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Do we bear any moral responsibility for improving cancer care in Africa?

2006; Elsevier BV; Volume: 17; Issue: 12 Linguagem: Inglês

10.1093/annonc/mdl442

1569-8041

Fiona Kerr, David Kerr,

Ethics and Legal Issues in Pediatric Healthcare

The health of persons in developing countries is receiving increased attention for several important reasons. First, health is acknowledged to be a major factor in international development; countries whose citizens are in poor health are disadvantaged in economic competition with other countries. Second, the health problems of developing countries and industrialised countries are becoming shared problems. For example, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), a disease that first occurred in sub-Saharan African (SSA), has now spread to all parts of the industrialised world. Smoking and obesity, problems usually identified with industrialised countries, are now also taking a toll in the developing world. Third, health is increasingly viewed as a human rights issue. The inequalities of health between rich and poor countries represent a violation of these rights.It has been projected by the International Agency for Research on Cancer that 27 million people will discover they have cancer in 2030, two-thirds of them in newly industrialised and developing countries. In all, 12.5% of all deaths are caused by cancer, more than the proportion of deaths caused by HIV/AIDS, tuberculosis and malaria put together.In this editorial, we propose to examine the philosophical framework through which we might approach construction of a case for investment in Africa.We will use the principles of utilitarianism to explore the contrasting demands that those in relative poverty and those in absolute poverty make upon us, arguing that those in absolute poverty take precedence over those in relative poverty, thus showing we are morally bound to the poverty stricken by the concept of equality, as it is unjust that some people have much more than others. Simply put, this vast gulf between the poverty stricken and the affluent should be addressed by those who have more.There are two types of poverty: the relative and the absolute. Robert McNamara, a former president of the World Bank, coined the phrase ‘absolute poverty’. This state of poverty is not relative as those inflicted are not poor in comparison to their neighbours but by an objective standard. Those in absolute poverty have an incommensurable standard of living. Their basic human needs of clean water, uncontaminated food, shelter and health care are not being met. Each day is characterised by the struggle to survive, hampering their flourishing as human beings. Peter Townsend based the definition of relative poverty on a deprivation index. He selected 12 key indicators of deprivation (such as not having a cooked meal one day in a fortnight) and used these to locate the most deprived areas. Relative poverty is defined in relation to a generally accepted standard of living in a specific society at a specific time, going beyond biological needs [1.Jones C. Global Justice. Oxford University Press, 1999Google Scholar, 2.Pogge T. World Poverty Human Rights. Polity Press, 2002Google Scholar].We will contrast two populations, that of the African district of Malawi, where the inhabitants exist in absolute poverty, and those in the district of Maryhill in Glasgow (where one of us was born and the other currently resides), where many of the inhabitants exist in relative poverty.There are many outcome measurements used to define poverty; however, perhaps the most compelling would be an estimate of projected life span (as there is a strong correlation between wealth and life expectancy). This is where our two selected populations converge. With the predicted average life expectancy of a male child born in 1998 in Malawi being 42 years which is similar to the 54 years of his Maryhill comparator.We will primarily assert why the affluent have a moral obligation to forfeit their luxuries for the poverty stricken. Utilitarianism is a moral theory based upon equality, which we have chosen to accept as the correct moral stance. Equality does not claim that all individuals are the same: it is obvious that the human race spans a broad spectrum of characteristics, genders and races. Instead it accepts that humans do not differ through gender or race, but as individuals. So the morally significant factor that binds the affluent with the poverty stricken is grounded in the concept that no human is of more inherent worth than another. One must consider the consequences of an action with regard to how much benefit they will produce for every individual. When deliberating outcome, concern is shown equally to all people, so everyone's interests should be taken into account by adopting an impartial standpoint. Utilitarian theories dictate that we are morally required to bring about the greatest amount of total utility. In relation to poverty, the most accurate model of utility translates as the meeting of basic needs. Basic needs are the necessary conditions for not suffering serious harm in life, the need for clean water, shelter, clothing, food and health care. The affluent are obligated to make sacrifices for the poverty stricken to the extent that it does not morally hinder them because no individual is more inherently superior than another. The wealthy weigh the consequences of their everyday actions against saving a life and determine which will result in the greatest total utility. Utilitarianism shows why responding to poverty is not a supererogatory act, namely, above and beyond the call of duty, but an obligation on every human being.Having argued why equality makes moral demands upon us, we will now argue that these moral demands are