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JUSTICE IN GLOBAL HEALTH

Rather than making another attempt at proposing a single and unifying

theory of global health justice, this timely collection brings together, instead,
scholars from a range of traditions to frame the issue more broadly,
highlighting not only different perspectives but also key topics and debates.
The volume features chapters that offer both new theoretical approaches
to global health justice, as well as fresh takes on existing frameworks. Others
adopt a bottom-up approach to tackle specific problems, including the sexual
rights of children and adolescents, artificial intelligence (AI) in medicine, framing
of neglected tropical diseases, securitisation of health, and trademarks in global
health. Brought together within one volume, the breadth of these chapters
provides a unique and enlightening contribution to the wider Global Health field.
This important volume will be a fascinating read for students and researchers
across Global Health, Bioethics, Political Philosophy, and Global Development.

Himani Bhakuni is a Lecturer at York Law School, United Kingdom. Before

that, she was the Assistant Professor of Justice in Global Health Research at
the University Medical Center, Utrecht University. She primarily works on
issues within global health and human rights, particularly on questions
surrounding justice, reparations, and global health law.

Lucas Miotto is a Senior Lecturer in Law at the University of Surrey and a

core member of the Surrey Centre for Law and Philosophy. He works at the
intersection between legal, moral, and political philosophy, dealing with
questions about coercion, manipulation, wrongful interference, and forms of
just governance.
JUSTICE IN GLOBAL
HEALTH
New Perspectives and
Current Issues

Edited by Himani Bhakuni and

Lucas Miotto
Designed cover image: Getty Images
First published 2024
by Routledge
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© 2024 selection and editorial matter, Himani Bhakuni and Lucas Miotto;
individual chapters, the contributors
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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
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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
Names: Bhakuni, Himani, editor. | Miotto, Lucas, editor.
Title: Justice in global health : new perspectives and current issues / edited by
Himani Bhakuni, and Lucas Miotto. Description: Abingdon, Oxon [UK] ;
New York, NY : Routledge, 2023. | Includes bibliographical references and
index. |
Identifiers: LCCN 2023020046 | ISBN 9781032508474 (hardback) |
ISBN 9781032508450 (paperback) | ISBN 9781003399933 (ebook)
Subjects: LCSH: Right to health. | Human rights. | Public health laws. | Bioethics.
Classification: LCC K3260.3 .J87 2023 | DDC 344.03/21‐‐dc23/eng/20230802
LC record available at https://lccn.loc.gov/2023020046

ISBN: 978-1-032-50847-4 (hbk)

ISBN: 978-1-032-50845-0 (pbk)
ISBN: 978-1-003-39993-3 (ebk)
DOI: 10.4324/9781003399933
Typeset in Sabon
by MPS Limited, Dehradun
CONTENTS

Contributor Biographies viii

Introduction: Justice in Global Health 1

Himani Bhakuni and Lucas Miotto

PART I
Citizenship, Power, and Relational Justice 13

1 World Citizenship and Global Health 15

Xuanpu Zhuang

2 AI-DSS in Healthcare and Their Power over

Health-Insecure Collectives 38
Nils Freyer and Hendrik Kempt

PART II
Responsibility for Justice: Law, Civil Society,
and the Private Sector 57

3 Everything is Unconstitutional: Contesting Structural

Violence in Health Systems with Legal Mobilisation 59
Luciano Bottini Filho
vi Contents

4 Framing Noma: Human Rights and Neglected

Tropical Diseases as Paths for Advocacy 82
Alice Trotter and Ioana Cismas

5 Trade Marks and the Right to Health:

A Growing Tension 111
Alvaro Fernandez-Mora

PART III
Sexual Rights and Reproductive Justice 131

6 The Capability Approach and the Sexual Rights

of Children and Adolescents 133
Gottfried Schweiger

7 Reproductive Justice and Ethics of Consent in Assisted

Living Facilities for Disabled People: A Critical
Reflection for Socio-Legal Policies on Long-Term
Care in India 150
Keerty Nakray

PART IV
Health Governance, Security, and Transitions 175

8 Justice in Global Health Governance:

The Role of Enforcement 177
Daniel Elliot Weissglass

9 The Ethical Issues Raised by the Securitisation

of Health 201
Ryoa Chung and Joanne Liu

10 Transitional Health Justice 216

Himani Bhakuni and Lucas Miotto
 Contents vii

PART V
Global Health Justice: New Frames,
New Approaches 239

11 Redistribution and Recognition in the Pursuit

of Health Justice: An Application of
Nancy Fraser’s Framework 241
Erika Blacksher

12 Beyond Egalitarianism: A Confucian Approach

to Global Health Justice 271
Man-to Tang

13 What Do We Want from a Theory of

Global Health Justice? 289
Sridhar Venkatapuram

Index 305
CONTRIBUTORS

Alice Trotter is a PhD candidate at the Centre for Applied Human Rights
at the University of York, United Kingdom. Alice has been involved in
the pluridisciplinary project ‘Noma, The Neglected Disease. An
Interdisciplinary Exploration of Its Realities, Burden, and Framing’. Her
other research focuses on human rights in cities.

Alvaro Fernandez-Mora is a Lecturer at York Law School, United Kingdom. He

holds a DPhil from the University of Oxford (DPhil) and an LLM from
Harvard Law School (LLM). Dr Fernandez-Mora’s research interests lie at the
intersection between intellectual property law and other fields – notably
human rights and competition law and economics. Dr Fernandez-Mora’s
work has been published in the Berkeley Journal of International Law (BJIL),
the International Review of Intellectual Property and Competition Law (IIC),
and the Intellectual Property Quarterly (IPQ), among others.

Daniel Elliot Weissglass is an Assistant Professor of Philosophy at Duke

Kunshan University. His chief research interests with respect to health
include models for improving the moral and political adequacy of global
health governance, models of decision making for persons with
compromised and/or variable cognitive capacities, assessing the values
implicit in the tools used to measure and report health outcomes, and the
risks and benefits of medical AI – especially in LMICs.

Erika Blacksher is the John B. Francis Chair at the Center for Practical
Bioethics and Research Professor in the Department of History and
 Contributors ix

Philosophy of Medicine at the University of Kansas School of Medicine. Dr.

