Abstract
Norman Daniels, in applying Rawls’ theory of justice to the issue of human health, ideally presupposes that society exists in a state of moderate scarcity. However, faced with problems like climate change, many societies find that their state of moderate scarcity is increasingly under threat. The first part of this essay aims to determine the consequences for Daniels’ theory of just health when we incorporate into Rawls’ understanding of justice the idea that the condition of moderate scarcity can fail. Most significantly, I argue for a generation-neutral principle of basic needs that is lexically prior to Rawls’ familiar principles of justice. The second part of this paper aims to demonstrate how my reformulated version of Daniels’ conception of just health can help to justify action on climate change and guide climate policy within liberal-egalitarian societies.
This is a preview of subscription content, log in via an institution to check access.
Similar content being viewed by others
Notes
Daniels (2008, 1, 11). Henceforth, all references to this work will be made in the main body of the text with the page number only.
To be more concrete, environmental degradation could make food, water and other essential resources scarce; rapid depletion of energy resources, like oil, on which the global economy currently depends could undermine the provision of essential goods and services; and demographic shifts, such as unsustainable population growth or global ageing, could push essential goods into scarcity. One could add to the list of threats to moderate scarcity things like war and catastrophic events.
I use the term global warming to refer to the increase of average temperatures at the Earth’s surface, which today is largely caused by human activities that involve greenhouse gas emissions. The primary consequence of global warming is climate change, which is a term I use to refer to the way in which weather patterns are shifting on a global level due to rising temperatures.
Public health services, for Daniels, concern themselves with preventative health measures such as food protection, waste disposal and public information. Medical services, on the other hand, provide rehabilitative services that restore individuals as close as possible to a state of normal species functioning (62).
Elsewhere Daniels stresses that we must avoid misunderstanding this claim to mean that people should have as many opportunities as possible, according to their talents and skills. Rather, he insists that protecting the normal opportunity range means that individuals should have those opportunities they would have if they were in good health in that context (Daniels 2009, 37).
One intriguing example to support this contention comes from the Whitehall Study, a study conducted on British civil servants over the course of their careers which revealed that life expectancy improved at the higher echelons of the civil service. As Daniels suggests, this indicates that the degree of control that one has over one’s work is related to stress and thereby has an impact on health (88).
In 1995, for instance, Costa Rica had a similar GNP to Iraq but had a life expectancy that was over 17 years greater. In 2005, to take another example, Greece had an average income of US $34,000 and a life expectancy of 76.9 years while Cuban’s had a life expectancy of 76.5 years despite an average income of US $10,000 (Marmot 2005, 1100). What such examples show, for Daniels, is that income levels are of limited importance when it comes to determining the health of a population. He argues that levels of population health are largely explicable by the degree of justice achieved by the social organisation and government policies of these countries (83–4). In particular, he underlines the importance of investing in human capital (e.g. education) and public health generally (87–8) when it comes to determining population health.
Inequalities can be of benefit to the worst-off in society, for Rawls, because such inequalities can make the socioeconomic pie greater than it would otherwise have been. In other words, on Rawls’ account, unequal shares of a large pie are better than equal shares of a small pie so long as the larger pie is divided in such a way that the worst-off get more than they otherwise would from equal shares of the small pie (92–3).
Segall (2007, 348).
Ibid.
It might be argued that it is no failure on Daniels’ part for neglecting to explain the precise sense in which health is special. Rawls, for instance, gives few indications of how the basic liberties might be weighed against one another. As he explains, to provide such an account would stand in the way of individual societies flexibly adapting the principles of justice to their socio-historical circumstances (Rawls 2003, 54). Similarly, it might be claimed that Daniels’ is under no theoretical obligation to suggest how health as a good might be weighted against others. However, unlike Rawls, Daniels is insisting on a specialness thesis which is a claim that must be more thoroughly explained and justified if it is to have much meaning.
Wilson (2009, 5).
Rawls (2003, 54).
Daniel P. Thero makes a fair point when he claims that despite the influence of social factors, certain aspects of health remain as simply natural contingencies. As such, he briefly states that appropriate aspects of health should be included in both natural and social primary goods (Thero 1995, 96). For the purposes of a theory of justice concerned with the equitable distribution of goods, however, we must focus on the profound determination of human health by social circumstances.
Wilson (2009, 5–6).
