Global Health and Justice Bioethics ISSN 0269-9702 (print); 1467-8519 (online) Volume 19 Numbers 5–6 2005 © Blackwell Publishing Ltd. 2005, 9600 Garsington Road, Oxford OX4 2DQ , UK and 350 Main Street, Malden, MA 02148, USA. Blackwell Publishing Ltd.Oxford, UK and Malden, USABIOTBioethics0269-9702Blackwell Publishing Ltd. 20052005195–6460475Articles GLOBAL HEALTH AND JUSTICEJAMES DWYER GLOBAL HEALTH AND JUSTICE JAMES DWYER ABSTRACT In Australia, Japan, Sweden, and Switzerland, the average life expectancy is now greater than 80 years. But in Angola, Malawi, Sierra Leone, and Zimbabwe, the average life expectancy is less than 40 years. The situation is even worse than these statistics suggest because average figures tend to mask inequalities within countries. What are we to make of a world with such unequal health prospects? What does justice demand in terms of global health? To address these questions, I characterize justice at the local level, at the domestic or social level, and at the international or global level. Because social conditions, structures, and institutions have such a profound influence on the health of populations, I begin by focusing attention on the relationship between social justice and health prospects. Then I go on to discuss health prospects and the problem of global justice. Here I distinguish two views: a cosmopolitan view and a political view of global justice. In my account of global justice, I modify and use the political view that John Rawls developed in The Law of Peoples . I try to show why an adequate political account must include three duties: a duty not to harm, a duty to reconstruct international arrangements, and a duty to assist. In Australia, Japan, Sweden, and Switzerland, the average life expectancy is greater than 80 years. In Angola, Malawi, Sierra Leone, and Zimbabwe, the average life expectancy is less than 40 years. What are we to make of a world with such unequal health prospects? What does justice demand in terms of global health? I have thought about those questions for many years. In fact, I have fallen into a pattern that is both commendable and deplor- able. I grow concerned, study the causes, think about the moral implications, and take some action. Then, gradually, I slip back into my daily concerns and work. These concerns and work are GLOBAL HEALTH AND JUSTICE 461 © Blackwell Publishing Ltd. 2005 not without merit, but they don’t provide much space for activities that promote global health and justice. It is time to try again, to think about the issues afresh, and to dedicate myself anew. This time I want to think things through in a more basic way and to act in a more sustainable way. The purpose of this paper is to articulate, for myself and others, a view of global health and justice that could guide action. I want to develop a perspective that helps us approach the problems, iden- tify the important points, and evaluate courses of action. To begin, I shall describe differences in health prospects in the world. Then I shall frame the issues in terms of justice. In the discussion of justice, I shall interpret and extend the work that John Rawls did on global justice. HEALTH PROSPECTS IN THE WORLD Most of us are vaguely aware of the large inequalities in health that exist in the world, but we don’t often reflect on the extent, nature, and implications of these inequalities. So I want to describe some measures of population health that illustrate these inequalities. And I want to recount these measures in a way that allows us to grasp some of the human meaning – some of the effects on people’s lives. One measure of population health is average life expectancy. This is simply the number of years that people who are born now can expect to live. 1 As I said before, people born in Australia, Japan, Sweden, and Switzerland can now expect to live more than 80 years. In the United States, life expectancy is 77 years. In 36 countries, life expectancy is greater than 75 years. While people born in these countries can expect to live long, relatively healthy lives, people born in other countries cannot. Life expectancy in Sierra Leone is 35 years; in Angola and Malawi, 36 years; in Zambia and Zimbabwe, 37 years. Although these are the only countries with life expectancies of less than 40 years, there are 30 countries in which life expectancy is less than 50 years. Another measure of population health is the under-five mor- tality rate. This is simply the number of children, per 1,000 live births, who will die before they are five years old. 2 In Denmark, 1 The statistics on life expectancy are drawn from the WHO. 2002. The World Health Report 2002 . Geneva. World Health Organization. 2 The statistics on under-five mortality and maternal mortality are drawn from UNICEF. 