Blacksher studies questions of responsibility and justice raised by U.S. health
inequalities and the potential for democratic deliberation to build shared
purpose across race, class, and geography and to make health a shared value.
Her current work focuses on intersectional health inequalities, with a focus
on class, poverty, and race, and the methodology of democratic deliberation.

Gottfried Schweiger is a Senior Scientist at the Centre for Ethics and Poverty
Research (CEPR) and a member of the Philosophy Department (KTH) of the
University of Salzburg, Austria. His research revolves around social and
political philosophy with a focus on poverty, social and global justice,
migration, childhood and youth, social work, sports, and critical theory.

Hendrik Kempt works mostly in applied ethics, with a focus on the ethics of
medical AI, natural language processing, and human–machine relationships.
He has published several books and articles, his latest being on “Synthetic
Friends”. He is a research associate at the Applied Ethics Group at RWTH
Aachen.

Himani Bhakuni is a Lecturer at York Law School, United Kingdom. Before

that, she was the Assistant Professor of Justice in Global Health Research at
the University Medical Center, Utrecht University. She primarily works on
issues within global health and human rights, particularly on questions
surrounding justice, reparations, and global health law.

Ioana Cismas is a Reader and the Co-Director of the Centre for Applied
Human Rights at the University of York, United Kingdom. Dr Cismas’
interests span the broad discipline of public international law, the specialist
branches of international human rights law and international humanitarian
law, and related fields, such as law and religion and transitional justice. Her
work has attracted substantial research grants from the UK Economic and
Social Research Council (ESRC), the Swiss National Science Foundation,
the Swiss Network of International Studies (SNIS), and several non-govern-
mental organisations and charities. Currently, Dr Cismas co-coordinates the
SNIS-funded project Noma, The Neglected Disease. An Interdisciplinary
Exploration of Its Realities, Burden, and Framing.

Joanne Liu is an Associate Professor of Medicine at the University of

Montreal, a Professor of Clinical Medicine at McGill University, and the
former International President of Médecins sans Frontières. She is also a
paediatric emergency medicine physician in Montreal.
x Contributors

Keerty Nakray is a Professor at Jindal Global Law School, NCR Delhi and
Adjunct Faculty at the Centre for Ethics, Yenepoya University, Mangalore.
She holds a PhD in Sociology and Social Policy from Queen’s University
Belfast, Northern Ireland. Her research deals with topics such as gender-
based violence, social policy, child poverty, and social exclusion.

Lucas Miotto is a Senior Lecturer in Law at the University of Surrey and a

core member of the Surrey Centre for Law and Philosophy. He works at the
intersection between legal, moral, and political philosophy, dealing with
questions about coercion, manipulation, wrongful interference, and forms of
just governance.

Luciano Bottini Filho is a Lecturer in Human Rights Advocacy at Sheffield

Hallam University and an affiliated researcher at the Petrie-Flom Center for
Health Law Policy, Biotechnology, and Bioethics at Harvard University. His
research studies resource allocation, global health, and the right to health.
He has been both a Modern Law Review Scholar for his PhD studies at
Bristol and a Chevening Scholar by nomination of the UK Foreign,
Commonwealth and Development Office (FCDO).

Man-to Tang is a Visiting Fellow at the Department of Public and

International Affairs, City University of Hong Kong. His research interests
are in phenomenology, classical and contemporary Confucianism, and
political philosophy.

Nils Freyer works in the field of machine learning, especially active learning
and natural language processing. His research interests also include
questions of AI ethics, with a focus on medical AI. He is currently a
research assistant at FH Aachen – University of Applied Sciences.

Ryoa Chung is a Full Professor in the Department of Philosophy of the

University of Montreal and Co-Director of the Center for Research in Ethics.
She works in the field of international ethics, feminist philosophy, political
philosophy, and health inequality. She also teaches medical ethics/bioethics
at the Faculty of Medicine of the University of Montreal. Her works have
appeared in edited volumes published by Oxford University Press, Presses
universitaires de France, and in journals such as Journal of Social
Philosophy, Journal of Medical Ethics, Public Health Ethics, The Lancet,
and Hastings Center Report.

Sridhar Venkatapuram is an Associate Professor of Global Health and

Philosophy at King’s College London in the United Kingdom. He is based
 Contributors xi

at the Global Health Institute, where he is Deputy Director, and Director of

Global Health Education. He is the author of Health Justice: An Argument
from the Capabilities Approach (2011), co-editor of Vulnerable: The Law,
Policy and Ethics of Covid-19 (2020) and The Routledge Handbook of
Philosophy of Public Health (2022). He can be found at @sridhartweet.

Xuanpu Zhuang is a PhD candidate at Bowling Green State University,

Department of Philosophy. Xuanpu works on issues within political and
practical philosophy, particularly on issues pertaining to equality, citizenship,
and justice.
INTRODUCTION
Justice in Global Health

Himani Bhakuni and Lucas Miotto

As we write this introduction in early 2023, we are fortunate to have sur-

vived one of the most daunting global health emergencies of our time, but the
world lost many to COVID-19. Health emergencies tend to refocus our
attention not only on the value of life, but also on the centrality of health in
preserving life. In the early days of the pandemic, COVID-19 was called
“a great equaliser”, that it would affect everyone the same. But soon enough,
that thought went out the window quite like almost everything else that has
been called a great equaliser before. It is not news that our world is riddled
with staggering inequalities. Everything that threatens humankind tends to
threaten some bits of humankind more than others. But that we continue
to bear these inequalities despite there being other ways to think, reason, and
act is even more staggering.
This book is about that – not about continuing to bear the different forms
of health inequalities – but about challenging them. Our contributors, from
varied disciplines, have thought of some problems in global health and have
given reasons for why we would all be better off in thinking of a given
problem in a particular way. Some have provided legal solutions; others
have questioned the way we frame issues. Some have proposed newer fra-
meworks that could be used to tackle injustices in global health, while others
have used pre-existing theories of justice and applied them to modern-day
health issues. But the goal of each chapter in this edited volume is the same –
to provide some guidance on what would aid the field of global health in
achieving its lofty aspiration of improving health for all people worldwide.
We choose the overarching language of justice to do so.
Up until a few decades ago the notion of justice (in academic circles at
least) was predominantly territory bound. There was international justice,

