Solidarity: A (New) Ethic for Global Health Policy

Biotechnology is here used to denote the application of new and emerging technologies to the study of living organisms or that uses living organisms or derivatives thereof to produce or modify (health) products and services. See the definition in the Convention on Biological Diversity (1992), signed by 168 states, as well as those at www.mayominnesotapartnership.org/glossary.htm and www.uni-hohenheim.de/biotech/eng/def_biotech.htm.

Biotechnological advances will increase the variety and predictability of diagnostic processes, widen the scope and effectiveness of treatment processes, and generally alter the social setting within which medicine is practiced [50, 51].

Attempts to define these and other values and to measure the propriety of tomorrow’s biotechnologies have been undertaken within the rubric of various moral approaches, including principlism, virtuism, feminism, etc. For the purposes of this paper, no particular “approach” or overarching “theory” of rights or morality is espoused.

In African traditionalism, note the maxim simunye (we are one; unity strength). In Buddhism, Hinduism and Christianity, note concepts of brotherhood and interconnectedness. In Judaism, note clal yisrael (unity despite differences) and brit (the covenant which binds Jews to one another and to God, and the fostering of reut or “neighbourliness”). In Islam, note tawhid (unity and oneness of humanity).

In African traditionalism, note the widely held maxim, umuntu ngumuntu ngabantu (to be human is to affirm one’s humanity by recognizing the humanity of others). In Buddhism, note the admonition against excess. In Confucianism, note the emphasis on love of life and mutual respect. In Hinduism and Christianity, note concepts of reciprocity. In Judaism, note arevut (mutual obligation). In Islam, note hubb (love), rahma (mercy/compassion).

In some African traditions, note shosholoza (working as a team; group spirit in adversity) and the shared responsibility of dialogue and cooperative action. In some Asia traditions, note kalayanamitra (friends helping friends). In Buddhism, note concepts of enduring sacrifice in others’ interests. In Confucianism, note concepts of duties and action toward others. In Hinduism, note da da da (give and be merciful) and concepts of obligation to others. In Judaism, note kiruv (reaching out, partnering with humanity) and tzedaka (duties to help the poor). In Christianity, note John 15:13 (self-sacrifice) and Mark 10:21, Luke 6:20 and John 3:17 (mutual assistance, often in relation to the poor). In Islam, note zakat (obligation to give to the poor), sadaqah (charity/altruism), and concepts of ‘adl (justice) and wast (equilibrium) which underpin principles condemning exploitation and the isolation of oneself from the rest of humanity.

J. Habermas [47] Zur Bestimmung der Moral (Frankfurt: Suhrkamp, 1986), uses the term “intersubjectivity.”

Only by situating the individual within society can we determine whether we have obligations toward one another as citizens of a community [60].

The income of the richest 20% of humanity is 80x that of the poorest 20%, and more than 2 billion people live on less than US$2 per day ([9], at 112). See also UNDP, Human Development Report 1999 (Geneva: [101], at http://hdr.undp.org/reports/global/1999/en/, and R. Falk, Predatory Globalization: A Critique (Cambridge: Polity Press, 1999).

Global population has risen from 4,452,645,562 (1980), to 5,282,765,827 (1990), to 6,081,527,896 (2000), to 6,460,560,374 (2005): see www.census.gov/ipc/www/worldpop.html (Aug. 16/05). It is expected to rise to 9.1 billion by 2050: see www.overpopulation.org/faq.html (Aug. 16/05).

Whereas the global population increases by approximately 3,000 every 20 min (+/−), one or more species of animal or plant life becomes extinct (some 27,000 species per year): www.overpopulation.org/faq.html (Aug. 16/05). Freshwater consumption has increased 6× in the last 100 years; 5 million people die annually from diarrhoea due to polluted water; 20% of the world’s freshwater fish have disappeared or are endangered; some 63% of all species have been lost in the last 100 years and extinctions are occurring at increased rates; some 80% of forests have been cut worldwide and 40% of the remainder are threatened [84]. Extinction rates are estimated at between 1,000 and 10,000 times greater than they would be naturally [93]. Some 40% of the world’s forests are threatened by mining, and 25% of the world’s mammals and 11% of the world’s birds are at risk of extinction due to population growth and loss of habitat: Population Connection, at www.populationconnection.org/factoids/ (Aug. 16/05).

