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An Introduction to Global Health Ethics

The field of global health is expanding rapidly. An increasing number of trainees are studying and
working with marginalized populations, often within low- and middle-income countries. Such
endeavours are beset by ethical dilemmas: mitigating power differentials, addressing cultural
differences in how health and illness are viewed, and obtaining individual and community consent
in research. This introductory textbook supports students to understand and work through key areas
of concern, assisting them in moving towards a more critical view of global health practice.
Divided into two sections covering the theory and practice of global health ethics, the text begins
by looking at definitions of global health and the field’s historical context. It draws on anti-colonial
perspectives and concepts, developing social justice and solidarity as key principles to guide
students. The second part focuses on ethical challenges students may face in clinical experiences or
research. Topics such as working with indigenous communities, the politics of global health
governance, and the ethical challenges of advocacy are explored using a case study approach.
An Introduction to Global Health Ethics includes recommended resources and further readings,
and is ideal for students from a range of disciplines – including public health, medicine, nursing,
law and development studies – who are undertaking undergraduate and graduate courses in ethics
or placements overseas.
Andrew D. Pinto is a family physician, and Public Health and Preventive Medicine specialist in
the Department of Family and Community Medicine of St Michael’s Hospital in Toronto. He is also
a research fellow at the Centre for Research on Inner City Health in the Keenan Research Centre at
the Li Ka Shing Knowledge Institute.
Ross E.G. Upshur is former Director of the University of Toronto Joint Centre for Bioethics, and a
staff physician at Sunnybrook Health Sciences Centre. He is the Canada Research Chair in Primary
Care Research and, at the University of Toronto, he is a Professor at the Department of Family and
Community Medicine and Dalla Lana School of Public Health, Adjunct Scientist at the Institute of
Clinical Evaluative Sciences, an affiliate of the Institute of the History and Philosophy of Science
and Technology, and a member of the Centre for Environment.

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To Kim, Olivia and Sara with great love for making all things possible.
– Ross Upshur
To my parents, Barbara and Brian, for the values you taught me, and to my
wife, Malika, for helping me to live them.
– Andrew Pinto

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An Introduction to
Global Health Ethics

Edited by
Andrew D. Pinto
Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto
Centre for Research on Inner City Health, Li Ka Shing Knowledge Institute, St. Michael’s Hospital

Ross E.G. Upshur
Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, University
of Toronto
Dalla Lana School of Public Health, University of Toronto
Canada Research Chair in Primary Care Research

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First published 2013
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
Simultaneously published in the USA and Canada
by Routledge
711 Third Avenue, New York, NY 10017

Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2013 selection and editorial material, Andrew D. Pinto and Ross E.G.
Upshur; individual chapters, the contributors
The right of the editors to be identified as the authors of the editorial
material, and of the authors for their individual chapters, has been asserted
in accordance with sections 77 and 78 of the Copyright, Designs and
Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilized in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.

Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.

British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library.

Library of Congress Cataloguing in Publication Data
An introduction to global health ethics / [edited by] Andrew D. Pinto and
Ross E.G. Upshur.
p.; cm.
Includes bibliographical references
I. Pinto, Andrew D. II. Upshur, Ross.
[DNLM: 1. World Health – ethics. 2. Healthcare Disparities – ethics. 3.
International Cooperation. 4. Public Health – ethics. WA 530.1]
174.2 – dc23
2012022269
ISBN: 978-0-415-67352-5 (hbk)
ISBN: 978-0-415-68183-4 (pbk)
ISBN: 978-0-203-08222-5 (ebk)
Typeset in Sabon
by Saxon Graphics Ltd, Derby

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Contents
List of contributors
Foreword

James Orbinski

PART I: THEORY
1

The context of global health ethics

Andrew D. Pinto, Anne-Emanuelle Birn and Ross E.G. Upshur
A) Introduction
B) Historical roots of global health
C) Global health today
D) Political economy of health
E) Global health ethics and its values
F) Conclusion
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Ethics and global health

Ross E.G. Upshur, Solomon Benatar and Andrew D. Pinto
A) Introduction
B) Ethical concepts and ethical reasoning
C) Ethical theory and applied ethics
D) Key dimensions of global health ethics
E) Social justice and global health
F) Solidarity and global health
G) Conclusion
3

Approaching global health as a learner

Malika Sharma and Kelly Anderson
A) Introduction
B) The global health learning cycle
C) Conclusion
4

Human rights discourse within global health ethics

Lisa Forman and Stephanie Nixon
A) Introduction
B) The right to health
C) Human rights and global health
D) How global health ethics advances human rights

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E) How human rights advances global health ethics
F) Conclusion
5

Global health governance and ethics

Jerome Amir Singh
A) Introduction
B) Genesis of global health governance
C) World Health Organization
D) Zoonoses infection control governance
E) Pandemic management: infection control governance strategies
F) Ethical, human rights and social implications of public health containment strategies
G) Confinement and social factors
H) Conclusion
6

Indigenous health and ethics: lessons for global health

Andrew D. Pinto and Janet Smylie
A) Introduction
B) The health of Indigenous people globally
C) Colonization and resistance
D) “Decolonizing methodologies”
E) Ethical principles from research involving Indigenous communities
F) Conclusion
PART II: PRACTICE
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Ethics and clinical work in global health

Athanase Kiromera, Jane Philpott, Sarah Marsh and Adrienne K. Chan
A) Introduction
B) Discussion of Case Study 7.1
C) Discussion of Case Study 7.2
D) Discussion of Case Study 7.3
E) Discussion of Case Study 7.4
F) Conclusion
8

Ethical challenges in global health research

Ghaiath Hussein and Ross E.G. Upshur
A) Introduction
B) Historical background to the ethical oversight of research
C) Principles of research ethics
D) Contextual considerations in research in LMICs
E) A checklist for researchers
F) Conclusion
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Ethical considerations of global health partnerships

Jill Murphy, Victor R. Neufeld, Demissie Habte, Abraham Aseffa, Kaosar Afsana, Anant
Kumar, Maria de Lourdes Larrea and Jennifer Hatfield

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A) Introduction
B) Benefits of partnerships
C) Challenges of pa
D) Principles for conducting partnerships
E) Conclusion
10 Perspectives on global health from the South

Ana Sanchez and Victor A. López
A) Introduction
B) Guidelines for international collaborations
C) Recommendations
11 The political context of global health and advocacy

Nathan Ford
A) Introduction
B) A framework for global health advocacy
C) How students have supported global advocacy to increase access to antiretroviral therapy
D) Conclusions
12 Teaching global health ethics

Donald C. Cole, Lori Hanson, Katherine D. Rouleau, Kevin Pottie and Neil Arya
A) Why discuss the teaching of global health ethics?
B) How should we approach the teaching of global health ethics?
C) Where can we engage in global health ethics teaching?
D) When might we teach global health ethics?
E) Shaping institutions to support the learning of global health ethics
F) How do we evaluate trainee competency in global health ethics?
G) Future directions in global health ethics teaching
Afterword