DOI: 10.4324/9781003399933-1
2 Himani Bhakuni and Lucas Miotto

but it was largely about justice amongst nations. Lately, factors including
globalisation, digitalisation, increasing climate change, economic inter-
dependence, and enduring global effects of colonial histories, have all led to
the expansion of the scope of justice. Today, we talk about global justice not
only when we consider duties that we have towards others beyond nation-
states, but also when we talk about worldwide inequalities as moral prob-
lems which are embedded in local contexts and shared norms. Global health
justice then becomes an area of research that focuses on proposing, creating,
and maintaining conditions that would enable everyone, not just a privileged
few, to experience and achieve good health and life.
Philosophers and political theorists have attempted to provide an
overarching theory of global health justice, wherein they have been par-
ticularly inspired by the capabilities approach.1 Some have extended pre-
existing theories of global justice and the rights-based approach to
health.2 Despite all these commendable efforts, it is quite likely that,
given the multitude of global health problems, a single overarching theory
of justice would still at best be a partial explanation of the duties and
obligations of various stakeholders involved in the debate. Which is why
this edited volume adopts a mix of approaches to look at justice in global
health, it provides some new philosophical frames and fresher takes on
existing frames, but it also tackles some more specific problems that we
believe that any successful overarching theory of global health justice
must address. While general frameworks of justice help to provide a better
understanding of our world and our responsibilities within it, more spe-
cific incursions on specific issues allow us to see solutions to problems
that might not be immediately available or salient to those who attempt
to provide unifying frameworks.
We are aware that this book is releasing at a time when people might be
going through a health-topic fatigue. A lot has been written (and is being
written) about health, daily. But we nonetheless believe that this volume
adds much more than just noise to the conversation. The volume contains 13
original contributions, most of which were first presented online at the
Justice in Global Health Workshop Series in October 2022. The contribu-
tions address a wide range of issues and topics within global health justice:
from specific challenges associated with an overlooked disease, future in-
justices caused by the development of new technologies, role of law in
addressing commercial determinants of health, and institutional reforms,
to new theoretical frameworks for global health justice. As editors, we are
proud of the volume’s thematic breadth. But we are also proud of the
interdisciplinary dialogue that took place amongst contributors from dif-
ferent backgrounds and corners of the world. Such dialogue allowed us to
identify some common threads and insights running across contributions,
which we think would be valuable to anyone interested in global health and
 Introduction 3

global health justice. To make the threads clearer to our readers, we have
divided the volume into five parts. This division, however, should not be seen
as an attempt to draw hard boundaries; some themes, arguments, and
concepts recur through the volume. In what follows we provide an overview
of the volume’s contributions.

Part I. Citizenship, Power, and Relational Justice

The first part illustrates a pervasive theme in the book. Justice in global
health requires more than a fair distribution of resources – it requires a fair
distribution of the burdens necessary to maintain our health systems glob-
ally. It also requires addressing morally problematic relations of power and,
more specifically, that we relate to one another as equals and respectfully in
health-related contexts. Relational justice is, therefore, integral to global
health justice. However, promoting relational justice in global health may
require radical shifts in our current institutional and political architecture,
as is argued by the two chapters in this part.
In World Citizenship and Global Health (Chapter 1), Xuanpu Zhuang
argues for one of those shifts by favouring the introduction of the cosmo-
politan ideal of world citizenship. “People are not just abstract moral
beings”; their identity, rights, and obligations are shaped by their social and
political arrangements. Citizenship marks an important form of membership
in a social and political arrangement. It typically determines the political
rights, liberties, and obligations that individuals have towards the state and
towards other individuals living in the same territory. Often, however, social
and political relations outgrow the confines of a state or territory: individuals
interact as a global community on global matters. This raises a question
about the need for a form of world citizenship which, Zhuang argues, is not
simply national citizenship writ large. It is, instead, an extra layer of social
and political association significant enough to ground certain entitlements to
social goods, welfare, and capabilities.
Global health enters the scene because the capability of being healthy is,
according to Zhuang, a necessary condition of functioning as a world citizen.
To justify this claim, Zhuang introduces the four “Problematic Hierarchies”;
four ways in which the absence of health undermines the sort of egalitarian
relations which are constitutive of world citizenship. From the discussion, it
becomes apparent that strengthening global health is necessary for main-
taining the relational egalitarian ideal of world citizenship. But – the chapter
also seems to entail – the relationship goes both ways: not only is the
capability of being healthy a necessary condition of world citizenship, but
some demands to promote global health justice also flow from and are (at
least partly) constituted by broader demands of relational equality and
respect enshrined in world citizenship.
4 Himani Bhakuni and Lucas Miotto

A good illustration of the relationship between global health justice and

relational egalitarianism is found in AI-DSS in Healthcare and Their Power
over Health Insecure Collectives (Chapter 2). In this chapter, Nils Freyer and
Hendrik Kempt discuss a dilemma that arises from the introduction of
artificial intelligence-led decision support systems (AI-DSS) in expert-scarce
areas – for example, a system that diagnoses and recommends treatment for
a disease without the interference of a medical expert. These systems require
what is known as “explainability standards”: standards that allow humans
to understand and assess the reliability of the conclusions and recommen-
dations reached by an automated system. For optimal reliability, these
standards must be stringent. But the costs, technology, and qualified per-
sonnel required to maintain stringent explainability standards cannot often
be met by expert-scarce communities – or “collectives”, as the authors
believe we should call them. Hence the dilemma: either expert-scarce col-
lectives do not introduce automated systems and abandon their hopes to
reap the health benefits that these systems bring, or these collectives settle for
a cheaper alternative and accept whatever explainability standards are of-
fered to them by the relevant corporations. Because the second horn of this
dilemma is often the more tempting one, the emergence of a “colonial
mindset” and the introduction of a relation of domination between collec-
tives and corporations are obvious risks.
The main difficulty, then, is whether this relation of domination can be
avoided without abdicating the potential health benefits introduced by AI-
DSS. The authors propose a way to negotiate explainability standards that do
not require eschewing relational justice. The solution explored in the chapter is
instructive, as it can be extended to contexts where a similar clash between
health benefits and relational justice arises. For example, in contexts of clinical
research where some researchers and participants are tempted to relax
research regulations in the name of efficiency or short-term health benefits.