2002. The State of the World’s Children 2003 . New York. The United Nations Children’s Fund. 462 JAMES DWYER © Blackwell Publishing Ltd. 2005 Iceland, Norway, Singapore, and Sweden, fewer than five out of 1,000 children will die before they are five years old. In the United States, the under-five mortality rate is eight. In 42 coun- tries the rate is less than 10. But in other countries, children die at a high rate. In Sierra Leone, the under-five mortality rate is 316. Although Sierra Leone is the only country with a rate above 300, 50 countries have a rate greater than 100. In these countries 10% of all children will die before they reach their fifth birthday. Even after studying health prospects in low-income countries, I find one statistic particularly shocking: the number of women who will die of causes related to their pregnancies. Israel, Kuwait, Sweden, and Switzerland report maternal death rates of five per 100,000. The rate in the United States is eight. Twenty- eight countries have rates of less than 10. But in other places, pregnant women face grave risks. In the Central African Repub- lic, Malawi, Mozambique, Rwanda, and Sierra Leone, the mater- nal mortality rate is greater than 1,000. In these countries, more than 1% of pregnant women will die of causes related to their pregnancies. This risk of death is repeated with each pregnancy. Life expectancy, under-five mortality, and maternal mortality are useful measures, but health prospects are actually worse than these measures suggest. Because these measures are all based on mortality, they do not take into account morbidity. They ignore the suffering, impairment, and lost opportunity that comes with illness. Measures that do take these factors into account – mea- sures that use healthy life expectancy or disability-adjusted life years – suggest a grimmer picture. The situation is even worse than I described because all the measures I cited are averages, and averages tend to mask inequal- ities within a country. The poor and marginalized within a country often have shorter life expectancies, higher mortality rates, and more illness than average. Inequalities vary from country to coun- try, but measures of health inequalities in the United States give us some idea of the inequalities that we might find in other countries. A region by region comparison in the United States found that life expectancy varied by 13 years among women and 16 years among men. 3 This regional variation is correlated with race, income, and other social factors. 3 C. Murray et al. 1998. U.S. Patterns of Mortality by County and Race. Cam- bridge, MA. Harvard Center for Population and Development Studies. GLOBAL HEALTH AND JUSTICE 463 © Blackwell Publishing Ltd. 2005 JUSTICE Most of us react to measures of population health because we are able to identify with other people’s needs, concerns, and condi- tions. Our initial reactions are signs of ethical sensibility, but by themselves they do not take us very far. They need to be devel- oped, supplemented, and guided. Here an account of justice may prove useful. It could help to orient us in experience, guide sustainable action, and integrate ethical concerns into political institutions. It could even function to articulate social hope. I shall try to use, interpret, and extend some of John Rawls’s work to address issues of global health. Because Rawls does not want to presuppose traditional views about the sovereignty of states or nations, he refers to his work on global justice as the law of peoples. He makes explicit the ideas that motivate this work: Two main ideas motivate the Law of Peoples. One is that the great evils of human history – unjust war and oppression, reli- gious persecution and the denial of liberty of conscience, star- vation and poverty, not to mention genocide and mass murder – follow from political injustice, with its own cruelties and callousness . . . The other main idea, obviously connected with the first, is that, once the gravest forms of political injustice are eliminated by following just (or at least decent) social policies and establishing just (or at least decent) basic institutions, these great evils will eventually disappear. 4 Rawls tries to specify a conception of justice that will address the great evils that destroy lives and plague human history. To the list of evils that destroy lives and plague human history, I want to add two: ill health and premature death. That seems plausible enough. But I also want to suggest that these evils follow from political injustice. That seems implausible at first. Don’t people die of diseases and accidents, caused by microbes and mishaps? Yes and no. Health depends on susceptibility to illness, exposure to risks, access to resources and care, the social conse- quences of ill health, and many other factors. But all these factors are influenced by the justice of the social environment. Whereas the health of an individual may depend on particular susceptibil- ities or exposures, the health of a population often depends on justice. Or so I shall argue. 4 J. Rawls. 1999. The Law of Peoples. Cambridge, MA. Harvard University Press: 6–7. 464 JAMES DWYER © Blackwell Publishing Ltd. 2005 To begin, it is useful to distinguish three levels at which issues of justice can arise: the local level, the domestic or social level, and the international or global level. Rawls explains: Altogether then we have three levels of justice, moving from inside outward: first, local justice (principles applying directly to institutions and associations); second, domestic justice (prin- ciples applying to the basic structure of society); and finally global justice (principles applying to international law). 