stronger for those in absolute poverty than those in relative poverty, using the principles of utilitarianism. The three-place grammar of desert scheme dictates that person A deserves treatment B in virtue of desert base C. The meritocratic society in which we live states that the proper desert base for social reward is merit, the combination of talent and hard work. A meritocrat recognises that being born into inherited wealth, male or female, black or white, rich or poor are factors beyond one's control. They are results of the social lottery. These are matters of luck, so form no basis for special reward or superior treatment and, accordingly, do not give rise to desert. So the affluent have been rewarded their riches as they work harder and use more talent. Therefore, those in relative poverty have the potential opportunity to become richer if they choose. Those in absolute poverty do not have a choice. The people from Maryhill make lifestyle choices, such as poor diet, alcohol, substance abuse and smoking, to lead to their low life expectancy. Their life expectancy is self-imposed, highlighted by the fact that their neighbours in Milngavie have made different choices and gained 20 years of life. The Malawian is denied choice. Those in absolute poverty were born into severe circumstances through no fault of their own; their low life expectancy is a result of wars imposed by others, disease, environmental and social factors. The Malawian has no way of escaping, through operating different choices; they do not even have the opportunity to make choices concerning cultural matters. Therefore, according to utilitarianism, the greatest amount of total utility would be brought about by bringing those in absolute poverty up to the standard of living where their basic needs are fulfilled.Some may oppose this claim by stating that those in relative poverty are also born into circumstances beyond their control. Maryhill is designated one of the most deprived communities in the United Kingdom. Recent government statistics suggest the gap, measured in life expectancy, is growing when we compare deprived communities with their affluent neighbours. So much so that there are now >20 lost years of life comparing the least with the most well off. A person in Maryhill may be socially restricted, for example, born of drug-addicted parents. They know no other path to follow than that of the drug addict. It may be argued their choices are limited.However, we refute this claim, as those in Maryhill still have the opportunity of becoming richer, within our meritocratic society. Although it is harder for those in relative poverty to obtain more wealth in comparison to those in Milngavie, it is not impossible. While those in absolute poverty have no hope, they are confined to this inescapable existence if the affluent do not aid them. Those in Maryhill have opportunity. The Malawian has no opportunity. If we evaluate the limits on the Malawian and a resident of Maryhill, we can conclude the Malawian's are more severe, thus more demanding. So, providing the Malawian with the prospect to live as an autonomous being, by satisfying their basic needs, would bring about the greatest amount of total utility. Thus, instead of indulging in luxuries, the affluent should divert their dispensable income to those in absolute poverty.The fact that relative poverty is indeed relative by some standard shows it is based upon comparison. Those inflicted by relative poverty are by definition poor in comparison—they are lower on the scale than their neighbours. Those in absolute poverty, however, are immeasurable by comparison; their lives are determined by their need to meet basic needs. So solely on the basis of the defining features of these strands of poverty, our moral obligation is greater to that of the Malawian. Even as you read this article, thousands of people across Africa will die in the next few weeks as a result of drought. A disturbance in environment on the smallest scale is amplified to drive those in absolute poverty to the point of life or death situations. If a natural disaster occurred in Maryhill, those affected would be supported by the government; there is a safety net in place which would not allow them to fall below a certain standard of living. The Malawian has no safety net. If we consider this factor, the total amount of utility would be brought about by ensuring those in absolute poverty are brought up to a certain standard of living that fulfils their basic needs. Therefore, the affluent are under a moral obligation to sacrifice that which does not morally hinder them in their own environment.To conclude, some citizens object to aiding those in absolute poverty before those in relative poverty on the basis that problems in our own society are more urgent than those of other countries. We have already established, however, through utilitarianism, that every human is of equal worth, regardless of where they live. The cosmopolitan theory of international affairs supports this claim. It states that the boundaries between nations are morally irrelevant. Nations do not need food and clean water like human individuals; nations cannot suffer from disease and die. So nations cannot be viewed in the same ways as human individuals. The boundaries of our current nations are man-made; they are the result of historical accidents. We could easily have ended up with different national boundaries, with different people inhabiting them. Principles of equality demand us to distribute wealth more evenly, starting with fulfilling the basic needs of those in absolute poverty, and then addressing those in relative poverty. We can use this philosophic [3.Singer P. Practical Ethics.2nd edition. CUP, Cambridge1993Google Scholar] framework to develop an action plan that mandates those of us who