Part II. Responsibility for Justice: Law, Civil Society, and the Private Sector
The second part of the volume focuses on the role and responsibilities of
courts, advocacy groups, and the private sector in the promotion of global
health justice. The opening chapter, Everything Is Unconstitutional –
Contesting Structural Violence in Health Systems with Legal Mobilisation
(Chapter 3), highlights the use of constitutional remedies as a tool for
the elimination of structural violence and inequality in global health. The
author, Luciano Bottini Filho, centres the discussion on a case from 2021
where the Brazilian Supreme Court relied on the “state of unconstitutional
affairs” doctrine to declare the entirety of the Brazilian public health system
unconstitutional in light of its systematic and enduring violation of trans-
gender people’s right to health, life, and dignity.
 Introduction 5

The Court’s decision helps to highlight the importance of relational justice

in the context of global health justice. As we can infer from the chapter,
not only was the declaration of unconstitutionality grounded on the denial of
health resources, but it was also (and perhaps primarily) based on the sys-
tematic discrimination and exclusion of transgender people in the context of
healthcare. The chapter also illustrates the vital role that courts can play in
the broader transformation of health systems and society more generally.
In so doing, it also aligns with the discussion about the just transformation
of health systems that appears later in the volume (Chapter 10).
In Framing Noma: Human Rights and Neglected Tropical Diseases as
Paths for Advocacy (Chapter 4), Alice Trotter and Ioana Cismas discuss the
strategic importance of framing to strengthen the efforts of advocacy groups
and campaigns and to bring about changes in global health. Roughly, to
“frame” a given issue is to choose the way in which the issue is communi-
cated to a selected audience; thus, a “frame” can be seen as a rhetorical
device. In the chapter, the authors discuss the findings from their own em-
pirical research on the uses of alternative frames for tackling noma, a rela-
tively unknown disease that, despite being preventable and treatable, has an
estimated mortality rate of around 90% in children. Noma primarily affects
those living in extreme poverty, and its effects were initially framed as a
medical or humanitarian emergency which, despite the relative success in
attracting aid from charities and doctors from the Global North, also
brought with it relations of dependency and “signalled a ‘white saviour’
trope”. Here the chapter brings us back to the importance of relational
justice to global health: the alternative framings considered by the authors –
framing noma as a neglected tropical disease and as a human rights issue –
were used precisely to make both material progress in combating the disease
and relational progress, as it were, in avoiding the emergence of problematic
social relations in the context of health. The chapter, therefore, illustrates
how civil society and advocacy groups can play an effective role in tackling
global health injustices by carefully choosing how to frame these injustices.
In this part’s last chapter, Trade Marks and the Right to Health: A
Growing Tension (Chapter 5), Alvaro Fernandez-Mora discusses policy-
makers’ use of trade mark-restrictive policies to protect health and health
rights. Such policies range from advertisement bans to more aggressive
restrictions on packaging and aim at making harmful products less attractive
to consumers. These policies stem from the assumption that manufacturers
of such harmful products – most notably the tobacco industry – cannot be
exempted from a responsibility to promote health. Hence, the sacrifice of
their rights to intellectual property and freedom of expression in the name of
health seems justified. Be this as it may, Fernandez-Mora identifies a rapid
expansion of such health-oriented restrictions into the control of alcoholic
products and foods high in fat, sugar, and salt. There, the justification of
6 Himani Bhakuni and Lucas Miotto

implementing such restrictions may not be straightforward, and the risk of

undesirable spillover effects is higher. Courts, being key to the success of
health-promoting policies, must be mindful of these hurdles when deciding
on the adequacy and legality of such expansionist policies. Though tempting,
the “protect health by any means” approach can sometimes cause more
harm than the prospective harms from which health-oriented policies seek to
protect us. Doing justice in global health – and this is a lesson that we can
draw from the chapter – sometimes requires that we take a counter-intuitive
step away from the short-term protection of the right to health and focus our
efforts on other rights which can sometimes be more important to societal
well-being in the long run.

Part III. Sexual Rights and Reproductive Justice

The third part of the volume considers some significant issues within a
specific branch of global health justice: sexual and reproductive justice.
Sexual health and rights are often subsumed under reproductive health
and rights, but both are conceptually distinct, albeit related, areas. WHO’s
working definition of sexual health states that it “requires a positive and
respectful approach to sexuality and sexual relationships, as well as the
possibility of having pleasurable and safe sexual experiences, free of coer-
cion, discrimination and violence”.3 While much has been written about
sexual rights of adults and able-bodied persons, two groups stand out as
understudied and undertheorized in this area: children and adolescents and
persons with disabilities (PWDs). The chapters included in this part address
these two groups.
In The Capability Approach and the Sexual Rights of Children and
Adolescents (Chapter 6), Gottfried Schweiger considers how sexual rights
reflect the developmental dynamics of child and adolescent autonomy and
what aspects of well-being, or what capabilities, these rights protect and
enable. Schweiger uses the capability approach to enumerate the sexual
rights of children and adolescents, while also focusing on the differences
between children and adolescents. His argument is that while sexual rights of
children largely deal with defence against dangers and attacks, they must not
be limited to that. By relying on the capabilities approach, he proposes a
conceptual expansion of sexual rights for children and adolescents: sexual
rights should also empower and enable children and adolescents to develop
in a sexually healthy way so that they can express their agency according to
their level of maturity. This conceptual expansion places sexual education
policies as well as measures to raise awareness of contraceptives and sexually
transmitted diseases amongst teenagers at the forefront of children and
adolescent health. The capabilities approach assists in clarifying that sexual
development is part of healthy development and that there are good reasons
 Introduction 7