Solomon Benatar
Index

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Contributors
Kaosar Afsana
Health Programme, BRAC, Dhaka, Bangladesh
James P. Grant School of Public Health, BRAC University, Dhaka, Bangladesh
Kelly Anderson
Department of Family and Community Medicine, St. Michael’s Hospital, University of Toronto,
Toronto, Canada
Neil Arya
Office of Global Health, Schulich School of Medicine & Dentistry, University of Western Ontario,
London, Canada
Environment and Resource Studies University of Waterloo, Waterloo, Canada
Department of Family Medicine, McMaster University, Hamilton, Canada
Abraham Aseffa
Armauer Hansen Research Institute, Addis Ababa, Ethiopia
Solomon Benatar
Bioethics Centre, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Joint Centre for Bioethics & Dalla Lana School of Public Health, University of Toronto, Toronto,
Canada
Anne-Emanuelle Birn
Social and Behavioural Health Sciences and Global Health Divisions, Dalla Lana School of Public
Health, University of Toronto, Toronto, Canada
Centre for Critical Development Studies, University of Toronto-Scarborough, Toronto, Canada
Adrienne K. Chan
Division of Infectious Diseases and Institute of Health Policy, Management & Evaluation,
Department of Medicine, University of Toronto, Toronto, Canada
Dignitas International, Toronto, Canada
Global Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto,
Canada
Donald C. Cole
Global Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto,
Canada
Nathan Ford
Médecins Sans Frontières, Cape Town, South Africa
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Centre for Infectious Disease Epidemiology and Research, University of Cape Town, Cape Town,
South Africa
Lisa Forman
Global Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto,
Canada Munk School of Global Affairs, University of Toronto, Toronto, Canada
Demissie Habte
Ethiopian Academy of Sciences, Addis Ababa, Ethiopia
Lori Hanson
Department of Community Health and Epidemiology, College of Medicine, University of
Saskatchewan, Saskatoon, Canada
Jennifer Hatfield
Global Health & International Partnerships, Department of Community Health Sciences, O’Brien
Centre for the Bachelor of Health Sciences, Faculty of Medicine, University of Calgary, Canada
Ghaiath Hussein
Department of Medical Ethics, Faculty of Medicine, King Fahad Medical City, Saudi Arabia
Athanase Kiromera
Department of Family and Community Medicine, University of Toronto, Toronto, Canada
Anant Kumar
Xavier Institute of Social Service, Ranchi, India
Maria de Lourdes Larrea
Universidad Andina Simon Bolivar, Quito, Ecuador
Victor A. López
Trauma and Global Health Program, Universidad de San Carlos de Guatemala, Guatemala City,
Guatemala Centro Integral del INCAP para la Prevención de las Enfermedades Crónicas,
Guatemala City, Guatemala
Sarah Marsh
School of Nursing, University of Texas at Austin, Austin, United States of America
Jill Murphy
Faculty of Health Sciences, Simon Fraser University, Vancouver, Canada
Victor R. Neufeld
Canadian Coalition for Global Health Research, Ottawa, Canada
Stephanie Nixon
Department of Physical Therapy, Faculty of Medicine, University of Toronto, Toronto, Canada
Global Health Division, Dalla Lana School of Public Health, University of Toronto, Toronto,
Canada
Director, International Centre for Disability and Rehabilitation, University of Toronto, Toronto,
Canada
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James Orbinski
Balsillie School of International Affairs, Wilfrid Laurier University, Waterloo, Canada
Jane Philpott
Department of Family and Community Medicine, University of Toronto, Toronto, Canada
Department of Family Medicine, Markham Stouffville Hospital, Markham, Canada
Andrew D. Pinto
Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Canada
Centre for Research on Inner City Health, Keenan Research Centre, Li Ka Shing Knowledge
Institute,
St. Michael’s Hospital, Toronto, Canada
Kevin Pottie
Centre for Global Health, Institute of Population Health and Bruyere Research Institute,
Departments of Family Medicine and Epidemiology and Community Medicine, Faculty of
Medicine, University of Ottawa, Ottawa, Canada
Katherine D. Rouleau
Global Health Program, Department of Family and Community Medicine, University of Toronto,
Toronto, Canada
Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Canada
Ana Sanchez
Department of Community Health Sciences, Faculty of Applied Health Sciences, Brock University,
St Catharines, Canada
Malika Sharma
Department of Infectious Diseases, Division of Medicine, University of Toronto, Toronto, Canada
Jerome Amir Singh
Centre for the AIDS Programme of Research in South Africa, University of KwaZulu-Natal,
Durban, South Africa Dalla Lana School of Public Health, Joint Centre for Bioethics, and Sandra
Rotman Centre, University of Toronto, Toronto, Canada
Janet K. Smylie
Centre for Research on Inner City Health, Keenan Research Centre, Li Ka Shing Knowledge
Institute, St. Michael’s Hospital, Toronto, Canada
Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Canada Dalla
Lana School of Public Health, University of Toronto, Toronto, Canada
Ross E.G. Upshur
Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto,
Canada Dalla Lana School of Public Health, University of Toronto, Toronto, Canada Canada
Research Chair in Primary Care Research

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Foreword
James Orbinski
Global health in its broadest conceptualization connotes wellbeing in a state of justice. If global
health is to be something other than an ideal perpetually beyond our grasp, it needs a framework
rooted in fact, history, contemporary political reality and morality.
The primary factors that shape the health of citizens are not medical treatments or lifestyle
changes, but rather the living conditions people experience and inequities in the societal
determinants of health (Rasanathan and Krech 2011). A 2008 World Health Organization
Commission concluded that ‘social injustice is killing people on a grand scale’ (WHO 2008: 6).
Addressing injustice and enhancing global health is a matter of practical action. It requires
careful thinking, initiative and a willingness to experiment with new approaches. Most importantly,
it requires that we think ethically and then act ethically. Ethics is not morality, but is dependent on
it. Ethics demands that we are explicit about our moral frameworks and our choices, and that we
explicitly explore the consequences that arise from these.
The purpose of ethical decision-making is not to provide a singularly correct answer or ‘the
Truth’. No one set of fixed rules will suffice to guide ethical choices, as most ethical issues cannot
be pursued in a purely algorithmic way. There is often an inherent dilemma in weighing competing
principles. Ethics allows us to initiate action with explicit moral reasoning and to evaluate
outcomes from both objective and moral perspectives in order to improve our future choices and
actions in the pursuit of global health.
This book is not about what perfect arrangements in global health may be. It is about how to
think about and act toward achieving this ideal. It lays out power structures and traces their origin;
it explores the dynamics of the challenges posed by global health; it identifies the moral goods that
are at issue and how to approach their ethical consideration.
If the pursuit of global health is to avoid reinforcing and reproducing inequity and injustice –
through, for example, the negative effects of good intentions – ethics must be central to reframing
and reformulating our choices and actions. This book offers a masterful introduction to the ethical
pursuit of global health and is a bold beginning to this necessary and good enterprise.

References
Rasanathan, K. and Krech, R. (2011) ‘Action on social determinations of health is essential to
tackle noncommunicable diseases’, Bulletin of the World Health Organization, 89: 775-76. doi:
10.2471/BLT.11.094243
WHO (2008) Closing the Gap in a Generation: Health Equity through Action on the Social
Determinants of Health. Final Report of the Commission on the Social Determinants of Health.
Geneva: World Health Organization.

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PART I
Theory

13

The context of global health
ethics

1

Andrew D. Pinto, Anne-Emanuelle Birn and Ross E.G. Upshur

Objectives
To present a historical perspective on global health, using a political economy framework
To discuss past and current definitions of global international health and relate this
discussion to ethics
To develop a rationale for global health ethics

A) Introduction
We live in a radically unequal world in terms of both health and its underlying determinants. Even
the most cursory review of the available data makes this evident. On average, a person born in 2010
in Afghanistan, Chad or the Central African Republic can expect to live to approximately 48 years,
whereas the average life expectancy is 80 years in the Republic of Korea, 82 in Iceland, and 83 in
Japan (WHO 2011a). Globally, in 2009, approximately 8.1 million children died before their fifth
birthday, deaths occurring almost exclusively in low- and middle-income countries (LMIC) (WHO
2011b). The vast majority of these are preventable deaths due to diarrhea, pneumonia and malaria
(Jones et al. 2003). It is estimated that in 2008, 358,000 women died in childbirth, with 99 per cent
occurring in LMIC. This has remained consistent ‘year after year’ and again, these deaths were/are
almost entirely preventable through existing knowledge, health services and interventions to
improve living conditions (Campbell et al. 2006).
Stark as these figures are, national averages hide within-country differences that are even more
striking. Evidence cited in the Final Report of the Commission on the Social Determinants of
Health (WHO 2008) demonstrates that the health of individuals and communities is intricately tied
to social factors. These include income, class, education level, employment relations and
race/ethnicity (Public Health Agency of Canada 2004).To take just one determinant, in every
country, the poor fare worse than the wealthy. In Scotland, there is a gap of over ten years in
healthy life expectancy – years spent in good health – between residents of the most deprived and
least deprived neighbourhoods (Wood et al. 2006). Similarly, the maternal mortality rate is three to
four times higher among the poor compared with the rich in Indonesia (Graham et al. 2004), and in
Peru infant mortality is almost five times higher in the poorest quintile of the population compared
with the wealthiest (Gwatkin et al. 2007). Across the world, certain racial and ethnic groups fare
worse than others living in the same country. In an oft-cited example, African-American men in
Harlem, New York were found to be less likely to reach the age of 65 than the average man in
Bangladesh (McCord and Freeman 1990). Indigenous peoples, referring to communities that share
a historic link with pre-colonial societies, have lower life expectancies than their non-indigenous
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counterparts in every country where this has been studied (see Chapter 6). For example, Indigenous
Australian men have a life expectancy at birth of 59 years, compared with 77 years for all
Australian men (Australian Government 2009). In Canada, Aboriginal men live on average eight
years less than the male population as a whole (Anderson et al. 2006). Such disparities between rich
and poor nations, and between privileged elites and marginalized populations within each country,
are expected to worsen with the negative effects of climate change (Costello et al. 2009) – which is
likely to affect LMIC disproportionately – and by the fallout of the 2008 global financial crisis
(Catalano et al. 2011; Stuckler et al. 2011).
None of these realities is new or surprising to health professionals, academics and policy-makers
who are interested in global health. As never before, we have available an abundance of knowledge
about such deplorable health inequities, a term referring to the differences in levels of health
between groups in a society that are unjust, unfair and avoidable (Whitehead 1992; Starfield 2006).
Further, tackling such health inequities has risen on the political agenda. In October 2011,
representatives from 125 governments met at the World Conference on Social Determinants of
Health in Rio de Janeiro, Brazil. The text of the conference’s Political Declaration contains
statements such as ‘we need to do more to accelerate progress in addressing the unequal
distribution of health resources as well as conditions damaging to health at all levels’ (WHO 2011c:
2). Addressing social inequity is even entering the conversation at the 2012 World Economic
Forum, where typically the focus is on economic growth and competitiveness (WEF 2012).
Given the evidence that significant, remediable differences in health exist globally, and that there
is a stated goal to address them, what is being done? Clearly not enough: inequities in health have
persisted – and even increased – despite enormous resources being channelled into reducing them,
despite a rich body of evidence on effective measures, and despite strongly worded statements by
international bodies that these efforts should be a top priority (WHO 2008).
This book aims to help you explore why this is the case and what can and should be done.
Changing the systems that result in unnecessary death and suffering is a key goal of global health
practitioners. Here we hope to move the reader from an intuitive sense that something is wrong to a
deeper understanding of how power, access to resources, justice and fairness apply to health –
questions with which global health ethicists are wrestling in an ongoing manner. This chapter
begins by reflecting on what is meant by global health and how the field and its precursors have
evolved over time: before solutions can be proposed to address inequities, it is essential to
understand in what context they have arisen. Recognizing that there is a multitude of ways to
address a problem, we then argue that ethical perspectives can contribute towards formulating
responses – in terms of both avoiding doing harm and actually improving global health inequities.
Finally, we highlight what the remaining chapters will cover as an entrée to engaging in global
health ethics.