work in high-income countries to provide mentorship, training, human and capital resources to establish cancer control programmes in SSA. The health of persons in developing countries is receiving increased attention for several important reasons. First, health is acknowledged to be a major factor in international development; countries whose citizens are in poor health are disadvantaged in economic competition with other countries. Second, the health problems of developing countries and industrialised countries are becoming shared problems. For example, human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS), a disease that first occurred in sub-Saharan African (SSA), has now spread to all parts of the industrialised world. Smoking and obesity, problems usually identified with industrialised countries, are now also taking a toll in the developing world. Third, health is increasingly viewed as a human rights issue. The inequalities of health between rich and poor countries represent a violation of these rights. It has been projected by the International Agency for Research on Cancer that 27 million people will discover they have cancer in 2030, two-thirds of them in newly industrialised and developing countries. In all, 12.5% of all deaths are caused by cancer, more than the proportion of deaths caused by HIV/AIDS, tuberculosis and malaria put together. In this editorial, we propose to examine the philosophical framework through which we might approach construction of a case for investment in Africa. We will use the principles of utilitarianism to explore the contrasting demands that those in relative poverty and those in absolute poverty make upon us, arguing that those in absolute poverty take precedence over those in relative poverty, thus showing we are morally bound to the poverty stricken by the concept of equality, as it is unjust that some people have much more than others. Simply put, this vast gulf between the poverty stricken and the affluent should be addressed by those who have more. There are two types of poverty: the relative and the absolute. Robert McNamara, a former president of the World Bank, coined the phrase ‘absolute poverty’. This state of poverty is not relative as those inflicted are not poor in comparison to their neighbours but by an objective standard. Those in absolute poverty have an incommensurable standard of living. Their basic human needs of clean water, uncontaminated food, shelter and health care are not being met. Each day is characterised by the struggle to survive, hampering their flourishing as human beings. Peter Townsend based the definition of relative poverty on a deprivation index. He selected 12 key indicators of deprivation (such as not having a cooked meal one day in a fortnight) and used these to locate the most deprived areas. Relative poverty is defined in relation to a generally accepted standard of living in a specific society at a specific time, going beyond biological needs [1.Jones C. Global Justice. Oxford University Press, 1999Google Scholar, 2.Pogge T. World Poverty Human Rights. Polity Press, 2002Google Scholar]. We will contrast two populations, that of the African district of Malawi, where the inhabitants exist in absolute poverty, and those in the district of Maryhill in Glasgow (where one of us was born and the other currently resides), where many of the inhabitants exist in relative poverty. There are many outcome measurements used to define poverty; however, perhaps the most compelling would be an estimate of projected life span (as there is a strong correlation between wealth and life expectancy). This is where our two selected populations converge. With the predicted average life expectancy of a male child born in 1998 in Malawi being 42 years which is similar to the 54 years of his Maryhill comparator. We will primarily assert why the affluent have a moral obligation to forfeit their luxuries for the poverty stricken. Utilitarianism is a moral theory based upon equality, which we have chosen to accept as the correct moral stance. Equality does not claim that all individuals are the same: it is obvious that the human race spans a broad spectrum of characteristics, genders and races. Instead it accepts that humans do not differ through gender or race, but as individuals. So the morally significant factor that binds the affluent with the poverty stricken is grounded in the concept that no human is of more inherent worth than another. One must consider the consequences of an action with regard to how much benefit they will produce for every individual. When deliberating outcome, concern is shown equally to all people, so everyone's interests should be taken into account by adopting an impartial standpoint. Utilitarian theories dictate that we are morally required to bring about the greatest amount of total utility. In relation to poverty, the most accurate model of utility translates as the meeting of basic needs. Basic needs are the necessary conditions for not suffering serious harm in life, the need for clean water, shelter, clothing, food and health care. The affluent are obligated to make sacrifices for the poverty stricken to the extent that it does not morally hinder them because no individual is more inherently superior than another. The wealthy weigh the consequences of their everyday actions against saving a life and determine which will result in the greatest total utility. Utilitarianism shows why responding to poverty is not a supererogatory act, namely, above and beyond the call of duty, but an obligation on every human being. Having argued why equality makes moral demands upon us, we will now argue that these moral demands are stronger for those in absolute poverty than those in relative poverty, using the principles of utilitarianism. The three-place grammar of desert