to break some of the taboos associated with the talk about sexual health of
children and adolescents if we want to make progress in global health.
In Reproductive Justice and Ethics of Consent in Assisted Living Facilities
for Disabled People: A Critical Reflection for Socio-Legal Policies on Long-
Term Care in India (Chapter 7), Keerty Nakray claims that people suffering
from severe intellectual disability are subjected to what is known as “erotic
segregation”: the conception according to which disabled people are asexual
and not supposed to engage in sexual activities. She uses the framework of
critical disability studies to diagnose the cause for this as stigma and dis-
crimination faced by not only the PWDs but also their carers. Her chapter
summarises the Indian legal framework dealing with consent of PWDs and
discusses leading precedents that demonstrate that despite having a legally
recognised right to consent over sexual and reproductive matters, this right
for PWDs is barely upheld. Given this and other issues with long-term social
care in India, Nakray proposes that some individuals might be able to
achieve sexual decision-making capacity through the assistance of a decision-
making support network. And that such “network consent” could create
opportunities for new social justice paradigms and assure long-term humane
care of PWDs.

Part IV. Health Governance, Security, and Transitions

Global health governance refers to the use of formal and informal institu-
tions, processes, and rules created and employed by various stakeholders
to effectively deal with challenges to global health that require collective
action within and across borders. Since its inception, the World Health
Organization (WHO) has been the primary institution dealing with health
governance as it remains the only international health organisation that can
promulgate treaties and regulations with the power to legally bind member
states. But (sometimes) with great power, comes greater scrutiny. In the
chapter Justice in Global Health Governance: The Role of Enforcement
(Chapter 8), Daniel Elliot Weissglass scrutinises some key provisions of
the WHOs legally binding International Health Regulations (IHR) and es-
tablishes a pattern of pervasive noncompliance with those provisions. He
argues that noncompliance with IHR creates not only practical, but political
problems, as it creates an environment for the continuation of both sub-
stantive and procedural injustices.
Weissglass regards noncompliance as a violation of the Rawlsian ‘prin-
ciple of fidelity’, which in short means that promise keeping under appro-
priate circumstances is a fundamental principle of justice. When states fail to
meet their obligations under IHR they violate this principle which leads to
unfairness in the outcomes of the global health system and perpetuation of
health disparities. He further argues that noncompliance leads to unfairness
8 Himani Bhakuni and Lucas Miotto

in the processes of global health governance as it erodes the very normative

force of IHR and results in weaker perceived obligations by state parties,
thereby feeding further noncompliance. But Weissglass does not stop at
merely making a factual and philosophical case for the role of compliance in
global health governance. As steps towards increasing compliance, he sug-
gests that the WHO could name and shame noncompliant states, provide
conditional support (for instance, by ‘outcasting’ or make access to funds
and other cooperative enterprises contingent on compliance of member
states), and deploy sanctions (beginning with least severe and coercive and
escalating based on the situation).
Global health governance is not only suffering from a problem of non-
compliance, but also reeling from some adverse consequences of the narra-
tive of securitisation of health. In The Ethical Issues Raised by the
Securitization of Health (Chapter 9), Ryoa Chung and Joanne Liu consider
the moral conundrums associated with framing health issues as national
and international security threats. The salience of framing established in
Chapter 4 is also illustrated in this chapter. Framing and elevating matters as
security threats provides governments a podium through which emergency
and other non-standard measures can be hoisted upon people, and often
these measures subordinate human rights of people both within and outside
national borders.
The authors provide three illustrations of the clash between securitisation
of health and human rights. The first being states’ responses to SARS-Cov-2
which, among other human rights violations, disproportionately exacerbates
health nationalism. The second example involves instrumentalisation of
health issues in the context of armed conflict or violent political tensions
(e.g., attacks on hospitals and health workers during armed conflicts or
violent tensions). And the third example builds upon the perception of ref-
ugees, asylum seekers, and irregular migrants as security threats and a
burden on the health system. Chung and Liu argue that securitisation of
health can aggravate the perceived threat posed by migrant populations to
the health systems and well-being of nationals. By combining topical illus-
trations and philosophical reflection on the ethical issues raised by the nar-
rative of securitisation of health, the authors urge us to strengthen the human
right to health, at least until other conceptual and practical alternative
proves itself more successful.
The last chapter in this part is by the editors of this volume. In Transitional
Health Justice (Chapter 10), we find important similarities between failing
political systems in conflict-affected states and failing health systems post
health emergencies, viz., pervasive structural inequality, normalised indi-
vidual or collective wrongdoing, existential uncertainty, and uncertainty
about authority. These similarities led us to borrow some theoretical insights
from the traditional transitional justice framework and to derivatively name
 Introduction 9

our account “transitional health justice” (THJ). If transitional justice aims

at just transformation of a society, THJ demands just transformation of
health systems. But transforming our health systems within a background
of resource scarcity and inequality would not be easy. It would require the
relevant actors to make important choices about how to deal with past
failures and the wrongs perpetrated by their respective health systems. These
choices would also require a balance between distributive and reparative
demands, blame and forgiveness, truth and efficiency.
In proposing a structure of THJ, we look to improve the circumstances of
transitional health justice. Essentially this would require institutional re-
forms; reforms which will aid in the rebuilding of social trust in health
institutions, abating of existential uncertainty, and tackling the uncertainty
regarding the authority of health experts and governments on questions of
health. These reforms will also aid in reducing structural health inequalities
and in reckoning with the truth of past wrongs. We offer some ways in which
heath systems in transition could do all this and conclude the chapter by
positing that THJ can have an important role in allowing for broader
projects of societal transformation which are typical of transitional justice
initiatives.