B) Historical roots of global health
‘Global health’ has entered into widespread use relatively recently and has been rapidly adopted,
particularly in North America, as a field of study and practice. Yet whether it is even a new or
separate field remains controversial (Farmer et al. 2009; Fried et al. 2010). Using the term ‘global
health’ became common in the early 1990s, when the end of the Cold War appeared to open up
new possibilities for health cooperation across countries to address problems of shared concern
(Kickbusch 2002; Birn 2011; Bozorgmehr 2010). Among powerful players it has largely replaced
‘international health’, which in turn displaced ‘tropical medicine’ or ‘colonial medicine’ as the
dominant term to capture the activities characterizing this field. Tracing the links between these
conceptualizations is important to understanding the values and theories that underpin the field
today.
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Going back more than a millennium, outbreaks of plague periodically turned health into a
regional or even a global problem, but until the rise of the modern state and a system of inter-state
relationships, there was no organized mechanism to focus worldwide attention on health. By the
nineteenth century, a confluence of developments – the most intense period of (European) conquest
and imperialism, the industrial revolution, the concomitant revolutions in transport and global
commerce, and the rise of modern medicine – forced sustained attention to health as more than a
local matter.
Starting with Spain and Portugal’s first invasions of Africa, South Asia and the Americas in the
fifteenth century, the nations that established colonies in the so-called tropics were concerned with
protecting soldiers, settlers and merchants from novel diseases that they were exposed to, both to
secure their investments and to maintain their hold on power (Berlinguer 1992). As imperial
enterprises became more permanent, colonial authorities also became concerned with maintaining
the productivity of, for example, miners and plantation workers. Colonial powers set up medical
offices and systems of regulation and intervention across their possessions to control epidemics,
stave off uprisings, protect settler populations, and apply the disease-control tools of the day to
‘civilise’ subject populations (Birn et al. 2009).
Tropical medicine emerged in the nineteenth century, together with the new fields of
bacteriology, parasitology and helminthology, closely related to the needs of colonialism (Arnold
1997). The development of this field was underpinned by the formulation in the colonial
imagination of the ‘tropics’ as an exotic other (Said 1979) with purportedly distinct ecological
characteristics. European and colonial tropical medicine institutes mounted field trials and
measures focusing on epidemics and other health problems that threatened trade, productivity and
the viability of colonies (De Cock et al. 1995). Religious missionary work and proselytizing was
also closely related to the expansion of colonies and provided moral justification, especially
through the building of hospitals and clinics and the provision of health services to indigenous
communities as a key part of winning over the local population. For example, the Belgian regime in
the Congo was extremely brutal, even as missionaries from a variety of countries helped it establish
one of the most extensive networks of health clinics in any colonial territory. These efforts drew on
European conceptualizations of indigenous peoples as weak, of different races being more or less
suited for labor in the tropics, and of the racial superiority of people of European stock (MacLeod
and Lewis 1998).
During the second half of the nineteenth century – at the height of the industrial revolution – the
modern international health system was conceived, motivated by a growing (if divisive) belief that
disease could spread rapidly through trade (e.g. the nineteenth century’s repeated cholera
pandemics) and the movement of people (in terms of large-scale immigration and the annual Hajj).
Facilitated by a diplomatic context favouring state-state cooperation in the wake of the 1815
Congress of Vienna, most European countries recognized that the ongoing threat posed by
epidemics to commerce and to their populations demanded some form of international agreement to
reform quarantine measures (Harrison 2006). The first International Sanitary Conference was held
in Paris in 1851, but inter-imperial rivalries resulted in little concrete action for several decades,
even as the opening of the Suez Canal in 1869 shortened trade routes between Europe and East and
South Asia (Bynum 1993). Finally, in 1907, the Paris-based Office International d’Hygiène
Publique, mandated with the interchange of health information and the development and oversight
of sanitary treaties, was founded. A fully fledged international health organization was founded
after World War I – the League of Nations Health Organization (LNHO), based in Geneva.
Drawing on social medicine approaches, the LNHO’s ambitious agenda included not only
infectious disease control, but also: vital and health statistics standardization and dissemination;
running expert commissions charged with standardizing medications and vaccines; and studies of
broad public health issues such as housing, medical education, health systems and services,
16

economic depression, nutrition, human trafficking, rural hygiene, chronic disease, and the social
causes of infant mortality (Borowy 2009).
By this time, an International Sanitary Bureau for the Americas had already been established in
Washington, DC (in 1902, eventually becoming the Pan-American Health Organization in 1958),
technically the world’s first multilateral health organization. With the United States as the
hemisphere’s dominant power, and bolstered by its invasion and occupation of Cuba (justified
largely as a means of controlling yellow fever), international sanitary agreement was easier to
reach, especially given yellow fever’s ongoing threat to commerce throughout the region. The
renewal of the construction of the Panama Canal in 1904, key to the USA’s global trade aspirations,
further stimulated intra-continental disease-control efforts. Under French control since the 1880s,
the project had stalled for decades after some 20,000 French and Jamaican workers died from
yellow fever and malaria. A massive US military-led effort was marshalled to eliminate the
breeding grounds of insect vectors, but it ignored the endemic problems of local populations such
as tuberculosis and infant diarrhea. Once the Canal opened in 1914, there were renewed fears about
– and redoubled efforts to control – the spread of communicable diseases through international
trade.
A key player in this period was the Rockefeller Foundation, which helped popularize the term
‘international health’ through its influential International Health Board and Division (Cueto 1994).
Launched in 1913, the Foundation pioneered cooperative public health efforts in almost 100
countries and colonies across the world through disease campaigns, support for public health
institutionalization training, the establishment of schools of public health, and funding for
thousands of fellows to pursue graduate study in North America (Birn 2006). This was the
beginning of US-led international health ‘philanthropy’, foreshadowing and influencing the
Milbank and Commonwealth Funds, the Kellogg and Ford Foundations, and the more recent Bill
and Melinda Gates Foundation, which have substantially shaped the global health agenda.
International humanitarian NGOs, such as the International Committee of the Red Cross (ICRC),
established in 1863, also became active in this period. The ICRC was an important purveyor of care
to refugees, wounded combatants and other war victims during World Wars I and II. It also played
a significant role in shaping ideas about ethical standards during wartime, especially through the
Geneva Conventions, although the ICRC has been critiqued for not having taken a stance against
war itself (Hutchison 1996).
‘International health’ thus began to replace tropical medicine in the early twentieth century,
related to the rise of internationalism and cooperation between nations. Like tropical medicine,
international health emerged from a worldview where metropolitan centres – the imperial powers in
Europe, North America and Japan – extended significant influence to their peripheral colonies and
former colonies, patterns that were resisted in a variety of ways. Initiatives framed in international
health terms often served the political and commercial interests of the dominant nations, but were
also caught up in rivalries between major powers. Despite the optimism with which the United
Nations (UN) was established in the wake of World War II – and the founding of the World Health
Organization (WHO) in 1948, its sister UN agencies, and a range of bilateral and non-governmental
organizations with a wide purview over international health (and development) activities – the
international health arena became embroiled in the competition between the Cold War’s
superpowers. For almost half a century (1946–91), the US-led Western bloc and the Soviet-led
Eastern bloc competed for allies and support among the ‘non-aligned’ countries of the Third World,
with health frequently utilized as a foreign policy pawn in this effort (Packard 1997).
Notwithstanding these pressures, in 1978 a broad coalition of public health actors across the world
committed themselves to the goal of ‘Health for All by the Year 2000’ at the largest international
health conference ever held, under the auspices of WHO and UNICEF in Alma-Ata in the former
Soviet Union (Brown et al. 2006).
17

