Comment
Offline: The incontestable moral value of health
In March, 2020, chief science advisers from 12 countries,
including the US, the UK, and Germany, issued a call to
scholarly publishers “to voluntarily agree to make their
COVID-19 and coronavirus-related publications, and the
available data supporting them, immediately accessible
in PubMed Central and other appropriate public reposi­
tories.” That same month, over 30 publishers, including
The Lancet, signed up to this request. The call reflected
the urgency of the pandemic and “the associated global
health crisis.” We have made all of our coronavirus-related
content freely available through a COVID-19 Resource
Centre. But why stop with a pandemic? Are there not other
global health crises that would benefit from immediate
access to new scientific findings? Where should one draw
the line in deciding what scientific information is instantly
and freely available? And who should draw that line?
*
The pandemic has accelerated massive change in scientific
publishing. Preprints of COVID-19-related research papers
are now routinely posted. On balance, preprints have
been a positive step forward for science. Immediate access
to new, although non-peer-reviewed, results has been
helpful for policy makers, journalists, and a public eager to
devour every new discovery. Occasionally, there has been
unscrupulous behaviour. Some institutions have issued
press releases publicising preprints in ways that have
given too much credence to provisional findings. But my
concern isn’t with preprints or even with this pandemic.
My unease lies with the arbitrary criteria for defining a
“global health crisis” and so the capricious justifications
for denying immediate access to new research findings.
Isn’t AIDS an urgent global health crisis? Or any one of an
array of non-communicable diseases ravaging socially
excluded and poor communities? Debates about access to
scientific research usually and quickly devolve into disputes
about the merits of open access mandates. Or the material
contributions society publishers make to the disciplines
they champion. Or the benefits commercial publishers
bring to the wider economy. Sometimes, important
principles are enunciated—publicly funded research must
be publicly accessible. But none of these arguments cuts
through to what I think is the crucial distinction this
pandemic has revealed—that health and health research
have a special moral importance to society, an importance
www.thelancet.com Vol 399 January 15, 2022
that should demand zero tolerance to any barrier limiting
access to healthcare and health information.
*
The philosopher Norman Daniels put forward a compelling
case for the special moral importance of health in his 2008
book, Just Health. The “fundamental question” he posed
was, “As a matter of justice, what do we owe each other to
promote and protect health in a population and to assist
people when they are ill or disabled?” Part of his answer
was to establish the obligations we have to promote and
secure health, obligations that do not apply to other goods.
Daniels’ claim is that health is of special moral importance
because protecting health—keeping people functioning
normally by meeting their health needs—protects the
opportunities open to us. By opportunities, Daniels means
“the array of life plans reasonable persons are likely to
develop for themselves.” Poor health diminishes those fair
opportunities. Daniels based his argument on John Rawls’
theory of justice. Rawls claimed there could be no justice
without fair opportunities for all. Justice demands the
protection of those fair opportunities. If, therefore, fair
Harvard T H Chan School of Public Health
opportunity is a crucial dimension of justice, and if those
opportunities depend on health, then justice must give a
special moral place to health. Daniels defines health needs
as adequate nutrition; sanitary, safe, unpolluted living and
working conditions; healthy lifestyles; medical services;
social care; and “an appropriate distribution of other social
determinants of health”. To these, I would add reliable
health information, which provides the basis for any high-
quality health system. The post-COVID-19 challenge for
scientific editors is to address the reasoned claims that
health and health research are foundational components
of a just society, that health and health research occupy
positions of special moral importance to that society, and
that journal editors have a responsibility to advocate for
the removal of all access barriers to the results of scientific
research. There is no logical or ethical basis for designating
COVID-19 a special case. The argument for immediate
access to new health research findings is a straightforward
matter of justice, not expediency. It’s time for editors to
say so clearly and forcefully.
Steve Pyke/Getty Images
Richard Horton
richard.horton@lancet.com
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