Derek Bell claims that if we extend Rawls’ principles of justice to include health, they must therefore extend to environmental policy since environmental circumstances, such as air pollution and access to open spaces, impact human health (Bell 2004). Indeed, Daniels appears to support this view when he includes certain environmental conditions, like those just mentioned, amongst the determinants of health (12, 42–3). In the following sections, I could be seen as arguing for a version of this view. It is a view, however, that’s quite distinct from that of Daniels or Bell since it is derived from an important consideration neglected by both authors: specifically, that the relatively well-balanced natural environment on which society depends can become unstable and ultimately collapse.
WHO et al. (2003).
Confalonieri et al. (2007).
Ibid, 407. WHO defines Disability Adjusted Life Years as the sum of (a) years of life lost due to premature death and (b) years of life lived with disability (WHO et al. 2003, 18).
Mann (2009, 221).
We find a parallel claim in a 2009 WHO report stating: ‘In the long run, the greatest health risks may be not from natural disasters or disease epidemics, but from the slow build-up of pressures on natural, economic and social systems that sustain health. These are already under stress, particularly in the developing world.’ WHO (2009, 12)
Pogge (2007, 102).
Ibid.
Rawls (2005, 7).
Ibid.
Ibid, 166.
Like Daniels (34–4), I am not making the claim that normal functioning is required for happiness and therefore of fundamental importance for justice. Nor am I saying that disability precludes citizenship. What I am suggesting is the relatively uncontroversial claim that a certain minimum of health is required to fruitfully exercise one’s basic liberties and that there is a strong tendency towards citizens being better able to exercise their liberties if they are healthy.
According to Daniels, ‘health needs are paradigmatic among an important category of basic needs’ (46). Although he does not develop his account of just health on a theory of basic needs, this strong claim on the important status of health in the context of basic needs serves as appealing evidence that he would have some sympathy for the view I am setting forth.
Pogge (2007, 103–104).
Let’s take a simple case where basic needs and basic liberties conflict in order to exemplify how prioritising a principle of basic needs could impact real world decisions. Suppose a society in a state of significant scarcity is concerned by the welfare of its population in two districts. In one district mortality rates from malnutrition are rapidly increasing, while in the other, substantial minorities are deprived many of their basic liberties (but none of their basic needs) by fascist groups. Now suppose, given the limited resources, the state could either invest in food and agricultural programmes to meet the needs of the starving or it could invest in a stronger police force to meet the needs of oppressed minorities. I maintain that the principle of basic needs gives voice to our intuition that meeting basic needs, such as food, take priority over securing basic liberties.
Wolff (2009, 364).
A positive consequentialist principle would move contrary to the direction of liberal-egalitarianism—which seeks the best advantage for the worst off—since such a principle would justify sacrificing the advantage of the worst off for the greater advantage of society at large.
Wolff (2009, 358).
Rawls (2005, 14, 274).
Rawls (2003, 255).
Brock (2000, 31).
J. Rawls, Political Liberalism, 166. For example, in a poor country access to a trained midwife might be considered the limit of basic healthcare needs, while in wealthy nations they are likely to be more comprehensive. Indeed, we must also decide the cut-off point for goods like sufficient food and adequate shelter when it comes to basic needs. Daniels’ account of how priority setting decisions can be made through a fair deliberative process is easily applicable to the issue of determining the fair cut-off point for basic needs in a given society.
By climate policy I mean decisions to combat climate change through mitigation or adaptation strategies. I explain the meaning of these terms shortly.
Mann (2009, 196). A clear example of this is the melting of polar ice. The fear is that beyond a certain level of global warming, polar ice will tip into unstoppable melting. Significant melting of polar ice is likely to act as a positive feedback to global warming, as this would reduce the reflectivity of the Earth’s surface thereby allowing more solar radiation to be absorbed by the Earth’s surface [Ibid].
WHO et al. (2003, 10).
WHO (2009, 3).
Confalonieri et al. (2007, 418).
Environmental Protection Agency (2009, 66, 497).
Ibid, 66,500.
Mann (2009, 221).
Ibid, 221–2.
An anonymous reviewer has insightfully pointed out that we must not forget that mitigation and adaptation measures are not exhaustive when it comes to tacking climate change. When mitigation and adaptation strategies fail there will be serious consequences for human health, potentially leading to humanitarian disasters. In these cases, emergency aid would be required. Although we could add this third category of disaster relief to the strategies available to combat climate change, I focus on mitigation and adaptation both for the sake of simplicity and because they are currently the dominant concerns of climate policy. However, the more acutely climate change is felt the more emphasis will need to be placed on disaster relief strategies. And, indeed, NP would demand this so long as short-term disaster relief does not drain the resources of mitigation and adaptation strategies such that it puts future generations at even greater risk than those in the present.