The end of the Cold War in the early 1990s was a mixed time for international health efforts. On
one hand, a much hoped-for peace dividend gave greater prominence to influential humanitarian
NGOs, particularly Médecins Sans Frontières (MSF, founded 1971), an organization that literally
emphasized a borderless world (see Chapter 11). However, the growing dominance of
neoliberalism, the globalization of trade, and the influence of the World Bank and wealthy nations
shaped international health priorities in a different direction. WHO lost (control of) much of its
funding, and it was compelled to return to more traditional disease control efforts (Walt 1993),
although the founding of UNAIDS did portend more ethical and collective approaches to
addressing HIV/AIDS (see Chapters 4, 5 and 11). Further, after the attacks of September 11, 2001,
health once again became part of the USA’s and other Western nations’ security agenda. The spread
of disease in LMIC was now framed as a potential security threat to high-income countries (HIC)
(Gow 2002).

C) Global health today
Global health is the current paradigm of health cooperation between nations and multilateral
organizations, particular to contemporary political, economic and social arrangements, but also
unavoidably retaining historical antecedents in tropical and colonial medicine and international
health (Macfarlane et al. 2008). A single definition of global health remains elusive. For example,
the US Institute of Medicine defined it in 1997 as ‘health problems, issues, and concerns that
transcend national boundaries, may be influenced by circumstances or experiences in other
countries, and are best addressed by cooperative actions and solutions’ (Institute of Medicine 1997:
11). This evolved into a 2009 definition of ‘the goal of improving health for all people in all nations
by promoting wellness and eliminating avoidable disease, disabilities, and deaths…improv[ing]
health in low and middle-income countries’ (Institute of Medicine 2009: 1). As Birn et al. (2009)
have noted, there is a clear relationship between the popularization of ‘global health’ and the term
‘globalization’. For example, academic health science centres in HIC often view global health as a
way to operationalize ‘global agendas’ (MacLean and MacLean 2009; Crane 2011) (see Chapter 9).
Globalization – the increasing interconnectedness between people, but also the powerful influence
of global neoliberalism – has had a profound impact on the health of populations (Labonté et al.
2011). It has influenced which interventions have come to dominate global health, shaped by the
role of market forces to address health needs (WHO 2012) and the emphasis on delivering technical
solutions to improve population health (Larson et al. 2011).
An influential definition that has been taken up widely is:
global health is an area for study, research, and practice that places a priority on improving
health and achieving equity in health for all people worldwide. Global health emphasises
transnational health issues, determinants, and solutions; involves many disciplines within and
beyond the health sciences and promotes interdisciplinary collaboration; and is a synthesis of
population based prevention with individual-level clinical care.
(Koplan et al. 2009: 1995)

Other definitions, including ‘the health of marginalized populations, wherever they exist’ (Pinto
and Upshur 2009), have tied global health to human rights more specifically (see Chapter 4) and
speak more directly to upstream determinants of health. Many of these definitions are silent about
the underlying causes of inequity, and do not speak to issues of power and resistance that are so
essential to how change takes place (Birn 2011). The root causes of health inequities relate to the
complex issue of how power and resources are distributed globally, and how this (unfair)
18

distribution is maintained by a range of political and economic forces (WHO 2008). Definitions
that ignore these matters are particularly unhelpful when considering the ethics of global health.
As such, global health is a contested term used mostly by academics, health practitioners and
donors in HIC to describe activities that previously were labelled tropical medicine or international
health (Benatar and Upshur 2011). Still, because the stated goals of global health typically include
reducing health inequities and achieving health for all – reflecting roots in public health and the
influence of the human rights agenda – and because it is now pervasive in North America, we use
the term ‘global health’ in this book. Efforts that are labelled global health span a wide range of
activities, from technical solutions at the molecular level to population-level interventions, and cut
across a variety of academic disciplines and health professions. Just as was the case with tropical
medicine and international health, such interventions and activities are heavily influenced by the
social, political and economic philosophies of those who fund and direct them. This also means that
they have the potential to incorporate ethical perspectives.
Global health today is a complex field of practice, involving thousands of individuals who come
from an enormous number of disciplines conducting work with communities in both HIC and
LMIC. Such activities occur through a myriad of actors with multiple and often conflicting
motivations, including academic centres (typically in HIC, increasingly in partnership with
institutions in LMIC; see Chapter 9), NGOs, government agencies and community service
agencies. This work is supported by a large pool of funds (McCoy et al. 2009), reflecting the
strategic interests of high-income governments (Ollila 2005), as well as trans-national corporations,
philanthropic institutions and international financial institutions such as the International Monetary
Fund and World Bank. Understanding the connections among academics, development workers,
humanitarian NGOs, funders and governments can prove difficult, particularly when attempting to
decipher who is responsible for what (see Chapter 5). Global health involves an overlapping and
shifting mix of research, development work, humanitarian assistance, clinical work, business,
public health, advocacy and political engagement (see Chapter 11). As an area of scholarship,
global health is attracting more and more students who engage in research and practicum
placements – called electives or international service learning – and who increasingly seek formal
education to become global health practitioners (see Chapters 3 and 12).

D) Political economy of health
Global health academics, professionals and educators concern themselves with a multitude of
interconnected problems. We propose a political economy of health model (Navarro 1981) to
begin to categorize these in a way that makes sense. As Birn et al. (2009: 134) note, this approach
‘considers the political, social, cultural, and economic contexts in which disease and illness arise
and examines the ways in which societal structures interact with the particular conditions or factors
that lead to good or ill health’.
At the individual level, let us imagine a common clinical scenario: an infant in a LMIC is seen
in a clinic run by a humanitarian NGO. She is diagnosed with pneumonia and requires an antibiotic.
This medication is readily available in resource-rich settings but not where this child is living. This
is seen as a problem – perhaps because it is considered unjust or unfair that this child should die for
lack of a cheap, simple treatment – and the solution proposed is to deliver this antibiotic to the child
when she needs it. Such a seemingly singular problem of access to care rapidly becomes several
things to consider that continue to fall within the scope of global health. Were the way in which the
child was examined, the diagnosis suggested, and the treatment recommended culturally
appropriate? Do they ‘translate’ for the caregivers? What about the ongoing care of this child, such
as dealing with an allergic reaction to the antibiotic? How will follow-up be ensured in case the
medication does not work? What about a vaccine that could have prevented this bout of
19

pneumonia? Is the infant predisposed to such infections because she is HIV+, and could this have
been tested for, treated – or even better – averted through prevention of mother-to-child
transmission programmes?
Thinking about the family level, did the caregivers/family have to pay a user fee to access the
clinic? Did they have to travel a long way, take time off work and pay for transport? How does this
infant’s risk of pneumonia relate to whether or not she was breastfed? Or to the living conditions,
income and education level of her mother? Does the income level of the father/household relate to
the nutritional status of the child? What about the family’s access to clean water and sanitation? Do
they have other children who are ill, what is the size of the family, and is their home crowded?
Does the gender of this infant influence the way her family influences her access to care and
resources? Do all children in this family have the same access to education? Are there cultural or
religious issues involved in these matters?
At the community level, is pneumonia common? What other diseases are prevalent, and why?
What are the conditions of the neighbourhood and region in which this family lives? Is there access
to schools and sources of employment? Why was there no access to government-supported health
services locally? Is there a pharmacy nearby where the antibiotic could be obtained? What are the
broader societal determinants of health (Birn 2009), including work conditions, transport services,
conditions of sanitation, housing and overcrowding? What resources are available to pay local
health providers to staff the clinic? Is this community seen as important in the eyes of the national
government, or is it relatively neglected compared with other regions? Are there many global
health organizations in the community, what do they do, and what has been the past experience
with these or similar organizations? Will the presence of this NGO clinic create conflict with local
traditional healers?
At the national level, what is included in the social policy agenda, and what measures exist to
protect low-income populations? How are the most marginalized reached? Who owns and controls
national resources? How does the government decide where to place health clinics and hospitals?
How does it decide on salaries for health workers, and how is this constrained by the national
budget? And by lenders such as the International Monetary Fund, World Bank, regional
development banks and commercial banks? What is the government policy around essential
medicines? And how did the national government come to power? How is political power
distributed (Navarro 1981)? Is there a system of accountability to voters? Is corruption prevalent?
What are the class/race/gender structures of ownership and the labor force? Is health – and its
determinants – seen as a human right, and, importantly, is there enforceable legislation to protect
this right? Are there civil society organizations active in this area?
At the international level, is this country an ally of wealthy and powerful countries, including
emerging middle-income countries? Can it influence trade policies? What does it produce and what
does it buy and sell on the international market? How is it affected by the practices of certain HIC,
such as the recruitment of health professionals? What is the impact of international treaties on the
patenting of drugs, food subsidies, social rights, the movement of refugees and addressing climate
change? What is the role of advocacy groups in creating change around some of these ‘upstream’
determinants? What is the role of influential current global health actors, including the Global Fund
for AIDS, Tuberculosis and Malaria, the Gates Foundation and political bodies such as the United
Nations?