5 Injustices at all three levels can have a profound influence on health. Consider, for example, the problem of malnutrition. A child may be malnourished because in her particular family, boys are fed first and given more to eat. A marginalized group may be malnourished because of the way pastures and agricultural lands are distributed in its society. Groups within society may be mal- nourished because their relative situation within society has been made worse by war or global trade. Thus people’s nutritional status and susceptibility to disease may be influenced by the jus- tice of local, social, and global arrangements. Rawls cautions us not to assume that one simple set of princi- ples should apply to all levels. He writes: One should not assume in advance that principles that are reasonable and just for the basic structure are also reasonable and just for institutions, associations, and social practices gen- erally. While the principles of justice as fairness impose limits on these social arrangements within the basic structure, the basic structure and the associations and social forms within it are each governed by distinct principles in view of their differ- ent aims and purposes and their peculiar nature and special requirements. Justice as fairness is a political, not a general, conception of justice: it applies first to the basic structure and sees these other questions of local justice and also questions of global justice (what I call the law of peoples) as calling for separate consideration on their merits. 6 Although the different levels may call for different principles, there are relationships to keep in mind: just as principles of social justice rightfully limit some local practices, principles of global justice may rightfully limit some national practices. 5 J. Rawls. 2001. Justice as Fairness. Cambridge, MA. Harvard University Press: 11. 6 Ibid. p. 11. GLOBAL HEALTH AND JUSTICE 465 © Blackwell Publishing Ltd. 2005 In thinking about global health and justice, we could begin at any level. Where we actually begin will depend on our practical purposes and philosophical convictions. I shall begin at the social level for two reasons. First, I believe that the basic structure of a society has a profound influence on the health prospects of sub- populations within that society. Secondly, I believe that beginning with social justice will help to clarify the nature and role of global justice. SOCIAL JUSTICE To illustrate the influence that social structures and organizations have on health prospects, I want to discuss a problem that I mentioned before. Malnutrition remains a serious health prob- lem, perhaps the most serious health problem, in countries with high mortality rates. The World Health Report 2002 estimates that, in countries with high mortality rates, 14.9% of the burden of disease is due to underweight, 3.2% to zinc deficiency, 3.1% to iron deficiency, and 3.0% to vitamin A deficiency. 7 In total, almost 25% of the burden of disease is due to malnutrition. Chronic malnutrition and outright starvation are rarely due to a lack of resources or to declining food production within a country. Amartya Sen and others have shown that famines and malnutrition are often due to the way food, entitlements, and power are distributed. 8 The real problem is that governments and privileged groups do not care enough to create systems of entitlements to supplement the food supplies that marginalized groups have. Although the particular cause of a particular illness may be a vitamin deficiency, the root cause is often embedded in the social structure. What is true of malnutrition is also true, to a greater or lesser degree, of many health problems in countries with high mortality rates. One could examine, for example, the role that social struc- tures and gender inequalities play in the HIV epidemic. Although Rawls does not discuss health prospects, his general point applies to health: the problem is often not the lack of natural resources. Many societies with unfavorable conditions don’t lack for resources. Well-ordered societies can get on with very little; their wealth 7 World Health Report , op. cit. note 1, p. 162. 8 A. Sen. 1981. Poverty and Famines . Oxford. Clarendon Press; J. Drèze & A. Sen. 1989. Hunger and Public Action . Oxford. Clarendon Press; F. Lappé & J. Collins. 1986. World Hunger: Twelve Myths . New York. Grove Press. 466 JAMES DWYER © Blackwell Publishing Ltd. 2005 lies elsewhere: in their political and cultural traditions, in their human capital and knowledge, and in their capacity for political and economic organization. Rather, the problem is commonly the nature of the public political culture and the religious and philosophical traditions that underlie its institu- tions. The great social evils in poorer societies are likely to be oppressive government and corrupt elites; the subjection of women abetted by unreasonable religion, with the resulting overpopulation relative to what the economy of the society can decently sustain. Perhaps there is no society anywhere in the world whose people, were they reasonably and rationally gov- erned, and their numbers sensibly adjusted to their economy and resources, could not have a decent and worthwhile life. 9 What allows societies to have relatively healthy populations is not the natural resources they possess, but the social organizations they develop. Many examples support the claim that social factors are more important than natural resources. Japan and Sweden are hardly distinguished for their natural resources, yet they have very good measures of population health. The United States enjoys consid- erable natural resources and great economic wealth, but usually ranks around 20th to 30th in measures of population health. The most telling examples of all are societies that have achieved rela- tively good measures of population health in spite of limited economic wealth and moderate natural resources. The state of Kerala, in India, is a good example. Its economic wealth, in terms of GNP, is less than $1,000 per capita. It does possess some natural resources, but no more than many low-income countries. Its spending on health care per person per year is less than $50 (as compared with over $4,000 per year in the US). And yet Kerala’s measures of population health are relatively good. Life expect- ancy at birth is 73 years. 