Are disparities ethically wrong? A Theory of Human Functioning

Many scholars and activists simply assert that global health disparities are unethical, suggesting that inequalities are self-evidently wrong or that they violate fundamental human rights. But, stating that inequalities are unfair, without more, does little to explain why it is so. Nor is an appeal to human rights convincing because, used in this way, “rights discourse” is just another rhetorical device without explanatory power. The internationally recognized “right to health,” as explained further below, principally focuses on States’ obligations to meet the health needs of their own populations. In any event, the text of an international legal instrument cannot be read as a principled ethical argument that State A owes a duty to improve the health of State B’s population.

Perhaps the strongest claim that health disparities are unethical is based on what I call a theory of human functioning. Health has special meaning and importance to individuals and the community as a whole. Health is necessary for much of the joy, creativity, and productivity that a person derives from life. Individuals with physical and mental health recreate, socialize, work, and engage in family and social activities that bring meaning and happiness to their lives. Every person strives for the best physical and mental health achievable, even in the face of existing disease, injury, or disability.

Perhaps not as obvious, health also is essential for the functioning of populations. Without minimum levels of health, people cannot fully engage in social interactions, participate in the political process, exercise rights of citizenship, generate wealth, create art, and provide for the common security. A safe and healthy population builds strong roots for a country’s governmental structures, social organizations, cultural endowment, economic prosperity, and national defense. Population health becomes a transcendent value because a certain level of human functioning is a prerequisite for activities that are critical to the public’s welfare—social, political, and economic.

Amartya Sen famously theorized that the capability to avoid starvation, preventable morbidity, and early mortality is a substantive freedom that enriches human life. Depriving people of this capability strips them of their freedom to be who they want to be and “to do things that a person has reason to value.” Under a theory of human functioning, health deprivations are unethical because they unnecessarily reduce one’s ability to function and the capacity for human agency. Health, among all the other forms of disadvantage, is special and foundational, in that its effects on human capacities impact one’s opportunities in the world.