E) Global health ethics and its values
As is no doubt evident, the complexity of what seems at first to be a simple problem can be
overwhelming. There is a need to examine deeply each level and understand how the levels are
linked and intertwined. Ethical analysis can assist us in this process. By ethics, we mean
20

understanding how to evaluate different courses of action – and their social consequences – in a
given situation (see Chapter 2). Ethics can serve as a lens to understand relationships and power
dynamics between different groups, and it can help us discern who benefits and who bears the
burdens. Ethics commences with self-reflection, and hence brings to the surface our own
motivations for actions, requiring us to look inward (as individuals and collectively as societies) to
identify the impetus and consequences of these actions. Global health ethics is about both avoiding
the enormous risks of doing harm, and encouraging individuals to do what is best given particular
sets of circumstances and constraints. Ethics also requires dialogue and deliberation with others
who may or may not share the same guiding motivations. Often, the fundamental principles and
missions of individuals and organizations may not be transparent, requiring a disciplined and
critical approach to make them more evident.
Most professions require some training in ethics and also have standards and regulations around
professional behaviour. Global health ethics does not replace this, but builds on it. An additional
focus on the ethics of global health is necessary because the situations and problems encountered
may be different from the context in which a trainee or practitioner studies and works (Schwartz et
al. 2010). Resources in many communities – in both LMIC and HIC – are limited in various ways.
It is important to understand how material contexts change a situation and place a higher priority
on, for example, the need to limit waste or to reach the most vulnerable people. There is often a
great difference in power and privilege between the provider and recipient of services, particularly
within a clinical context. In LMIC, the roles of different actors may be less well defined and there
may be less oversight or regulation than in HIC. There may also be cultural differences and
diversity in social norms and political beliefs. It is precisely because global health – as noted above
– has emerged from a history of colonialism and imperialism that we must be mindful of how this
legacy influences relationships between communities and organizations (see Chapter 9). Global
health should thus be ‘inherently an ethical enterprise’ (DeCamp 2011: 92).
Global health ethics draws on classical clinical bioethics, public health ethics and humanitarian
ethics (see Chapters 3, 7 and 8) (Pinto and Upshur 2009). It builds on existing codes of professional
practice in the health arena, including those issued by the International Council of Nurses (2006),
the World Medical Association (2006), the International Federation of Red Cross and Red Crescent
Societies (1994) and the Humanitarian Charter (Sphere Project) (2004). Less work has been done
within health professional education programs (Crump et al. 2010; DeCamp 2011), and this book
aims to address the needs of those in training or who are early in their career.

F) Conclusion
To summarize, global health is an emerging discipline that traces its origins, norms and
organizational structure to tropical and colonial medicine and international health, making it highly
problematic in that it continues to reproduce the asymmetries of power extant in its predecessors.
Notwithstanding its enormous growth, global health remains a contested arena. Ethical analysis
creates a space for reflection and deliberation about issues such as social justice, fairness, our
professional duties and the duties of others. It is about asking why, interrogating power relations
and bringing a critical perspective to all such work. Such analysis must be grounded in the lives of
individuals and communities, lest it become an abstract intellectual exercise that does not truly
inform global health action (Benatar and Upshur 2011). We believe that global health ethics can
assist you in becoming a better practitioner, academic and educator, and that it is crucial to
achieving the goal of collectively improving health for all.

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24

Ethics and global health

2

Ross E.G. Upshur, Solomon Benatar and Andrew D. Pinto

Objectives
To introduce the range of ethical concepts and approaches to ethical analysis required in
global health work
To outline frameworks of principles that have been applied within clinical medicine,
public health and global health
To develop the concepts of solidarity and social justice as principles to guide global
health work

A) Introduction
In Chapter 1, the history and origins of global health were outlined. Consideration of ethical issues
at the level of global health requires first a clear understanding of the early twenty-first-century
context in which global health challenges need to be addressed. Three fundamental issues call for
particular attention: resource disparities and power relationships; the role of globalized/liberalized
trade; and global media and information. These frame our discussion on ethical principles and
ethical reasoning.

Resource disparities and power relationships
The world is characterized by grotesquely wide disparities in health and in access to the social,
economic, political and health care channels that could be used to reverse widening trends. Access
to power and how power is used lies at the heart of the problem of global health disparities. Power
is usually thought of as the hard power of the military or other forms of coercive force, and this is
not totally unrealistic. However, given the relationship between wealth – here modestly defined as
access to basic needs for human development and a flourishing life – and health, the fact that a
small proportion of people determine how the global economy operates and who will benefit, and at
whose expense, makes it clear that economic power outstrips military power in determining the
global distribution and burden of health and disease. Although these two forms of power are not
unlinked, the long-known adverse role of the currently structured global political economy has been
either denied or obfuscated by those in economic power who are covertly deeply implicated in
causing human poverty and misery on a massive scale (Benatar 2005). Additional evidence for this
is provided by the extent of human harm that has flowed from the recently unfolding global
economic crisis (Benatar et al. 2011b).
Consider for a moment the impact on Americans. Since the economic crisis began in 2008, $5
trillion has been lost by Americans in pensions and savings. Approximately $15 trillion was lost in
the value of homes by 2010, with 10,000 homes entering foreclosure each day (13 million expected
by 2014). In 2009, 1.4 million Americans filed for bankruptcy, an increase of 32 per cent from
2008. Moreover, medical bankruptcies accounted for 60 per cent, and 75 per cent of the latter were
25

filed by people with health insurance. Personal debt amounting to 65 per cent of income in 1980
increased to 125 per cent of income by February 2009 (DeGraw 2010).
Over the past century, annual income distribution to the top 1 per cent of people in the USA fell
from 25 per cent in 1925 to 10 per cent in 1970 (a period of economic and industrial growth and
expansion of the middle class), then rose back to 25 per cent by 2008 under the impact of the
neoliberal policies that geared economic growth to the benefit of the wealthy (Sachs 2011).
Disparities in wealth are thus almost as wide within the USA as they are across the globe, and these
are accompanied by wide disparities in health. Even in the USA, there is food insecurity among
children who suffer from preventable hunger, and the fact that 9 million American children lack
health insurance points to the potential for preventing premature suffering and death. These
examples, which highlight the impact of fiscal trends on the value accorded to the health and lives
of children in the wealthiest and most privatized health market (the United States), typify the global
redistribution of resources during the past half century, with disastrous effect on those who live
below subsistence levels elsewhere in the world (Benatar et al. 2011b).
For example, a combination of low economic growth, rising unemployment and rising food
prices in 2009 pushed up the number of chronically hungry people globally from 850 million to
over a billion. Between 2003 and 2006, maize increased in price by more than 50 per cent of its
average price, and by 2008 rice prices were 100 per cent higher than they were in 2003. Such
increases, together with the immediate effects of higher energy prices, have pushed more than 100
million people back into poverty and ill health.