10 Although examples can illustrate the possibility of achieving good population health with limited resources, they don’t really explain the relationship between social justice and population health. I want to suggest that this relationship is as much concep- tual as empirical. Good measures of population health do not always imply a high level of social justice. A society might have good measures of average health, and even a high degree of 9 J. Rawls 1999. Collected Papers . Cambridge, MA. Harvard University Press: 559. 10 Planning Commission. 2001. National Human Development Report 2001 . New Delhi. Government of India: 218. GLOBAL HEALTH AND JUSTICE 467 © Blackwell Publishing Ltd. 2005 equality in health, but deny its members political liberties and opportunities that are central to the idea of justice. But poor measures of population health often imply serious social in- justice. If a society possesses a moderate amount of natural resources, has access to basic scientific knowledge, and lives under fairly usual conditions, but allows basic social institutions to promote the privileges of some groups when reformed institu- tions could ensure the basic needs of all groups, then it fails as a just society. GLOBAL JUSTICE The danger of focusing on the role of social institutions within a country is that we’ll end up blaming the victims. We might not blame the actual victims – the marginalized people in low-income countries – but we will focus on the political traditions and privileged groups in those countries, while we ignore the international actions and structures that contribute to the situation. There are two ways to avoid this danger. One way is to develop a cosmopolitan view of global justice. Another way is to develop an appropriately political view of global justice. Many accounts of global justice adopt a cosmopolitan perspec- tive. They tend to deny that political boundaries have any moral significance and to view all human beings as world citizens. Some cosmopolitan accounts expand and emphasize the idea of human rights, the things that people are entitled to in virtue of their status as human beings. In these accounts, all matters of health become issues of human rights. Other cosmopolitan accounts, by arguing that the same principles of distribution should apply at both the global and national level, tend to conflate global justice and social justice. I respect the ethical concern that lies behind cosmopolitan accounts, but I want to explain how similar concern might be expressed in an account of global justice that is less cosmopolitan and more political. Rawls recognizes that political boundaries seem arbitrary, but this recognition does not lead him to adopt a cosmopolitan view. He writes: It does not follow from the fact that boundaries are historically arbitrary that their role in the Law of Peoples cannot be justi- fied. On the contrary, to fix on their arbitrariness is to fix on the wrong thing. In the absence of a world-state, there must be boundaries of some kind, which when viewed in isolation will 468 JAMES DWYER © Blackwell Publishing Ltd. 2005 seem arbitrary, and depend to some degree on historical cir- cumstances. 11 Although boundaries depend on historical contingencies, a defined territory may allow a people to exercise political auton- omy and create just social institutions. The idea of a world government does not appeal to Rawls. He writes: I follow Kant’s lead in Perpetual Peace (1795) in thinking that a world government – by which I mean a unified political regime with the legal powers normally exercised by central governments – would either be a global despotism or else would rule over a fragile empire torn by frequent civil strife as various regions and peoples tried to gain their political freedom and autonomy. 