Part V. Global Health Justice: New Frames, New Approaches

The fifth, and last, part of the volume is where three authors present the
foundations of three general frameworks – or theories, if you like – of global
health justice. Erika Blacksher opens this part by extending Nancy Fraser’s
two-dimensional theory of justice to matters of global health. Her contri-
bution, titled “Redistribution and Recognition in the Pursuit of Health
Justice: An Application of Nancy Fraser’s Framework” (Chapter 11), aptly
distinguishes between distributive and relational injustices (i.e., “mal-
distribution” and “misrecognition”) while acknowledging that these forms
of injustice intersect and interact. Under Fraser’s (and Blacksher’s) frame-
work, the legitimacy of claims of maldistribution and misrecognition – i.e.,
the measure of justice – is given by participatory parity: the requirement
“that social and economic arrangements permit all (adult) members of
society to interact with one another as peers”. Health and health inequalities
are relevant to justice (and questions about health injustices are genuine
questions of justice) – Blacksher argues – because health is both instru-
mentally and intrinsically valuable to participatory parity. Health is, there-
fore, as relevant to participatory parity as the latter is to health justice.
Blacksher also considers in some detail the application of the proposed
Fraser-inspired framework to population health studies. In so doing, she
demonstrates the practical upshot of the framework, which grants it some
plausibility points and, arguably, a comparative advantage over rival
10 Himani Bhakuni and Lucas Miotto

theoretical frameworks. It should be noted at this point that despite some

of the examples of epidemiological and population health studies as well as
some examples of social relations discussed in the chapter being from the
United States, they are not confined to the United States. They illustrate
much broader population trends and relations: relations of oppression,
domination, and discrimination in the context of health which are un-
fortunately omnipresent. For that reason, these are important examples to
think about in global health justice. Additionally, the United States has a
particular history of class and race inequalities – and a particular approach
to healthcare – that cannot be ignored by any theory of justice that strives to
be global in character.
It is also worth mentioning that Blacksher closes her chapter with some
initial thoughts on how the proposed framework could be further extended
to address questions of children and young people’s health. Interestingly, this
brings us back to Gottfried Schweiger’s contribution (Chapter 6) and to the
importance accorded to the development of children’s and adolescent’s
health capabilities. Perhaps the ability to explain the challenges associated
with children’s health is more important to a theory of global health justice
than is acknowledged by previous theorists of health justice.
In “Beyond Egalitarianism: A Confucian Approach to Justice in Global
Health” (Chapter 12), Man-to Tang proposes an alternative to theories of
global health justice centred around health rights and egalitarian principles.
Drawing from both contemporary and classical Confucian doctrine, Tang
defends the primacy of sufficientarian principles of distribution and an agent
centred, as opposed to institution-centred, approach to global health justice.
The core sufficientarian idea in global health justice entails the provision of
sufficient health resources and conditions. The measure of sufficiency is a
flourishing life, a life where one can cultivate harmony of social relations and
expand one’s cardinal virtues. Harmony of social relations may require the
introduction of hierarchies, and this may raise some questions about whether
Tang’s account can meet the demands of relational justice in the context of
global health. Tang, however, emphasises that the virtue of Ren – the
motivation and desire to care for oneself and for others – is a necessary
condition of harmonious social relations, which suggests that the proposed
account may have the theoretical resources to explain some forms of rela-
tional injustice.
Despite rejecting egalitarian principles, Confucian justice – Tang argues –
is sensitive to egalitarian considerations in a specific context: in extreme
circumstances where “resources are insufficient to maintain basic human
needs”. In such contexts, all must bear the burdens equally. This idea also
illustrates another core aspect of Confucian justice: that it is agent centred.
The responsibility to promote global health justice lies, according to Tang’s
account, on all individuals – and not exclusively (or primarily) on
 Introduction 11

institutions. Health justice arises from the gradual expansion of our virtues:
we first show concern for our own health, and then expand this concern to
our relatives, neighbours, friends, and ultimately to the global community.
Tang’s account is not intentioned to simply lay down some ideals for global
health justice; he sees it as belonging to the realm of non-ideal theory. Tang
illustrates the feasibility of his Confucian approach to health justice by
describing how a similar approach was implemented in Hong Kong during
the early stages of the COVID-19 pandemic.
The concern for a theory of global health justice to be feasible and apply to
real-world situations is shared by both Blacksher and Tang – despite both
endorsing largely distinct approaches to global health justice. In the final
chapter of this volume – What do We Want from a Theory of Global Health
Justice? (Chapter 13) – Sridhar Ventakapuram takes a step back and pro-
poses three criteria for a successful theory of global health justice. Not
surprisingly, the concern for feasibility and real-world application is the
first among them. This is what he calls the criterion of “relevance”, and it
involves both a theory’s ability to explain and identify real-world injustices
(theoretical relevance) as well as its ability to guide the elimination of such
injustices (practical relevance). Ventakapuram proposes two further criteria:
perseverance and inter-theoretical coherence. The former is a requirement to
avoid parochialism: theories of global health justice must not be solely
concerned with a specific health problem of the here and now; they must
have enough generality to deal with a broad spectrum of health injustices
over time. This may suggest that the criteria of perseverance and relevance
are mutually reinforcing. To guide the elimination of a broad spectrum of
health injustices over time, a theory of health justice must persevere. And to
persevere, the theory must remain relevant.
The final criterion, inter-theoretical coherence, works as a justificatory
standard: the more a theory of global health justice coheres and integrates
insights from other disciplines – such as economics, epidemiology, medical
and social sciences, anthropology, and so on – the more robust it is. Hence,
Ventakapuram invites global health justice theorists to get out of the confines
of their own disciplines and actively engage in cross-disciplinary work. He
briefly shows that some global health justice theorists have tried to do so, but
to a limited extent. He highlights the need to integrate a theory of global
health justice with history, something that he is trying to do in his ongoing
work. Towards the end, Ventakapuram offers a brief argument – couched in
some recent examples – in defence of a capabilities approach to global health
justice. According to him, the capabilities approach can not only meet all
the proposed criteria, but also offer a more refined and capacious under-
standing of health which allows us to see a theory of global health justice
“as an argument for not only more justice in global health but for more
global justice”.
12 Himani Bhakuni and Lucas Miotto

Notes
1 Venkatapuram S, Health Justice: An Argument from the Capabilities Approach
(Polity Press 2011); Ruger JP, Global Health Justice and Governance (Oxford
University Press 2018).
2 Pogge TW, ‘Human Rights and Global Health: A Research Program’ (2005) 36
Metaphilosophy 182; Segall S, Health, Luck, and Justice (Princeton University
Press 2009); Shue H, Basic Rights: Subsistence, Affluence, and U.S. Foreign Policy
(Second, Princeton University Press 1996); Daniels N, Just Health: Meeting Health
Needs Fairly (Cambridge University Press 2007); Ruger JP, Global Health Justice
and Governance (Oxford University Press 2018).
3 World Health Organization (WHO), Definition of Sexual Health, 2006a.
PART I

