches a very different lesson from the ideal, and in order to make the ideal - social, political, economic, or otherwise - a reality, individuals must share it through both communication and identification. As mass-societies existing in complex diversities within a multiplicity of State sovereigns and an international law system of variant rights and liberties, with economies harboring massive inequalities in the ownership of capital, real estate, and natural resources, human history is a storybook of inequality and terrible sufferings that could easily have been avoided had social masses simply chosen to believe another way, what the individual defines critically as the moral, the right, or the good. The current issues of hunger, healthcare, and standard of living relate to equality in economic and materialistic statistical terminology as an expression of the age. The main question, as posited at the beginning by Daniels in “Just Health” is to determine what responsibility society should take for the poorest of the poor and those who cannot take care of themselves, both locally and globally. Yet, each individual must choose for his or herself how much they can tolerate the suffering of others while balancing it with a realistic recognition of the limits of the personal situation to build social organizations that advance the ideals they believe in into the future. People, individuals and groups, must avoid what Raz calls “the presumption of liberty” and actually construct the facilities, agencies, and structures providing the services defined by rights and ideals in the charters of human right and political declarations. (Raz, 1988) What joins Daniels, Dworkin, Rawls, Sen, Raz, and others on this issue is the shared belief and practice of a priori moral judgments by consciousness preceding idealistic or ideological integration socially, and as such the subjective human sensitivity of the individual to moral issues will continue to be the binding issue which joins the variety of means of working towards equality and justice in the social distribution of basic resources and facilities such as food, clean water, adequate sanitation, healthcare, and education. What an individual would tolerate for his or her self as regards to an adequate standard of living may be significantly more or less than he or she would tolerate in the suffering of another individual. This is a recognition of imperfection in the altruistic nature of a human being or an aspect of selfishness and self-interest. In determining the degree to which the altruistic moral center is corrupted by self-interest or selfishness, one can similarly determine or expect the decision-making, both individual and collective, to be corrupted in the person or society. Politics is a type of functionality as defined by Sen, but far from an altruistic application of human ideals. If the “Democratic Equality” of Rawls is to serve as the mediating and decision-making process through which law and truth are composed, it must be based on the altruistic instinct which also fuels the moral center, feels the suffering of others, and takes action. When the system prevents the individual from taking action efficiently, the moral center and altruistic urge should provide the inspiration and means of addressing the problem through agencies outside of the State or popular process, even if the collective conscience or moral majority has failed to recognize the criticality of the situation, as is seen in the global hunger crisis and charity groups, NGOs, and other development assistance groups. As Joseph Raz writes in ‘The Morality of Freedom,’ "Not uncommonly the best way to implement new policies is to create new public institutions or rearrange or reform old ones." (Raz, 1988) SOURCES CITED: Brighouse, Harry and Robeyns, Ingrid (2010), Measuring Justice: Primary Goods and Capabilities, Cambridge University Press, 2010. Web. 31 March. 2011. ‹http://books.google.co.in/books?id=wooZesu9k4wC›. Brown, Alexander (2009), Ronald Dworkins Theory of Equality - Domestic and Global Perspectives, Palgrave Macmillan, 2009. Web. 31 March. 2011. ‹ http://www.palgrave.com/products/title.aspx?PID=297541›. Daniels, Norman (1985), Just Health Care, Cambridge University Press, 1985. Web. 31 March. 2011. ‹http://books.google.co.in/books?id=0875k5cZjWcC›. Daniels, Norman (2008), Just Health: Meeting Health Needs Fairly, Cambridge University Press, 2008. Web. 31 March. 2011. ‹http://books.google.co.in/books?id=DrVLvi0r6JIC›. Daniels, Norman (2008), Justice and Access to Health Care, The Stanford Encyclopedia of Philosophy, 2008. Web. 31 March. 2011. ‹ http://plato.stanford.edu/entries/justice-healthcareaccess/›. Dworkin, Ronald (1981), What is Equality? Part 1: Equality of Welfare, Philosophy & Public Affairs, Vol. 10, No. 3 (Summer, 1981), pp. 185-246. Web. 31 March. 2011. ‹http://www.jstor.org/pss/2264894›. Dworkin, Ronald (1981), What is Equality? Part 2: Equality of Resources, Philosophy & Public Affairs, Vol. 10, No. 4 (Autumn, 1981), pp. 283-345. Web. 31 March. 2011. ‹ http://www.jstor.org/pss/2265047›. Gosepath, Stefan (2007), Equality, The Stanford Encyclopedia of Philosophy, First published Tue Mar 27, 2001; substantive revision Wed Jun 27, 2007. Web. 31 March. 2011. ‹http://plato.stanford.edu/entries/equality/ ›. Green, Michael (2008), Rawls against libertarianism: Notes for April 16, Social and Political Philosophy, Philosophy 33, Spring 2008. Web. 31 March. 2011. ‹http://carneades.pomona.edu/2008-SPP/nts-0416.shtml›. Huitt, W. (2007), Maslows Hierarchy of Needs, Educational Psychology Interactive, Valdosta, GA: Valdosta State University, 2007. Web. 31 March. 2011. ‹http://www.edpsycinteractive.org/topics/regsys/maslow.html›. Rawls, John (1958), Justice as Fairness, Originally published in Philosophical Review Vol. LXVII. 1958. Web. 31 March. 2011. ‹http://www.hist-analytic.org/Rawlsfair.htm›. Raz, Joseph (1988), The Morality of Freedom, Oxford University Press, 1988. Web. 31 March. 2011. ‹http://books.google.co.in/books?id=XtTii12WFn0C›. United Nations (1948), The Universal Declaration of Human Rights, UN, 1948. Web. 31 March. 2011. ‹http://www.un.org/en/documents/udhr/index.shtml›. WFP (2011), Hunger Stats, World Food Programme, 2011. Web. 31 March. 2011. ‹http://www.wfp.org/hunger/stats›. Read More