The role of globalized/liberalized trade
Since the later 1970s, the global political economy and trade rules have been transformed by the
ideas and practices associated with the ideology of neoliberalism (Gill and Bakker 2011).
Disciplinary neoliberalism, the dominant discourse of political economy since 1970, serves
libertarian ideas, institutions, political forces and policies to deepen the power of capital and to
shape patterns of global economic and social development. The New Constitutionalism, which is
the political-juridical counterpart to disciplinary neoliberalism, creates treaties and codifies new
rights and freedoms for firms and investors. These are manifest in laws, rules and regulations, of
which intellectual property rights is one example (Gill and Bakker 2011)
Globalization and global trade, driven by these polices, have been promoted under the
assumption that ‘globalization is good for the poor’. However, the basis for this claim, and the
implications of trade policies for social equity, have been heavily criticized, most specifically in
relation to regulations affecting food and a range of health matters, including trade in
pharmaceuticals, the availability of vaccines in epidemics and the international recruitment of
health professionals.
Another result of such policies has been the exploitation of labor, nature and social processes,
with particularly adverse effects on health, welfare, education, and other social support structures
such as pensions. Health care, like food and oil, is increasingly becoming a commodity distributed
through the power of an emerging new hybrid of public and private health care institutions that are
extensively governed by world market forces. The privatization of goods and of services that serve
the common good has impaired the ability to reproduce the caring social institutions (health care,
education and other public social services) on which good societies depend in order for their
citizens to have the best opportunity to reach their human potential and to flourish. Pandering to the
endless entitlements of those at the top of the economic pyramid has been undertaken at the cost of
the health and wellbeing of the majority. As a consequence, almost 50 per cent of the world’s
population lives on less than $3 per day and on about 3 per cent of annual global product.
26

Global media and information
The media, in an era of rapid communication, disseminate vast amounts of information, with
increasing and often underappreciated influence on how we conceptualize the world around us,
what we believe and how we behave. The extent to which the media control how the public thinks
and acts (as exemplified by marketing strategies and the fear agenda actively promoted since 9/11,
allowing the acceptance of stringent new security processes that undermine hard-won liberties) has
deflected attention from garnering widespread support for the available constructive means of
improving the health and wellbeing of billions of people worldwide in the twenty-first century.
All these influences on global health call for ethical arguments to effect change.

B) Ethical concepts and ethical reasoning
You may be outraged about the existence of health inequities and the fact that it seems all lives are
not considered of equal value. In doing something about this, you probably want to do the right
thing. What is considered to be the right thing, in many given contexts, is neither self-evident nor
necessarily universally shared. In fact, it is more than likely that there may be conflict regarding
how different individuals, communities and organizations conceptualize the ‘right’ thing.
Ethics, in the broadest sense, embraces the range of methods used to critically analyze, interpret
and evaluate the variety of ways in which humans interact with each other. In the most general
terms, ethics seeks to provide an account of how humans, as agents, assign and evaluate the worth
of persons, organizations, their actions and their consequences. From a more philosophical
perspective, ethics engages in appraising the range of arguments offered to determine the rightness
or wrongness of actions and policies, and reflects upon the praiseworthiness or blameworthiness of
actors and organizations, and the justification for such judgments. Many of the concepts informing
such thinking emerge from culture with origins in a variety of traditions, both religious and secular.
Although there is a great deal of diversity in how people think about moral issues, there are no
societies without a concept of what is right and wrong. Ethics is distinct from the law in that it
addresses issues related to interpersonal duties and obligations that are not regulated or compelled
by external authority.
Historically, ethical reflection and ethical reasoning have embraced a wide range of accounts of
how these activities take place. Within the Western tradition, numerous attempts have been made to
systematize approaches to ethics in the form of major ethical theories. Some of these are based
entirely on secular considerations, others have their origin in theology or faith-based communities.
In this section we introduce some major themes in ethical analysis. We do so by very briefly
outlining the nature of ethical theory, and distinguishing ethical frameworks from ethical theories.
Some general considerations on defining and understanding ethical reasoning are also developed.
This is followed by a general discussion on the major schools of thought that have animated ethical
thinking, and a description of some of the major ethical frameworks used in health care. We then
discuss some of the features that make global health ethics distinct from clinical and public health
ethics.
In an introductory text, it is impossible to discuss such a rich, complex and varied literature in
detail. While this book does not intend to replace the education in bioethics that is a required
training component of health professionals and of other students considering work in global health,
it is recommended for use within such courses. It is our contention that ethical reasoning skills,
including an ability to identify and analyze the value issues that may be latent and undisclosed in
the many contexts relevant to global health, are essential and fundamental skills for global health
practitioners. There is no substitute for engaging in reflection and dialogue, a skill that improves
with practice.
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C) Ethical theory and applied ethics
It is important to recognize the distinction between ethical theories and applied ethics. Ethical
theories aspire to provide a comprehensive, consistent and defensible normative account of moral
activity. Historically, the field of ethical theory has been the domain of philosophy.
An ethical theory must achieve several goals: it must set out to explain and justify, in a unifying
manner, a wide range of considerations including the nature of morality, and the principles or
concepts and criteria by which human actions are evaluated. This often includes a systematic and
nuanced account of the positive reasons why a particular theory is more capable than rival theories
of providing accounts of moral issues. Hence the argumentation found in works of moral theory is
often dense, technical and exhaustive with respect to dealing with potential counterarguments to the
position articulated. It is important to distinguish descriptive from normative accounts of ethics (see
Box 2.1 ).

Box 2.1: Descriptive and normative ethics
Descriptive ethics relates to accounts of how humans actually behave in the world. It has a
strong empirical dimension as it derives from descriptions of how moral values play out in
determining what is right or wrong in various communities. It is thus dependent on reliable
empirical observations of how humans assess the rightness and wrongness of their actions. In
the field of global health, observations come from academic disciplines such as epidemiology,
sociology, anthropology, law, political science and psychology.
Normative ethics focuses on a different dimension of human activity. Rather than describing
what is actually done, normative ethics considers the question of what we should (or ought to)
do in order to bring about ‘ethical states’ of affairs rationally.

Predominant ethical theories in the Western tradition
Universalist approaches
Schools of thought can be considered universalist when the theory argues that a universal and
objective criterion or test can be applied to human actions to adjudicate its rightness or wrongness.
The Western tradition has been influenced and shaped by three dominant universalist approaches:
deontological, consequentialist and virtue based.

i) Deontological
Deontological approaches are typified by arguments that focus on the moral worth of actions, that
is, that certain acts are intrinsically right or wrong; and on rational analysis of such acts. It is
important to note that, according to this approach, ethical acts are appraised largely independently
of consciously calculated potential consequences that follow from them. This is not to deny that
outcomes in general shape what we consider to be right and wrong actions.
The foremost account of a deontological approach is found in the work of the philosopher
Immanuel Kant. Kant’s moral theory is based on the requirement that moral values be stated as
universal laws. The abstract and general formulation of the law-like structure of moral statements is
the categorical imperative. The categorical imperative states that one should act only ‘on that
maxim which you can at the same time will to be a universal law’. These laws are to command
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assent by all rational agents capable of acting freely upon them. The requirements are universal in
the sense that they do not depend on anything in the empirical world for their justification. That is,
the entire structure of laws is established a priori.
Kantianism is influential in that it establishes important conditions for the treatment of moral
agents. They must be treated as ends in themselves and not as means to an end. This notion is
influential in doctrines such as human rights, and informs standards for human subject protection in
global health research. It is the ethical theory most closely aligned with accounts of human dignity
and inherent worth.

ii) Consequentialist
Consequentialist theories view the rightness or wrongness of actions in terms of the consequences
that result from the action. The classical formulation of consequentialism is utilitarianism, where
the best action is that which creates the greatest good for the greatest number. Classic utilitarianism
is ‘hedonistic’ in nature, in that it argues that happiness and pleasure are the consequences to be
maximized. There are many variations on consequentialist theories, and they are prominent in
modern health ethics. Consequentialist theories are associated with economic analyses such as costbenefit and cost-effectiveness analysis, and with such tools as disability-adjusted life years
(DALYs), quality-adjusted life years (QALYs) and other outcome measures that are relied on in
making public health policies, as distinct from decisions about individual patients.
iii) Virtue based
Rather than focusing on acts or their consequences, virtue-based approaches examine the qualities,
characteristics and habitual actions of human agents. Thus they focus on the appraisal of character
in the context of action. Virtue theories focus on such manifest qualities as courage, humility,
caring and wisdom. In more broad community applications, virtue theory discusses the qualities
and characteristics of communities that give rise to virtuous citizens.

Relativist and non-cognitivist approaches
These are accounts of ethics arguing that morality is not based on objective, universal and rational
considerations, and that it cannot be so based. There are two principal schools of thought in this
regard: relativism and non-cognitivism.

i) Relativism
Relativism holds that standards of determining the rightness and wrongness of actions are related to
and hold only for those who participate in a particular culture and community. They admit to no
overarching universal claim that all humans should follow.
ii) Non-cognitivist
Non-cognitivist accounts hold that ethical statements have no truth-value whatsoever, and are
merely the expression of emotions and personal preferences.