Health and security are linked [102]. Increasingly vicious, ethnic-based wars in poor nations cause massive human suffering, social disruption, population displacement and loss of natural resources [26]. Some 90% of modern war victims are civilians, mostly women and children: Population Connection, at www.populationconnection.org/factoids/ (Aug. 16/05).

Life expectancy by region has been reported as follows: Africa—46 (M), 48 (F); Americas—71 (M), 77 (F); South-East Asia—61 (M), 64 (F); Europe—68 (M), 77 (F); Eastern Mediterranean—61 (M), 64 (F); Western Pacific—70 (M), 74 (F). The countries with the lowest life expectancy rates and healthy life expectancy rates are African. Compared to life expectancy in the UK of 76 (M) and 81 (F), life expectancy rates in Lesotho are 35 (M) and 40 (F), Swaziland are 33 (M) and 36 (F), and Zimbabwe are 37 (M) and 36 (F). ([103], at 13).

See Article 12 of the International Covenant on Economic, Social and Cultural Rights (1966). Also see the Jakarta Declaration on Health Promotion into the 21 Century (1997), the People’s Health Charter (2000), and J. Mann et al. (eds.), Health and Human Rights (NY: Routledge, 1999).

Of 1,223 new drugs developed between 1975 and 1997, only 11 were for the treatment of tropical diseases, which are some of the largest killers [94]. In 1993, cancer research spending in the UK alone was US$200 million, whereas malaria research spending was US$84 million worldwide ([80], at 23). Over 40 million people, mostly in resource-poor developing countries, have HIV/AIDS, and even those few that benefit from drug trials receive very little follow up treatment post-trial [6, 59).

The commodification of the intellectual property regime has permitted the pharmaceutical industry pursue artificial improvements (rather than truly new products) while keeping prices elevated. [24].

See Preamble, WHO Constitution (1948). Every country in the world is a party to at least one treaty addressing health-related rights, including the right to health: see www.who.int/hhr/en/ (Aug. 26/05).

For an example such claims in a legal instrument, see the Convention on Biomedicine (1997).

See Articles 2 (entitlement to rights without distinction) and 7 (no discrimination) of the UDHR (1948), Articles 2 (no distinctions on named grounds), 3 (equality of men and women), 26 (no discrimination) and 27 (minority rights) of the ICCPR (1966), Article 14 (no discrimination) of the ECHR (1950), and Article 14 (no discrimination), Part I of Schedule 1 of the HRA 1998.

See Articles 18 (thought, conscience, religion) and 19 (opinion, expression) of the UDHR (1948), Articles 18 (thought, conscience, religion) and 19 (opinion) of ICCPR (1966), Articles 9 (thought, conscience, religion) and 10 (expression) of the ECHR (1950), and Articles 9 (thought, conscience, religion) and 10 (expression), Part I of Schedule 1 of the HRA 1998.

See Articles 13 (movement) and 14 (asylum) of the UDHR (1948), Article 12 (movement) of the ICCPR (1966), Articles 2 (movement) and 3 (no expulsion) of Protocol 4 (1963) of the ECHR (1950).

See Articles 3 (life, liberty, security of the person), 8 (arrest, detention, exile), 10 (fair public hearing) of the UDHR (1948), Articles 6 (right to life) and 9 (liberty, security, fair trial) of the ICCPR (1966), Articles 5 (liberty, security) and 6 (fair trial) of the ECHR (1950), and Articles 5 (liberty, security) and 6 (fair trial), Part I of Schedule 1 of the HRA 1998.

See Chadwick and Berg [23], Callahan [18], Benatar [10], and others, who suggest that non-autonomy interests, when considered at all, are used to lead straight back to autonomy and individualism. Indeed, it has been claimed that autonomy is the primary if not the only interest worthy of protection [43].

In 1998, the USA, with approximately 4% of the world’s population, generated some 22% of the world’s green-house-effect causing CO₂ emissions: Your Planet Earth (2000), at www.yourplanetearth.org (Aug. 17/05).

From 1982–1990, southern countries received US$927 million in aid, grants, trade credits, direct private investment and loans, but paid out US$1.3 trillion in interest and principal. From 1991–1998, grants to developing countries went down from US$35 billion to US$23 billion [9].

UNESCO [97], at 10, has suggested that solidarity is an ethical imperative of growing importance given ideals of collective social protection and fair opportunity and the existence of serious inequalities in access to healthcare worldwide. Benatar et al. [9], claim that solidarity is the most important global health ethic and must be applied on a global basis. See also Mayor [71].