12 To reject a world government is not to reject federations, regula- tions, ethical duties, and limits to sovereignty. Rawls attaches some significance and function to political boundaries; he does not view people as world citizens in a world government, and he adopts a somewhat different standard for social justice and global justice. In these ways, his view is more political and less cosmopolitan. But his view is political in a deeper sense. When he wrote A Theory of Justice , he suggested that his account of justice was a comprehensive moral view. Later he emphasized that his account of justice is a political account that appeals to the idea of public reason and that recognizes the fact that a democratic culture will be marked by a plurality of reason- able comprehensive accounts of the good and the right. His work on global justice continues in this vein. It recognizes a plurality of reasonably just and decent societies, gives a prominent place to political autonomy, looks for an overlapping consensus, and appeals to the idea of public reason. But how can a political account of global justice avoid the danger I noted? An adequate political account needs to empha- size three kinds of duties: a duty not to harm, a duty to recon- struct, and a duty to assist. When considering global health, and the great disparities that exist between countries, many people have a tendency to focus on the duty to assist, but I think it is equally important to focus attention on the duty not to harm and the duty to reconstruct. I shall try to illustrate the role of each of these duties in an account of global justice. 11 Rawls, op. cit. note 4, p. 39. 12 Ibid. p. 36. GLOBAL HEALTH AND JUSTICE 469 © Blackwell Publishing Ltd. 2005 THE DUTY NOT TO HARM I want to illustrate the duty not to harm by considering the harm caused by unjust wars and the harm caused by environmental degradation. Both these forms of harm can have a profound effect on health prospects. It is no coincidence that many of the societies with poor population health have been ravaged by war, and it doesn’t take a subtle application of just war theory to find instances in which powerful countries have intervened unjustly. In his discussion of democratic peace theory, Rawls gives the following examples: given the great shortcomings of actual, allegedly constitutional democratic regimes, it is no surprise that they should often intervene in weaker countries, including those exhibiting some aspects of a democracy, or even that they should engage in war for expansionist reasons. As for the first situation, the United States overturned the democracies of Allende in Chile, Arbenz in Guatemala, Mossadegh in Iran, and, some would add, the Sandanistas in Nicaragua. Whatever the merits of these regimes, covert operations against them were carried out by a government prompted by monopolistic and oligarchic interests without the knowledge or criticism of the public. This subter- fuge was made easier by the handy appeal to national security in the context of superpower rivalry, which allowed such weak democracies to be cast, however implausibly, as a danger. Though democratic peoples are not expansionist, they do defend their security interest, and a democratic government can easily invoke this interest to support covert interventions, even when actually moved by economic interests behind the scenes. 13 Whatever form the unjust wars take, they often interfere with political autonomy, destroy political capital, hinder social justice, cause material damage, and harm the health of the most vulner- able populations. Another form of harm is environmental harm. It is easy to see how an environmental problem that is generated by one society can affect other societies. The generation of greenhouse gases is a classical and worrisome problem. It is certain enough that human activity is changing the climate. It is highly probable that this change will cause sea levels to rise, bring about more volatile 13 Ibid. p. 53. 470 JAMES DWYER © Blackwell Publishing Ltd. 2005 weather patterns, decrease food production at some latitudes, and contribute to the spread of tropical diseases. 14 In 2000 the rates of carbon emissions were as follows: Kuwaitis 5.97 metric tons per person; Americans 5.40; Australians 4.91; Canadians 3.87; Japanese 2.55; Swedes 1.44; Chinese 0.60; Costa Ricans 0.39; Indians 0.29. 15 Although I understand the historical explanation for the different rates of emission, I do not see any ethical justification for some people overusing the capacity of the atmosphere to act as sink. The ethical issue of climate change involves factors other than carbon emissions, but even when other factors are considered, climate change seems to be a clear case in which the benefits and burdens are unfairly distributed. The effects of climate change will not be felt uniformly across the globe. The impact will depend on geography, wealth, and social justice. Wealthy nations will be better able than poor nations to respond to a problem like rising sea levels. And within a nation, the people who will suffer most from decreases in food production or increases in tropical diseases will be the poorest and most marginalized. Social injustice often acts as a multiplier of global injustice. I tried to illustrate why an account of global justice needs to focus attention on the duty not to harm, but I do not want to claim, as a point of ethical theory, that the duty not to harm is always more important than other duties. I simply wanted to focus more attention on how societies can unjustly harm other societies, and how that harm impacts people who are unjustly treated in their own society. THE DUTY TO RECONSTRUCT Societies have a duty to reconstruct the structures and norms that regulate the interactions between them. I use the term ‘recon- struct’ for several reasons. The idea of reconstruction recognizes that there already exist structures, norms, and background con- ditions. It helps to counteract the idea that interactions take place in some natural and neutral space. The idea of reconstruction also recognizes that contexts change. Norms that functioned well in one context may not function well when new forces become oppressive and new needs become urgent. 