Religion-based approaches
Religious ethics cannot be ignored in considerations of individual or population health, as many
communities in the world base their institutions and practices in accord with religious principles. In
each of the three predominantly monotheistic religions, Islam, Judaism and Christianity, ethical
appraisal consists of the application of sacred texts and generations of commentary and reflection
29

on the ethical problem at issue. Casuistry is the term used to describe this ‘looking back’ to
precedents for guidance. Each of these major religions has several variations of practice and
interpretation of sacred texts (indicating significant within-religion disagreement). In religious
ethics, fidelity to the dictates of faith, as indicated by the sacred texts, is of critical importance.
There are many points of agreement, but also significant areas of disagreement between these
religions. There are numerous other faiths, such as Hinduism and Buddhism, that influence thinking
and popular ideas relevant to health care. It is imperative for practitioners to be aware of and
respectful of religious practices and how certain health activities may be interpreted in light of
revealed religion. While respecting individuals’ religious beliefs when they are choosing for
themselves, there is a need to be cautious that in the public realm some religious perspectives are
not privileged over others.

Applied ethics: the concept of ethical frameworks
There is considerable variation and complexity in how we can make sense of distinguishing which
human actions are ethical or moral. In order to facilitate the application of complex theory to
practice, the field of applied ethics has developed approaches intended to guide practitioners.
There are a variety of ways of doing this. One way is through the creation and application of
frameworks. In applied ethics, it is recognized that certain theories have attractive features in
certain circumstances, but seem strained in application to all cases that may be encountered. They
should be viewed as resources that aid in the understanding of ethical problems and in decisionmaking. In essence, such theories provide a set of diverse perspectives on how best to understand
an ethical issue.
Frameworks have been proposed as a way of making this complex landscape tractable, to aid in
the analysis of ethical issues and to guide reflection and decision-making. When there is reluctance
to engage with the finer points of moral theory, frameworks can be used as pragmatic tools to aid
decision-making. Frameworks can be very useful because they attempt to capture what is relevant
to decision-making in a particular area of practice. They help to simplify and make explicit factors
relevant to a decision. However, they can also be problematic if they are applied blindly (Dawson
2010). It is important that the framework is relevant to the particular area under discussion, as a
framework can yield a poor answer if it does not capture all the factors relevant for a particular
decision.
As global health is an immensely complex field, there is a need for a multiplicity of perspectives
to be understood and balanced. Understanding ethical issues in global health requires interprofessional, trans-disciplinary and transcultural understanding. Classical bioethics has explored
many ethical issues at the individual level. In most health care professional training, ethics is taught
in terms of the need to consider four key principles: autonomy, beneficence, non-maleficence and
justice. This classic formulation from the work of Thomas Beauchamp and James Childress (2005)
has been quite useful and influential in ethics pedagogy, and still serves a very useful purpose. It
attempts to reconcile the two main strands of thought in the Western tradition: deontology and
consequentialism.
A recently evolving discourse on public health ethics provides some additional principles and
frameworks for thinking and arguing about public health dilemmas, where there is a need to weigh
and balance the rights of individuals against the common good. This expanded discourse, like the
feminist approach, provides additional values for consideration and appropriate frameworks with
which to do so. Public health ethics, in many ways, provides a grounding for global health ethics in
that it addresses issues related to common goods, and employs concepts that focus on collective
responsibilities and mutuality (Dawson and Verweij 2007; Nixon et al. 2008).
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No one theory or framework will describe and analyze the same issue in the same way. Hence
familiarity, experience and practice are required. Frameworks aim to assist in understanding the
various dimensions involved in decision-making and acting, but they will not supply all the
answers, and individual judgment is still required.

Ethical reasoning and argumentation: a suggested approach
Ethical theories and ethical frameworks will direct practitioners to the substantive issues informing
an analysis of an ethical dilemma. Reasoning should be approached systematically and in a fair and
dispassionate manner.
One first consideration is fair explication of the various positions at issue. This requires close
reading and accurate knowledge of the relevant facts. It is important to understand the distinction
between factual claims and normative claims (see Box 2.2 ). Then one must be able to assess the
types of claims that are being made and the type of argument that is being stated. This requires
sorting out the various factual and moral claims that are at issue. Box 2.3 provides a systematic
approach to analyzing an ethical issue.

Box 2.2: Facts and values
Most philosophical accounts of ethics tend to make a sharp distinction between facts (usually
construed as statements from science or empirical observations) and values (desirable but
perhaps not realized states of affairs in the life world). What is factual tends, for the most part,
to reflect or contain descriptions of states of affairs. Values, on the other hand, reflect normative
evaluations about what ought to be the case. One issue arising from this is the gap between what
is the case (descriptive facts) and what ought to be the case (how things should change towards,
or be, for a more ethical state of affairs). Many have argued that it is impossible to derive an
‘ought’ from an ‘is’, that is, a description of a state of affairs in no way entails a prescription
about how to change that state of affairs in the world. While the distinction between facts and
values (‘isness’ and ‘oughtness’) plays a significant role in the evolution and history of moral
philosophy, these tend to interpenetrate considerably, particularly in the sphere of applied health
ethics.

Box 2.3: A systematic approach to ethical reasoning*
1
2

3
4
5
6

What are the morally relevant facts in the case?
How/on what basis are they morally relevant? That is, what moral principles, theories or
concepts underlie your determination of what is morally relevant? What are your underlying
implicit and explicit values?
How would you prioritize the ethical issues inherent in the case – which are the most
morally relevant? As above, what underlies your decision (principles, values, etc.)?
How would you deal with possible conflicting ethical considerations?
What bearing does moral psychology have? For example, can you discern the intent that lies
behind your moral reasoning?
Once you have worked through the above, have your views changed in terms of what is
morally relevant about the case?
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7
8

9

How would you discuss/dialogue with the community involved about your views on the
case?
How does your role/organizational-specific authority (e.g. legal, medical, professional)
impact on the way in which you adjudicate the case? What bearing might this have on how
you approach the above, particularly number 7?
Are there any particular global issues that arise in the analysis? If so, what are the morally
salient aspects of this global dimension? Are these issues arising at the personal, health
system, population and/or global levels?
*Adapted from Richardson (2007)

Argumentation consists of the ordering of reasons that lead to a well-justified conclusion. Premises
are statements that, taken together, demonstrate logical connection, consistency and coherence.
Much argumentation to which we are exposed in everyday life is at a very low level of
sophistication, and in fact is not argumentation, but simple assertion. It often consists of simple
declarations that ‘X is wrong’ or ‘X is unethical’ without supporting reasoning grounded on some
more basic principle. We must avoid simple assertion without supporting reasons. Many ethical
arguments concern the weighing and balancing of seemingly conflicting principles or goods that we
seek to attain. One common strategy is simply to argue for that which one believes. This often
results in not taking counterarguments seriously or acknowledging uncertainty or limitations in
one’s own perspective. Ideally, we should strive to take seriously all candidate arguments, positive
and negative, and seek out and rebut any potential objections to the perspective we are taking.
When we approach moral reasoning in this manner, we are taking a fair and measured approach
and enhancing reciprocal awareness and respect for others.

Concepts of justice
Justice is a fundamental concept in ethics, and accounts of justice date back to antiquity. In the
most fundamental sense, justice is concerned with issues related to equality and fairness. As
Aristotle noted, justice requires that we treat equal persons equally and unequal persons unequally.
Theories of justice have their basis in deontological, consequentialist, virtue theory and feminist
traditions. The concept of social justice is discussed in detail later in this chapter.
The most relevant considerations of justice in global health relate to various theories of
distributive justice. Distributive justice consists in the study of the normative principles guiding
how the benefits and burdens of economic activity are best allocated. Health is included in the
scope of these allocative decisions.
There is a range of competing theories of how best to allocate resources. These theories are
rooted in fundamental conceptions of how humans and societies are ideally to be constituted
(Lamont and Favor 2007). The most commonly held perspectives will be very briefly sketched out.
Most of these theories look at justice from within an established legitimate nation state. There is an
immense volume of literature on this topic, and readers are advised to consult the suggested reading
list at the end of this chapter for further exploration of the topic. Commonly held views include the
following.
Egalitarianism: that every person is owed the same level of benefits, and this is based on
concepts of equality of persons.
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Welfare: that the welfare of people is the paramount norm. All other principles of
distribution are secondary to the maximization of welfare.
Desert-based theories: that benefits and burdens should be distributed on the basis of the
actions of persons and societies that create the benefits.
Libertarianism: that benefits and burdens should be distributed according to the function
of free markets.
The work of John Rawls has been particularly influential in modern theories of justice (Rawls
1999). For Rawls, justice is fundamentally related to liberty, such as the right to basic freedoms and
equality of opportunity. Differences in terms of these fundamental liberties, such as inequalities of
opportunity, should exist only insofar as they are of benefit to those with least advantage.
Much writing in global justice seeks to overcome some of the limitations of the application of
theories of justice to within nation states alone. However, this is contentious and depends on
whether there are good arguments for obligations to others beyond state borders based on
considerations of justice. Thomas Pogge is one of the most influential theorists in this area. He
argues that severe poverty is the most pressing issue of global justice, and that as well as a positive
responsibility to alleviate poverty, there is a ‘negative responsibility to stop imposing the existing
global order and to prevent and mitigate the harms it continually causes for the world’s poorest
populations’ (Pogge 2001: 22).