Citizenship, Power, and

Relational Justice
1
WORLD CITIZENSHIP AND
GLOBAL HEALTH
Xuanpu Zhuang

1.1 Introduction
Although contemporary theorists usually endorse the ideal of moral equality
as one of the fundamental premises in social and political life, people do not
agree on what the ideal of moral equality requires.1 Egalitarians usually
assert some stronger claims on social life, e.g., certain egalitarian policies and
arrangements. There are two main groups of egalitarians in the discussions:
distributive egalitarians and relational egalitarians. To put it simply, dis-
tributive egalitarians pursue the distribution of certain social goods in a way
that reflects the ideal of equality.2 Differently, relational egalitarians believe
the point of equality is to live as equals.3 For relational egalitarians, justice
requires that people relate to one another as equals. And as the standard
question of justice focuses on a single society, an intuitive and direct claim
for relational egalitarians is that everyone ought to relate to one another as
equal citizens.4 But the claim based on the notion of national citizenship
meets some difficulties when we consider global justice. It is not hard to
recognise huge global distributional inequalities.5 In 2019, for example,
around a tenth of the world’s population lived on less than $1.90 a day and
more than 40% of the world’s population (almost 3.3 billion people) lived
below the $5.50 line, while individuals in high-income economies made
$12,696 or more.6,7 But what would the claim on the ideal of living as equals
demand from us regarding global inequalities? And what does relational
egalitarianism require for people who are not co-citizens in the usual sense?
In this chapter, I argue for a weak notion of equal world citizenship, which
implies that individuals in the world ought to live as equal world citizens in a
significant sense, and then discuss its implications in global health. In

DOI: 10.4324/9781003399933-3
16 Xuanpu Zhuang

Section 1.2, I present a relational egalitarian version of cosmopolitanism,

which requires people to relate to one another as equal and full participants
in global political and social activities. To support this conception of equal
world citizenship, I follow the capabilities approach, which requires suffi-
cient social goods for everyone to function as an equal world citizen in
Section 1.3. Among those social goods, medical support is crucial, as people
who lack health support are vulnerable and thus live as inferiors in different
aspects. Specifically, the lack of medical support causes, follows, and
strengthens some problematic social hierarchies in which some people do not
live as equal world citizens, which are exemplified in various ways. I examine
several cases to show why medical support is crucial in sustaining equal
world citizenship in Section 1.4. Finally, Section 1.5 discusses the importance
of certain egalitarian arrangements in the international order to sustain equal
world citizenship.

1.2 World Citizenship and Relational Egalitarianism

Equality is not always incompatible with differences in treatment. For ex-
ample, assume that Alf is a member of a dance club and Betty is a member of
a music club. As such, Alf, but not Betty, is allowed to enter the dance club’s
locker room. Alf and Betty are treated differently: they have different rights
and benefits associated with their identities (specifically, the club member-
ships). But this case of inequality seems neither unjust nor unreasonable;
Betty does not become inferior to Alf even without the right to enter the
locker room, as long as other conditions associated with her equal mem-
berships (e.g., being an equal fellow student on campus) are fulfilled.
Things become more difficult when we consider the inequalities between
citizens and foreigners (non-citizens) living in the same country. In this
context, it is unclear which inequalities, if any, would be justified. This
problem follows two seemingly conflicting intuitions. On the one hand, it
seems wrong if a foreigner is treated as inferior. On the other hand, there are
at least a few defensible differences between citizens and foreigners con-
cerning their statuses. For example, in some circumstances, it seems
impermissible for foreigners to have a say in a country’s long-lasting political
decisions. So, a country may be justified in depriving foreigners from the
right to vote or participating politically. But this is not devoid of problems,
after all political equality is usually the main indicator of the ideal of equality
today.8 For instance, suppose that a certain policy may harm the interests of
foreigners, e.g., some rules that may deprive them of opportunities to get a
better education in their country of residence.9 It is usually disallowed for
foreigners to donate money to a political candidate who argues against this.
But foreigners could choose to demonstrate or sign a petition. The latter kind
of action seems to be a reasonable claim on one’s interests, while the former
Another random document with
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The Project Gutenberg eBook of And miles to go
before I sleep
This ebook is for the use of anyone anywhere in the United States
and most other parts of the world at no cost and with almost no
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Title: And miles to go before I sleep

Author: William F. Nolan

Illustrator: Richard Kluga

Release date: November 4, 2023 [eBook #72030]

Language: English

Original publication: New York, NY: Royal Publications, Inc, 1958

Credits: Greg Weeks, Mary Meehan and the Online Distributed

Proofreading Team at http://www.pgdp.net

*** START OF THE PROJECT GUTENBERG EBOOK AND MILES

TO GO BEFORE I SLEEP ***
AND MILES TO GO BEFORE I
SLEEP

By WILLIAM F. NOLAN

Illustrated by RICHARD KLUGA

He knew, to the exact minute, when he was

going to die. And Earth was too far away to reach....