It is important to note that while I am endorsing Daniels’ formulation of the ideals of preventative health, these ideals have a somewhat different meaning for both of us. That is to say, for Daniels’, (1) and (2) are justified on the principle of fair equality of opportunity whereas for me health is a primary good and therefore (1) and (2) have to do with NP and the difference principle.
Although it is evident that NP demands that risks to basic health needs be reduced, the sense in which it requires these risks to be distributed equitably is perhaps less clear. Applying Wolff’s line of thought to the issue of risk reduction, the aim of NP is to minimise risk for the society at large, not to protect the most threatened first. If the latter was the case then society would have to look after the most threatened no matter what the cost to other citizens. The equitable nature of NP is that the risks to basic health needs must be reduced for all citizens insofar as that is possible. Where not all risks can be adequately reduced, NP will permit that the most threatened groups are left vulnerable since reducing their risks would make it impossible to address other urgent threats (Wolff 2009, 357).
WHO (2009, 3, 24).
I thank an anonymous reviewer for raising this insightful objection.
UNDP (2007, 4, 8).
References
Bell, D. 2004. Environmental justice and Rawls’ difference principle. Environmental Ethics 26(3): 287–306.
Brock, D. 2000. ‘Broadening the Bioethics Agenda’/Kennedy Institute of Ethics Journal, 10(1): 21–38.
Confalonieri, U., B. Menne, R. Akhtar, K.L. Ebi, M. Hauengue, R.S. Kovats, B. Revich and A. Woodward. 2007. ‘Human Health’. In Climate change 2007: Impacts, adaptation and vulnerability. Contribution of working group ii to the fourth assessment report of the intergovernmental panel on climate change, 391–431. Cambridge: Cambridge University Press.
Daniels, N. 2008. Just health: Meeting health needs fairly. NY: Cambridge University Press.
Daniels, N. 2009. Just health: Replies and further thoughts. Journal of Medical Ethics 35: 36–41.
Environmental Protection Agency. 2009. Endangerment and cause or contribute findings for greenhouse gases under section 202(a) of the clean air act; Final rule, Federal Register/vol. 74, no. 239/Tuesday, December 15, 2009, http://www.epa.gov/climatechange/endangerment/downloads/Federal_Register-EPA-HQ-OAR-2009-0171-Dec.15-09.pdf. Accessed 30/03/2010.
Mann, M.E. 2009. Do global warming and climate change represent a serious threat to our welfare and environment? Social Philosophy and Policy 26 (2): 193–230.
Manning, R. 1988. Environmental ethics and John Rawls’ theory of justice. Environmental Ethics 3(2): 155–166.
Marmot, M. 2005. Social determinants of health inequalities. Lancet 365: 1099–1104.
Pogge, T. 2007. trans. Kosch, M. John Rawls: His life and theory of justice. NY: Oxford University Press.
Rawls, J. 2003. A theory of justice revised edition. Cambridge MA: Harvard University Press.
Rawls, J. 2005. Political liberalism. NY: Columbia University Press.
Segall, S. 2007. Is health care (still) special? Journal of Political Philosophy 15 (3): 342–361.
Thero, D.P. 1995. Rawls and environmental ethics: A critical examination of the literature. Environmental Ethics 17(1): 93–106.
UNDP. 2007. Human development report 2007/2008—Fighting climate change: Human solidarity in a divided world. NY: Pelgrave McMillan.
Wilson, J. 2009. Not so special after all? Daniels and the social determinants of health. Journal of Medical Ethics 35: 3–6.
WHO. 2009. Protecting human health from climate change: Connecting science, policy and people, http://whqlibdoc.who.int/publications/2009/9789241598880_eng.pdf. Accessed 20 May 2010.
WHO, WMO, UNEP. 2003. Climate change and Human Health: Risks and responses. Summary, http://www.who.int/globalchange/environment/en/ccSCREEN.pdf. Accessed 18 March 2010.
Wolff, C. 2009. Intergenerational justice, human needs and climate policy. In Intergenerational justice, ed. A. Gossiers, and L.H. Meyer. Oxford: Oxford University Press.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Lacey, J. Climate change and Norman Daniels’ theory of just health: an essay on basic needs. Med Health Care and Philos 15, 3–14 (2012). https://doi.org/10.1007/s11019-011-9349-5
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11019-011-9349-5