Health and justice: the capability to be healthy.

This is an inter-disciplinary argument for a moral entitlement to a capability to be healthy. Motivated by the goal to make a human right to health intelligible and justifiable, the thesis extends the capability approach, advocated by Amartya Sen and Martha Nussbaum, to the theory and practice of the human health sciences. Moral claims related to human health are considered at the level of ethical theory, or a level of abstraction where principles of social justice that determine the purpose, form, and scope of basic social institutions are proposed, evaluated, and justified. The argument includes 1) a conception of health as capability, 2) a theory of causation and distribution of health capability as well as 3) an argument for the moral entitlement to a sufficient and equitable capability to be healthy grounded in the respect for human dignity. Moreover, the entitlement to the capability to be healthy is defended against alternative ethical approaches that focus on welfare or resources in evaluating and satisfying health claims. In specific, it is argued that human health is best understood as a capability to be healthy—a meta-capability to achieve a cluster of basic and inter-related capabilities and functionings. Such a cluster of capabilities and functionings is in line with Martha Nussbaum’s central human capabilities. A theory of causation and distribution of health capability is put forward that integrates the “classic” biomedical factors of disease (genetic endowment, exposure to hazardous materials, behaviour), social determinants of disease, and Drèze and Sen’s econometric analysis of the causation and distribution of acute and endemic malnutrition. Furthermore, the argument critiques Norman Daniels’s revised Rawlsian theory of health justice, and advocates for the capability approach to recognize group capabilities in light of “population health” phenomena. Lastly, the thesis also argues that a coherent, capability conception of health as a species-wide conception will tend to make any theory of justice recognizing health claims a cosmopolitan theory of justice

The Capability Approach: A Framework for Population Studies

The aim of this paper is to present the main elements of the Capability Approach (CA) and discuss how and to what extent it can be a useful framework for capturing and analyzing population issues. Since the initial idea of Sen in 1979 to introduce the notion of human “capabilities” as a coherent alternative to measuring poverty, an extensive interdisciplinary school of thought has developed an analytical and normative framework that is outlined here in the first section. After introducing the CA, we sketch out a step-by-step procedure to use the CA in empirical analysis, focusing on the linkages among the plurality of circumstances at the individual, household and contextual levels. The fourth section discusses the approach shared by the CA and the population paradigm as formulated at the Cairo conference, which shifted away from aggregate indicators and biological functionings to a focus on choice and capabilities

There Are Many Purposes for Conditional Incentives to Accessing Healthcare Comment on “Denial of Treatment to Obese Patients—the Wrong Policy on Personal Responsibility for Health”

This commentary is a brief response to Nir Eyal’s argument that health policies should not make healthy behaviour a condition or prerequisite in order to access healthcare as it could result in the people who need healthcare the most not being able to access healthcare. While in general agreement due to the shared concern for equity, I argue that making health behaviour a condition to accessing healthcare can serve to develop commitment to lifestyle changes, make the health intervention more successful, help appreciate the value of the resources being spent, and help reflect on the possible risks of the intervention. I also argue that exporting or importing the carrot and stick policies to other countries without a solid understanding of the fiscal and political context of the rise of such policies in the US can lead to perverse consequences

Limitations of the Millennium Development Goals: a literature review

With the Millennium Development Goals (MDGs) showing uneven progress, this review identifies possible limitations arising from the MDG framework itself rather than extrinsic issues. A multidisciplinary literature review was conducted with a focus on limitations in the formulation of the MDGs, their structure, content and implementation. Of 1837 MDG-related articles, 90 met criteria for analysis. Articles describe MDGs as being created by only a few stakeholders without adequate involvement by developing countries and overlooking development objectives previously agreed upon. Others claim MDGs are unachievable and simplistic, not adapted to national needs, do not specify accountable parties and reinforce vertical interventions. While MDGs have promoted increased health and well-being in many countries by recognising and deliberating on the possible constraints of the MDG framework, the post-2015 agenda may have even greater impact. Complex problems have simple, easy to understand, wrong answers (Henry Louis Mencken

Towards a Multi-Dimensional Index of Child Growth to Combat the Double Burden of Malnutrition

Background: There is growing awareness in the field of public health that combatting the double burden of malnutrition requires approaches that address its multi-dimensional origin, rather than focusing primarily on the biomedical domain. Current frameworks of malnutrition like the UNICEF conceptual framework, and the Lancet Series 2013 framework have been instrumental in understanding the determinants of malnutrition and developing appropriate interventions. However, these frameworks fail to explicitly address issues of agency, that is, about being able to pursue one’s goal. The capability approach as originally developed by Amartya Sen includes agency in the causal chain.Summary and key Messages In the past 5 years, the International Union of Nutritional Sciences Task Force “Towards a multi-dimensional index for child growth and development” has developed a capability framework for child growth, and conducted empirical research applying this framework. The working group discussed what would be needed to further develop the approach and explained the added value to international organisations and policy makers. We suggest developing an index of advantage that will be a proxy for a child’s agency. We hypothesise that such an index will explain much of the variance in studying inequalities in child nutrition and thus call for action to improve this focal point

Contextual equipoise: a novel concept to inform ethical implications for implementation research using randomised controlled trials in low- and middle-income countries

The call for universal health coverage requires the urgent implementation and scale-up of interventions that are known to be effective, in resource-poor settings. Achieving this objective requires high-quality implementation research (IR) that evaluates the complex phenomenon of the influence of context on the ability to effectively deliver evidence-based practice. Nevertheless, IR for global health is failing to apply a robust, theoretically driven approach, leading to ethical concerns associated with research that is not methodologically sound. Inappropriate methods are often used in IR to address and report on context. This may result in a lack in understanding of how to effectively adapt the intervention to the new setting and a lack of clarity in conceptualising whether there is sufficient evidence to generalise findings from previous IR to a new setting, or if a randomised controlled trial (RCT) is needed. Some of the ethical issues arising from this shortcoming include poor-quality research that may needlessly expose vulnerable participants to research that has not been adapted to suit local needs and priorities, and the inappropriate use of RCTs that denies participants in the control arm access to treatment that is effective within the local context. To address these concerns, we propose a complementary approach to clinical equipoise for IR, known as contextual equipoise. We discuss challenges in the evaluation of context and also with assessing the certainty of evidence to justify an RCT. Finally, we describe methods that can be applied to improve the evaluation and reporting of context and to help understand if contextual equipoise can be justified or if significant adaptations are required. We hope our analysis offers helpful insight to better understand and ensure that the ethical principle of beneficence is upheld in the real-world contexts of IR in low-resource settings