scheme dictates that person A deserves treatment B in virtue of desert base C. The meritocratic society in which we live states that the proper desert base for social reward is merit, the combination of talent and hard work. A meritocrat recognises that being born into inherited wealth, male or female, black or white, rich or poor are factors beyond one's control. They are results of the social lottery. These are matters of luck, so form no basis for special reward or superior treatment and, accordingly, do not give rise to desert. So the affluent have been rewarded their riches as they work harder and use more talent. Therefore, those in relative poverty have the potential opportunity to become richer if they choose. Those in absolute poverty do not have a choice. The people from Maryhill make lifestyle choices, such as poor diet, alcohol, substance abuse and smoking, to lead to their low life expectancy. Their life expectancy is self-imposed, highlighted by the fact that their neighbours in Milngavie have made different choices and gained 20 years of life. The Malawian is denied choice. Those in absolute poverty were born into severe circumstances through no fault of their own; their low life expectancy is a result of wars imposed by others, disease, environmental and social factors. The Malawian has no way of escaping, through operating different choices; they do not even have the opportunity to make choices concerning cultural matters. Therefore, according to utilitarianism, the greatest amount of total utility would be brought about by bringing those in absolute poverty up to the standard of living where their basic needs are fulfilled. Some may oppose this claim by stating that those in relative poverty are also born into circumstances beyond their control. Maryhill is designated one of the most deprived communities in the United Kingdom. Recent government statistics suggest the gap, measured in life expectancy, is growing when we compare deprived communities with their affluent neighbours. So much so that there are now >20 lost years of life comparing the least with the most well off. A person in Maryhill may be socially restricted, for example, born of drug-addicted parents. They know no other path to follow than that of the drug addict. It may be argued their choices are limited. However, we refute this claim, as those in Maryhill still have the opportunity of becoming richer, within our meritocratic society. Although it is harder for those in relative poverty to obtain more wealth in comparison to those in Milngavie, it is not impossible. While those in absolute poverty have no hope, they are confined to this inescapable existence if the affluent do not aid them. Those in Maryhill have opportunity. The Malawian has no opportunity. If we evaluate the limits on the Malawian and a resident of Maryhill, we can conclude the Malawian's are more severe, thus more demanding. So, providing the Malawian with the prospect to live as an autonomous being, by satisfying their basic needs, would bring about the greatest amount of total utility. Thus, instead of indulging in luxuries, the affluent should divert their dispensable income to those in absolute poverty. The fact that relative poverty is indeed relative by some standard shows it is based upon comparison. Those inflicted by relative poverty are by definition poor in comparison—they are lower on the scale than their neighbours. Those in absolute poverty, however, are immeasurable by comparison; their lives are determined by their need to meet basic needs. So solely on the basis of the defining features of these strands of poverty, our moral obligation is greater to that of the Malawian. Even as you read this article, thousands of people across Africa will die in the next few weeks as a result of drought. A disturbance in environment on the smallest scale is amplified to drive those in absolute poverty to the point of life or death situations. If a natural disaster occurred in Maryhill, those affected would be supported by the government; there is a safety net in place which would not allow them to fall below a certain standard of living. The Malawian has no safety net. If we consider this factor, the total amount of utility would be brought about by ensuring those in absolute poverty are brought up to a certain standard of living that fulfils their basic needs. Therefore, the affluent are under a moral obligation to sacrifice that which does not morally hinder them in their own environment. To conclude, some citizens object to aiding those in absolute poverty before those in relative poverty on the basis that problems in our own society are more urgent than those of other countries. We have already established, however, through utilitarianism, that every human is of equal worth, regardless of where they live. The cosmopolitan theory of international affairs supports this claim. It states that the boundaries between nations are morally irrelevant. Nations do not need food and clean water like human individuals; nations cannot suffer from disease and die. So nations cannot be viewed in the same ways as human individuals. The boundaries of our current nations are man-made; they are the result of historical accidents. We could easily have ended up with different national boundaries, with different people inhabiting them. Principles of equality demand us to distribute wealth more evenly, starting with fulfilling the basic needs of those in absolute poverty, and then addressing those in relative poverty. We can use this philosophic [3.Singer P. Practical Ethics.2nd edition. CUP, Cambridge1993Google Scholar] framework to develop an action plan that mandates those of us who work in high-income countries to provide mentorship, training, human and capital resources to establish cancer control programmes in SSA.