14 P. Singer. 2002. One World: The Ethics of Globalization . New Haven. Yale University Press: 17. 15 These rates are from G. Marland, T.A. Boden & R.J. Andres. 2000. Global, Regional, and National Fossil Fuel CO2 Emissions . Available at http:// cdiac.ornl.gov/trends/emis/top2000.cap (accessed August 2004). http://� http://� GLOBAL HEALTH AND JUSTICE 471 © Blackwell Publishing Ltd. 2005 Modern societies are interrelated by the influence that they have in many areas: the natural environment; war, peace, and security; legitimacy, political autonomy, and human rights; work, trade, and finance; migration and travel; disease and public health; communication and culture; and forms of aid. 16 Interac- tions and relationships in these areas often raise questions of justice. The hard questions are not about why some structures and norms in these areas need to be reconstructed, but about the directions and modes of change. An analogy between social justice and global justice may prove helpful here. In order to promote social justice, a society may need to reconstruct the norms and structures of the background institutions. The principles and ideals of justice to which we are committed help to specify the background conditions that are needed. In his account of social justice, Rawls is committed to securing equal liberties, ensuring the fair value of political liberty, promoting fair equality of opportunity, and improving the situa- tion of the least advantaged. These commitments require certain background institutions and conditions. Rawls gives the following example: background institutions must work to keep property and wealth evenly enough shared over time to preserve the fair value of the political liberties and fair equality of opportunity over generations. They do this by laws regulating bequest and inheritance of property, and other devices such as taxes, to prevent excessive concentrations of private power. 17 In a discussion of fair equality of opportunity, Rawls reiterates the need to attend to the background conditions: A free market system must be set within a framework of political and legal institutions that adjust the long-run trend of economic forces so as to prevent excessive concentrations of property and wealth, especially those likely to lead to political domination. Society must also establish, among other things, equal opportunities of education for all reg- ardless of family income. 18 Thus the aims of ensuring fair value of political liberty and promoting fair equality of opportunity may require considerable 16 Compare my list with Young’s: I. Young. 2000. Inclusion and Democracy . New York. Oxford University Press: 267. 17 Rawls, op. cit. note 5, p. 51. 18 Ibid. p. 44. 472 JAMES DWYER © Blackwell Publishing Ltd. 2005 regulation of economic institutions and conditions. A commit- ment to justice that ignores background conditions is naïve or hypocritical. Rawls says that the background conditions for global justice ‘have a role analogous to that of the basic structure in domestic society’. 19 But what are the aims of global justice and what con- ditions do they require? A cosmopolitan view of global justice aims rather directly to prevent suffering and improve the well- being of individual people. A political view is not indifferent to the fate of individual people, but it takes a more indirect approach. It aims to address political injustices in order to reduce social evils and create conditions in which people can live better lives. A political view aims to promote justice at two levels. It aims to promote just interactions between societies in matters relat- ing to peace, trade, the environment, and so on. It also aims to promote just or decent societies, so that these societies become good members of the society of peoples. The second aim is complicated by a proper regard for political autonomy and tol- erance. Tolerance does not imply that states have unlimited sovereignty and can disregard the human rights of their citi- zens. But tolerance does require an allowance for variations in social orders and sensitive deliberation about responses to injustices. But what conditions and structures do the aims of global justice require? Let me give two brief examples. The current norms of political legitimacy give a lot of weight to raw power. Tyrants who seize or hold power by military force, and violate the basic rights of people subjected to them, are often condemned. But then they are treated as legitimate representatives of their people. This recognition of legitimacy takes many forms. Thomas Pogge has called attention to a particularly harmful form: the international resource privilege. 20 Tyrants are accorded the right to sell natural resources like oil. Multinational corporations often buy the rights to these resources, and the international community tends to treat these interactions as legitimate. By providing tyrants with the 19 Rawls, op. cit. note 4, p. 42. 20 T. Pogge. 