[Transcriber's Note: This etext was produced from

Infinity August 1958.
Extensive research did not uncover any evidence that
the U.S. copyright on this publication was renewed.]
Alone within the humming ship, deep in its honeycombed metal
chambers, Murdock waited for death. While the rocket moved
inexorably toward Earth—an immense silver needle threading the
dark fabric of space—he waited calmly through the final hours,
knowing that the verdict was absolute, that hope no longer existed.
Electronically self-sufficient, the ship was doing its job perfectly, the
job it had been built to do. After twenty years in space, the ship was
taking Robert Murdock home.
Home. Earth. Thayerville, a small town in Kansas. Clean air, a
shaded street, and a white, two-story house at the end of the block.
Home—after two decades among the stars.
Sitting quietly before the round port, seeing and not seeing the
endless darkness surrounding him, Murdock was remembering.
He remembered the worried face of his mother, her whispered
prayers for his safety as he mounted the rocket ramp those twenty
years ago; he could still feel the final, crushing handshake of his
father moments before the outer airlock slid closed. His mother had
been 55 then, his father 63. It was almost impossible to believe that
they were now old and white-haired.
And what of himself?
He was now 41, and space had weathered him as the plains of
Kansas had weathered his father. He, too, had labored as his father
had labored—but on strange, alien worlds, under suns far hotter than
Sol. Murdock's face was square and hard-featured, his eyes dark and
deep under thrusting ledges of bone. He had changed as they had
changed.
He was a stranger going home to strangers.
Carefully, Murdock unfolded his mother's last letter, written in her
flowery, archaic hand, and received just before Earth take-off.
Dearest Bob,
Oh, we are so excited! Your father and I listened to your
voice on the tape over and over, telling us that you are
coming home to us at last. We are both so eager to see
you, son. As you know, we have not been too well of late.
Your father's heart does not allow him out much any more,
and I have had a few fainting spells over the past month.
But Doctor Thom says that we are all right, and you are not
to worry. Just hurry home to us, Bob. We both pray God
you will come back safely.

All our love,

Mother
Robert Murdock put the letter aside and clenched his fists. Only brief
hours remained to him, and the small Kansas town of Thayerville was
an impossible distance across space. He knew he would never reach
it alive.
The lines of an ancient poem by Robert Frost whispered through his
mind:

But I have promises to keep,

 And miles to go before I sleep

He had promised his parents that he would come home—and he

meant to keep that promise.
The doctors had shown him that it was impossible. They had charted
his death; they had told him when his heart would stop beating, when
his breathing would cease. Death, for Robert Murdock, was a
certainty. His alien disease was incurable.
But they had listened to his plan. They had listened, and agreed.
Now, with less than a half-hour of life remaining, Murdock was
walking down one of the ship's long corridors, his boot-heels ringing
on the narrow metal walkway.
He was ready, at last, to keep his promise.
Murdock paused before a wall storage locker, twisted a small dial. A
door slid smoothly back. He looked up at the tall man standing
motionless in the darkness. Reaching forward, Murdock made a quick
adjustment.
The tall man stepped down into the corridor, and the light flashed in
his deep-set eyes, almost hidden behind thrusting ledges of bone.
The man's face was hard and square-featured.
"My name is Robert Murdock," said the tall figure in the neat patrol
uniform. "I am 41 years of age, a rocket pilot going home to Earth."
He paused. "And I am sound of mind and body."
Murdock nodded slowly. "Indeed you are," he said.
"How much longer do you have, sir?"
"Another ten minutes. Perhaps a few seconds beyond that," replied
Murdock.
"I—I'm sorry," said the tall figure.
Murdock smiled. He knew that a machine, however perfect, could not
experience the emotion of sorrow, but it eased him to hear the words.
You will be fine, he thought. You will serve well in my place and my
parents will never suspect that their son has not come home to them.
"It must all be perfect," said Murdock.
"Of course," said the machine. "When the month I am to spend with
them is over they'll see me board a rocket for space—and they'll
understand that I cannot return to them for another twenty years.
They will accept the fact that a spaceman must return to the stars,
that he cannot leave the service before he is 60. Let me assure you,
sir, it will all go well."
Yes, Murdock told himself, it will go well; every detail has been
considered. My voice is his voice, my habits his own. The tapes I
have pre-recorded will continue to reach them at specified intervals
until their death. They will never know I'm gone.
"Are you ready now, sir?" the tall figure asked gently.
Murdock drew in his breath. "Yes," he said, "I'm ready now."
And they began to walk down the long corridor.

Murdock remembered how proud his parents had been when he was
finally accepted for Space Training—the only boy in Thayerville to be
chosen. But then, it was only right that he should have been the one.
The other boys, those who failed, had not lived the dream as he had
lived it. From the moment he'd watched the first moon rocket land he
had known, beyond any possible doubt, that he would become a
rocketman. He had stood there, in that cold December of 1980, a boy
of 12, watching the great rocket fire down from space, watching it
thaw and blacken the frozen earth. He had known that he would one
day follow it back to the stars, to vast and alien horizons, to worlds
past imagining.
He remembered his last night on Earth, twenty long years ago, when
he had felt the pressing immensity of the vast and terrible universe
surrounding him as he lay in his bed. He remembered the sleepless
hours before dawn, when he could feel the tension building within the
single room, within himself lying there in the heated stillness of the
small, white house. He remembered the rain, near morning,
drumming the roof, and the thunder roaring powerfully across the
Kansas sky. And then, somehow, the thunder's roar blended into the
deep atomic roar of a rocket, carrying him away from Earth, away to
the burning stars ... away ...
Away.

The tall figure in the neat patrol uniform closed the outer airlock and
watched the body drift into blackness. The ship and the android were
one; two complex and perfect machines doing their job. For Robert
Murdock, the journey was over, the long miles had come to an end.
Now he would sleep forever in space.

When the rocket landed, the crowds were there, waving and shouting
out Murdock's name as he appeared on the silver ramp. He smiled
and raised his hand in salute, standing there tall in the sun, his
splendid dress uniform reflecting the light in a thousand glittering
patterns.
At the far end of the ramp two figures waited. An old man, bowed and
trembling over a cane, and a seamed and wrinkled woman, her hair
blowing white, her eyes shining.
When the tall spaceman reached them they embraced him feverishly,
clinging tight to his arms.
Their son had returned. Robert Murdock had come home from space.

"Well," said a man at the fringe of the crowd, "there they go."
His companion sighed and shook his head. "I still don't think it's right
somehow. It just doesn't seem right to me."
"It's what they wanted, isn't it?" asked the other. "It's what they wrote
in their wills. They vowed their son would never come home to death.
In another month he'll be gone anyway. Back for another twenty
years. Why ruin it all for him?" The man paused, shading his eyes
against the sun. "And they are perfect, aren't they? He'll never know."
"I suppose you're right," nodded the second man. "He'll never know."
And he watched the old man and the old woman and the tall son until
they were out of sight.
*** END OF THE PROJECT GUTENBERG EBOOK AND MILES TO
GO BEFORE I SLEEP ***

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