The necessity for such collaborations is identified in the Bangkok Declaration (2000). See also Tollman [96], and Benatar and Singer [8]. The idea of capacity building in less enabled states is being pursued within Europe through the EU Framework Programs and the work of the EST, which encourages joint projects, multi-state funding and international peer review: Conference, “Towards a European Research Area” (Oct. 19–21, 2005).

For more on the inequity of the current distribution of medical resources, see www.pharmaportal.com, www.globalforumhealth.org.

See Article 27 of the UDHR (1948), Article 15 of the ICESCR (1966), and Articles 1, 2 and 7 of the Convention on Biological Diversity (1992), which espouse sharing technology so as to exploit and preserve biological/genetic resources, and Articles 12, 15, 16, 17 and 18 of the same Convention, which envision sharing knowledge, research and biotechnology with developing states.

Social and ethical accounting, auditing and reporting provides a practical mechanism for companies to integrate new patterns of civil accountability and governance with a business success model focused on deepening stakeholder relationships around both financial and non-financial interests, and that effective methods for doing so are evolving ([Zadek, 105], at 1428).

Cassel and Young [21], argue that over-reliance on autonomy-based consent in NHS research hinders the public good. Both Boter et al. [15], and Dawson [32], also describe research projects where obtaining prior informed consent was not appropriate. Bhagwanjee et al. [11], offer four conditions for foregoing consent.

It is at this stage that the differences between solidarity and altruism become apparent. Legislators are reluctant to legally impose altruism, rightfully likening that concept to a personal sense of unselfish concern for others which cannot be compelled. Its very definition implies the observance of conduct that is not demanded. I would suggest that solidarity is more active and, with its derivative duties, more appropriately compellable.

The Helsinki Declaration, adopted in 1964 and most recently revised in 2000 (with two subsequent “Clarifications”), was a response to the abuses perpetrated in Nazi Germany against involuntary human research subjects in the name of biomedical science. These abuses prompted the Nuremberg Trials and the subsequent Nuremberg Code, drafted by the US judges who tried the cases.

The CIOMS Guidelines, adopted in 1982 and most recently revised in 2002, is primarily concerned with the application of the Helsinki Declaration principles in the context of multinational research implicating developing countries. It was largely a response to the special concerns arising from the HIV/AIDS pandemic and research activities related thereto: see www.cioms.ch/guidelines_nov_2002_blurb.htm (Sep. 8/05).

Nonetheless, and despite their moral authority, universal compliance with them has been questioned ([69, 98], at 22–23).

Although it has been accused of representing the “doers” of research and not the “researched,” and of adopting an under-inclusive revision procedure [5]. The WMA [104] is comprised of representatives from approximately 80 national medical associations from all continents: see www.wma.net/e/about/index.htm (Sep. 2/05). CIOMS, founded under the auspices of the WHO and UNESCO in 1949, is comprised of 18 international organizations, 17 national representatives, and 25 associate members: see www.cioms.ch/frame_current_membership.htm (Sep. 7/05).

This interpretation is arrived at and lamented by Harris [52], and by Forster et al. [39], who also cite the removal of the distinction between therapeutic and non-therapeutic research in the new version as a weakness. However, Weijer and Anderson [100], state that the previous distinction between therapeutic and non-therapeutic research was a major flaw.

Indeed, there were almost immediate calls to revise Article 30, but the pressure to do so has thus far been resisted [40].

Christie [25], argues that something is either moral or not and the same ethical rules should apply wherever research is conducted.

Bastian [5], considers this a “limited approach” to the concept of access to research, which is absent in the Helsinki Declaration.

Guidelines 14 (children), 15 (mental/behavioural disorder), 16 (women) and 17 (pregnant women) offer guidance in specific circumstances. For more on vulnerability, see Macklin [70], and Zion et al. [106].

Calls for a shift from “adversarial national security paradigms” towards a more inclusive, compromising, multilateral and engaging “cooperative global security paradigms” have already been made [9, 74, 75, 99].

Although basic needs are common, disease burdens are not equally shared and capacities are not evenly enjoyed, so specific needs may be heterogeneous. As such, different communities will have different levels and particulars of needs (and responsibilities). This does not negate the validity of the statement that our needs draw us together, particularly now that global mobility is facilitating disease mobility.

One need only look at the impact of the SARS outbreak in China, which spread across the ocean to Canada. For more on that outbreak, see www.who.int/topics/sars/en/, and D. Macer (ed.) [67], at 24.