Justice and Global Health Research

One of the most interesting and knotty puzzles in global health justice can be found in Margaret Whitehead’s decision tree for determining which health inequalities across human beings demand a social response. Whitehead argued that the subset of health inequalities that are avoidable, unnecessary, and unfair or unjust are health “inequities” (Whitehead 1990). While inequalities are value-free observations, inequities are moral bads that demand social action. While the effort is praiseworthy, I have argued elsewhere that many aspects of the health equity principles are problematic (Venkatapuram 2011). In particular, at the first step, a health inequality or impairment that is deemed unavoidable is moved outside of the scope of equity, ethics, and justice. In philosophy, it is often stated that a moral “ought implies can.” So if a disease/impairment is unpreventable or untreatable, there cannot be an ethical duty to prevent or mitigate a resulting health inequality. However, such a first cut would also dissipate any claims to or duties to conduct research on a disease/impairment that is currently unavoidable because we lack the knowledge about how to do so. A health inequality can also be unavoidable because there are not enough resources in a specific location to apply extant knowledge such as in many developing countries. Therefore, in relation to health and more, the prevailing view has been that moral claims and duties that cannot be immediately fulfilled are meaningless. Informed by his analyses of famines and Ronald Dworkin’s account of rights, Amartya Sen offered a novel argument for a “meta-right”—a meta-right to x is a right to policies p(x) that genuinely aim to have the right to x realizable (Sen 1984). Sen’s meta-right challenges Whitehead’s first principle. When a health inequality is deemed unavoidable, a meta-right to health can still motivate both health sciences research and broader social and economic policies that aim toward realizing a right to health. That is why it is at the core of my argument for a human right to health or, more accurately, a meta-right to the metacapability to be healthy. It is thus noteworthy that Pratt and Hyder present a justice-based argument and an “ethical checklist” for the governance of transnational global health research consortia (GHRCs) (Pratt and Hyder 2016) They present criteria for what global health research should be done as well as who should do what, where, when, how, and so forth. Importantly, these criteria are said to reflect the capabilities approach (CA) to (global) health justice, particularly relying on Jennifer Prah Ruger’s prolific writings on health (care) governance. I am wholly sympathetic with the mission of linking global health research to conceptions of (global) justice, as well as to extending and utilizing the CA for such a mission. However, Pratt and Hyder’s argument is unsatisfactory. I focus on three aspects, including their principle of LMICs first and foremost; their priority of worst off in terms of shortfall equity; and their purpose of science. Throughout the article and in the checklist, Pratt and Hyder assert the importance of the GHRCs ensuring that their LMIC research partners are the center of the research endeavor; their voices and those of their community members must be heard; their priorities should determine the GHRC’s priorities; most of the GHRC’s resources should go to the LMIC researchers and research; and leadership roles should be given to LMIC researchers. Pratt and Hyder do not provide any justification for why research resources should be directed to LMICs in the first place, or for why GHRCs should be initially formed. They point to the CA for such justification, and focus on arguing for putting LMIC research(ers) first in various aspects of the functioning of the consortia. This is understandable as so much of health equity, human rights, and human-centered development thinking argues for participation of those affected (i.e., “nothing about us without us”). However, an important consideration moves against a uniform central role for LMIC researchers, especially codified into a checklist. In global justice philosophy, there is a general acceptance of an ethical duty to correct harms one has caused even if it occurs in other countries (Føllesdal and Pogge 2005). It is also recognized that there is an ethical duty to prevent possible future harms from one’s actions. Correcting past harms and preventing future harms could address significant human