2002. World Poverty and Human Rights . Malden, MA. Blackwell Publishers: 22–23, 113–115, 142. I should note that Pogge sees some of his work as an argument against Rawls’s account. I see the differences as a matter of emphasis. Rawls emphasizes national traditions and institutions, whereas Pogge emphasizes international norms and structures. I have tried to take both into account. GLOBAL HEALTH AND JUSTICE 473 © Blackwell Publishing Ltd. 2005 means they need to hold onto power, and by encouraging others to try to seize power, current norms do not promote just societies and just interactions between societies. Let me give a second example of the need to reconstruct norms and structures. In order to achieve the aims of social justice, a society needs to embed the market economy in a complex net- work of civil and political institutions. Likewise, to achieve the aims of global justice, the global market will need to be embedded in and regulated by appropriate political institutions. But the current form of globalization tends to subordinate political aims to economic power, to distort political interactions between soci- eties, and to limit the ways a society can even try to achieve social justice. For example, current forms of globalization encourage or even force low-income societies to limit the social provision of goods and to privatize goods like clean water and health care. Changing the global order won’t be easy, but it is naïve to think that global justice can flourish without attending to the back- ground conditions. DUTY TO ASSIST Although an account of global justice needs to emphasize the duty not to harm and the duty to reconstruct, it also needs to include a duty to assist. My division of duties into three categories is a pragmatic one. It is not justified because it describes natural kinds accurately, but because it serves human purposes well. This division of duties is justified if it helps us to see and act in a better way. (The duty to reconstruct, for example, involves issues of harm and assistance, but thinking of it as a separate category helps to focus our attention on structures and norms that regulate certain kinds of interactions.) Given my pragmatic view, I don’t have much patience with skeptical demands to justify a duty to assist. These demands often combine, in an ad hoc way, founda- tionalism and libertarianism. It seems strange and self-serving to accept a duty not to harm, but to demand a foundational justifi- cation for a duty to assist. I do recognize that we sometimes face conflicts of duties and need to address matters about the relative importance of these duties. But I don’t have much to say in general about how to resolve these conflicts. I do not want to claim that one duty always has priority over the others. Rather than debating, in general terms, the justification and the importance of the duty to assist, we should focus more attention on the aims of this duty and the various ways of fulfilling it. 474 JAMES DWYER © Blackwell Publishing Ltd. 2005 In a political account of global justice, the aim of the duty to assist is to help societies to create and maintain just (or decent) basic institutions so that the assisted societies become autonomous and good members of a just federation of peo- ples. Assistance should not aim to promote the narrow inter- ests of the assisting country, but to promote just and decent conditions in the assisted countries. In a political account of global justice, the duty to assist is complex because it combines different ideas: the importance of social justice, the ideal of meaningful autonomy (but not unlimited sovereignty), toler- ance within limits, and the hope that internally just societies will be more peaceful and fair in their foreign affairs. The duty to assist does aim to benefit people, but in an indirect way. What is the best way to fulfill the duty to assist? In general, the means should be chosen to further the aims. Well- designed assistance would promote conditions for just and sustainable institutions. It would promote autonomy and avoid the ignorance, arrogance, and paternalism that so often char- acterizes aid. And it would involve the right combination of short-term and long-term projects. To do all that in practice requires knowledge of particular situations, good political judgment, and a willingness to experiment. In some situa- tions, assistance to organizations in civil society may prove worthwhile. Some of these organizations are working to fight injustices and to increase community involvement. They serve to give voice to the very people who governments ignore or try to silence. THE PRACTICE OF JUSTICE There may be better accounts of global health and justice than the one I have given, but even the ‘best’ account will not, by itself, bring about the needed changes. Formulating an account of glo- bal health and justice is only part of the work that needs to be done. The other part is the work of realizing more just institu- tions. To do that, we will need to integrate our accounts and concerns into personal and political practices. And then we will probably need to revise our accounts in light of practices. Realiz- ing a more just order will not be easy. People don’t easily let go of special privileges, personal profits, entrenched habits, and out- moded ways of thinking. But the attempt to make practices and GLOBAL HEALTH AND JUSTICE 475 © Blackwell Publishing Ltd. 2005 institutions more just is worthy of a dedicated and sustained effort. James Dwyer, Ph.D. SUNY Upstate Medical University Center for Bioethics and Humanities Syracuse, NY 13210 USA dwyerja@upstate.edu mailto:dwyerja@upstate.edu