D) Key dimensions of global health ethics

What is global health ethics?
Hunter and Dawson (2011) provide an account of the ways in which global health ethics can be
regarded as a distinct field of inquiry. In essence, global health ethics requires an account for why
we should care about the fate and existence of others, often quite remote from us. This is
particularly challenging in times of economic hardship, when it may seem self-evident to be
concerned with one’s own locality.
Global health ethics can be understood in a geographic sense in that it addresses issues that have
broad spatial concern, such as climate change. This view of global health ethics is, however, likely
to be too limited when applied to the types of ethical issues that require analysis. A content view of
global health ethics is one that addresses specific ethical issues such as research ethics and global
health equity. This account is limited by a lack of systematic coherence.
Hunter and Dawson (2011) argue that global health ethics should be regarded as a substantive
normative endeavour in its own right. They outline three arguments in favour of this substantive
account: the beneficence argument; considerations of justice and harm; and cosmopolitanism.
The argument for beneficence regards global health inequalities as ‘morally objectionable in and
of themselves, because they hold that differences in outcomes need to be morally justified and that
there does not seem to be a justification in this case’ (Hunter and Dawson 2011: 79). This is best
expressed in Peter Singer’s claim that ‘If it is in our power to do or prevent something bad from
happening, without thereby sacrificing anything of comparable moral importance, we ought,
morally, to do it’ (Singer 1972 quoted in Hunter and Dawson 2011: 80). Arguments from
beneficence provide a ‘prima facie reason to accept substantive global health ethics’ (Hunter and
Dawson 2011: 80).
The argument from justice and harm is based on Thomas Pogge’s work, which argues that global
obligations are rooted in negative duties not to harm others and to make reparations when others
33

have been harmed. As shown in Chapter 1, the history of exploitation and domination by many
nations has led to the current state of global economic and health inequalities, many of which are
perpetuated by current global governance structures.
Cosmopolitanism indicates that we are citizens of a globalized world, and further argues that
moral considerations are not based solely on the prerogatives of membership in a particular nation
state, culture or ethnic group. Cosmopolitanism requires us to have a global frame of mind when
addressing issues in global health.

Frameworks in global health
As noted, frameworks are limited in what they can offer – providing only a way to view an issue or
a problem. However, they may assist students and practitioners to understand the morality of global
health, the ‘norms about right and wrong human conduct’ in this value-laden field. Values evolve
over time and in relation to their contexts and thus we should ask, what values should guide our
work at this moment in global health?
Benatar et al. (2011a) have outlined a framework that argues for global health ethics as a
rationale for mutual caring. They identify seven values required as a basis for global health ethics:
respect for all human life
human rights, responsibilities (duties) and needs – broadly considered
equity
freedom (freedom from ‘want’ as well as freedom ‘to do’)
democracy (in a participatory sense)
environmental ethics
solidarity.
They argue that none of these principles can stand alone to provide an overarching account of the
values of global health ethics, and that solidarity is the most important value of all.
They also propose a framework for transformational approaches:
developing a global state of mind
promoting long-term self-interest
striking a balance between optimism and pessimism
developing capacity (to be independent)
achieving widespread access to public goods.
Putting these transformational approaches into practice requires systematic reflection and
engagement with communities locally and globally. Chapter 4 on human rights and Chapter 11 on
advocacy explore how these transformational approaches can take place.
In the remainder of this chapter, we build upon this framework and one that we have proposed
previously: humility, introspection, social justice and solidarity (Pinto and Upshur 2009), adding
depth and broadening its applicability. Humility and introspection are addressed in Chapter 3. We
will place particular focus on social justice and solidarity.

E) Social justice and global health
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Social justice has been cited frequently as a core value that underpins global health. It is named in
the strategic plans of academic centres of global health, in the vision statements of nongovernmental organizations, and in the policy papers of key bodies such as the World Health
Organization (WHO). This can be traced to a long history of identifying social justice as central to
public health (Beauchamp 1976), and even as the foundational moral justification for interventions
at the population level (Powers and Faden 2006).
Yet diverse definitions exist about what social justice is and how we can achieve it (Braveman
2006). A recent WHO discussion paper focuses on looking at how societies are organized, and on
social justice as promoting the ‘ common good’ to which all in the society are expected to contribute
(WHO 2011). Further, promoting social justice is to uphold basic human rights and equitable
access to resources. Similarly, Krieger has defined social justice – particularly within a research
context – as about understanding who benefits and who is harmed by certain policies or decisions
(Krieger 2001). Many others reinforce the concept that social justice is about ensuring a minimum
standard of living, redistributing societal resources and achieving an egalitarian society. Public
health’s ‘dream’ of a society without the current unequal distribution of health and its determinants
– health inequities – is therefore closely tied to the aims of social justice (Beauchamp 1976).
To understand how this applies to global health, we focus on three interrelated areas: the drive to
reduce health inequities; distributional justice; and the health of marginalized populations
(Bayoumi and Guta 2012).
Reducing health inequities – unjust and unfair differences in health outcomes between groups
that are linked to the rules that govern society (Dahlgren and Whitehead 2007) – is central to the
mandate of global health (see Chapter 1). Identifying such differences between communities
requires forethought when designing epidemiological surveys and posing research questions; when
considering how to analyze the data collected; and when disseminating the results (see Chapter 8).
However, describing inequities is not sufficient to achieve social justice. Work to reduce inequities
requires innovative solutions that address root causes in the social determinants of health
(Muntaner et al. 2009).
Social justice as applied to global health is also concerned with distributional justice, meaning
identifying and rectifying differences in who benefits from global resources. Are those who have
equal need receiving equal treatment (horizontal equity)? And are those with a great need for
resources receiving more than those with lesser needs (vertical equity)? Within social justice, we
look beyond the classic interpretation of justice in the allocation of healthcare services at the
individual level to the distribution of wealth, opportunities for education and employment, and
access to healthy environments at the community, country and international levels. Often, such
calls for distributional justice are tied to the concept of human rights, or claims that citizens can
make on state powers (see Chapter 4). Concrete proposals for redistributing resources at the global
level have included novel taxes on financial transactions (e.g. Tobin tax), carbon taxes, and
exemptions to trade regulations (e.g. TRIPS exemptions). Calls for alternatives to global
neoliberalism, which exemplifies market justice rather than social justice, have been built on a
recognition that the growing gap between the rich and the poor is directly related to our current
economic and political system (Benatar et al. 2011b; Labonté and Schrecker 2011).
Many global health commentators have called for a focus on the most marginalized – those who
exist at the metaphorical margins of our society. As Farmer notes, global health should be based on
a preferential option for the most disadvantaged (Farmer 2003). This is a third part of unpacking
social justice, as the marginalization of groups and communities occurs due to discrimination,
racism, and the continuation of historical injustices and unfair policies that benefit some at the
expense of others. This has encouraged some to use equity lenses or health equity impact
assessment to draw attention to how interventions can sometimes worsen health differences
35

between groups. For example, when a health promotion campaign leads to improved uptake of a
positive behavior amongst the better-educated, wealthier segment of a population.
Western medicine – embedded within its historical and economic context – has often been
reluctant to engage in such issues as are deemed ‘too political’. Critical examination of society,
understanding overt and covert power relations, and identifying means to reduce inequities are
underdeveloped, with few exceptions (Waitzkin et al. 2001). A learned helplessness around social
justice sets in, particularly if a clinician is trained to see herself as working in isolation from others.
We contend that social justice is a societal-level challenge and requires multiple and related social
movements (see Box 2.4 ). Political problems call for political solutions, not technical solutions
(Bayoumi and Guta 2012). Throughout, community consultation must be taken seriously, with
action being directed at creating solutions that will actually benefit the most marginalized.

Box 2.4: Social movements
Social movements are distinct social processes where actors engage in collective action, and
are characterized by involvement in conflictual relations with clearly identified opponents,
dense informal networks, and a shared and distinctive collective identity (Porta and Diani
2006). Social movements relate to the central functions of public health, particularly that of
promoting healthy communities. When organized around perceived threats to health, they can
play a crucial role as advocates for change (Nathanson 1999).
Social movements emerge from the intersection of the personal, the collective and the
historical. They are impacted by societal norms and attitudes, political opposition and the
media, and do not emerge fully formed. Often, many small groups federate around a core idea
to achieve collective action around a common mission. Ultimately, they are composed of
people who become activated, who get politicized and in turn policitize others (Eyerman
1989).
Social movements develop out of certain contexts, typically a mix of four dimensions:
changes in basic conditions of life that produce discontent
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