An essay on health as a precondition of justice.
The lockdown in the end of March due to the coronavirus has paralyzed our society, – justly as it seems and with no major objections by the opposition or the people, at least no audible one. The parliamentarians acted fast and in unity like never before when supplying billions of dollars for economic aid and other measures to somehow absorb the economic and social shock of the quarantine for their citizens. That the shutdown of public life was the only possible and right way to deal with the virus seemed to be out of doubt.
However, things are changing.
Since the forced quarantine is progressing, its economical impacts, as well as the loss of our social and cultural life, start to form our reality. At the same time, the dangers of the virus seem to be veering away from our actual lives, becoming part of the indistinct background noise of our everyday business. „Back to normal“, is what you hear from economists and politicians, „as fast as possible!“.[1] Citizens are starting to question the forced lockdown as well. All over the country demonstrations pop up committed to defending civil rights, especially personal liberty. „You can‘t demonstrate against a virus“, is the reply of some, but this does not address the core of the issue. To me, it seems as if the fundamental question is why and whether we should give health a higher priority than other values, such as personal freedom. In the end, the goal of any modern democratic state is, according to Ernst-Wolfgang-Böckenförde, to provide „assurance of the preconditions for the sustainment of civil life and enabling the satisfaction of individual needs by the citizens“[2]. It is only legitimate, maybe even our duty as convinced democrats, to question whether the current strategy of our government is the best way to meet these goals. Why should we put health first? To me, it seems that before we can answer this question, we have to find what moral significance health has and if it should be considered an independent value from a philosophical point of view.
First of all, there are some practical reasons why health matters. Not only because it is crucial for the quality of the individual life, but because it generally benefits our society. The WHO states in an essay of David Woodward and Richard D. Smith that „the Commission on Macroeconomics and Health reported that each 10% improvement in life expectancy at birth is associated with an increase in economic growth of at least 0.3 percentage points per year, holding other growth factors constant“[3]. Health has a positive impact on economics, nationally and internationally. However, in the acute crisis, it is obvious that the general benefits of a healthy society are outweighed by the negative economical and social consequences of the anti-virus measures. Protecting health has become a burden rather than a benefit for society. Can we find a more fundamental philosophical account why it is important to protect health?
Norman Daniels argues for the special moral importance of health in his book Just health: meeting health needs fairly by referring to different theories of justice, mostly Rawls theory of „Justice as fairness“. To explain Daniels account this should be outlined shortly. As Annette Rid puts it „Rawls argues that a social contract among free and equal citizens would include three general principles of justice: a principle protecting equal basic liberties; a principle guaranteeing fair equality of opportunity; and a principle limiting inequalities to those that benefit the worst off“[4]. Daniel applies these principles to the concept of health. He argues that „protecting normal functioning helps to protect the range of opportunities“[5]. In a just society, according to Rawls, everybody has a fair share of the normal opportunity range. Fair share does not imply that it has to be equal: The range of opportunities we can select from depends on our own abilities and skills. However, pathology seriously impacts our ability to choose some of the opportunities that normally would be available to us. Therefore, it reduces our fair share of the normal opportunity range. This indicates that it is a matter of justice „to keep people functioning normally and thus to assure them the range of opportunities they would have in the absence of disease or disability“[6].
Put that way it becomes obvious that health is not a primary social good. Primary social goods are, according to Rawls, „given by reference to objective features of citizens’ social circumstances, features open to public view: Their secured institutional rights and liberties, their available fair opportunities, their (reasonable) expectations of income and wealth seen from their social position”[7] Health, accordingly, serves as a precondition for those primary goods.
This indicates the moral dilemma that we are facing at the moment. If primary social goods are, as Rawls states „what free and equal persons (as specified by the political conception) need as citizens”[8] and if at least some of these primary goods rely crucially on us being healthy, then assuring health seems to be fundamental for a just society. However, other primary social goods are severely constrained by our efforts to provide health for all citizens at the moment. We find ourselves in the same stalemate as before: Which primary good, which moral value weighs more?
However, the concept gives a moral justification of valuing health and therefore grounds to take part in the social debate.
Wolfgang Schäuble, the current president of the German parliament, stated in an interview with the newspaper Der Tagesspiegel:
But when I hear that everything else has to step back behind the protection of life I have to say: Put in this absolute way this isn‘t right. Basic rights limit each other reciprocally. If there is an absolute value in our constitution it‘s the dignity of man. It is inviolable but does not exclude that we have to die. [9]
Using Daniels‘ concept we have grounds to argue that even though there is no absolute right to health in our constitution, protecting health is closely connected with protecting the dignity of individuals.
According to Joseph Raz, „[r]especting human dignity entails treating humans as persons capable of planning and plotting their future. Thus, respecting people’s dignity includes respecting their autonomy, their right to control their future.“[10] To me this sounds quite alike Rawls ideas. Putting Raz statement in a more Rawlsian parlance might read: protecting human dignity involves protecting our fair share of normal opportunities. And this, as already shown above, relies crucially on the protection of the health of the individual.
Overall now, what did we gain? I want to stress that this is not an argument for health weighing more than other moral values. It is meant to show why health has moral significance from a philosophical perspective, an important base for the consideration of the first question. Now, that we understand how health can be considered a moral value (at least from one line of argumentation, namely that of Rawls, extended by Daniels), we have grounds to compare it with other values and also a better foundation to take part in the controversial debate about the current strategy of our government.
Which I hope we will all do.
Illustration: Hannes Pfeifer
[1] On Saturday 2nd may 2020: Der Bundesverband mittelständische Wirtschaft (BVMW) forderte, die Beschränkungen noch im Mai zu beenden. „Heben Sie den Lockdown auf, bevor es zu spät ist!“, heißt es nach Verbandsangaben in einem Offenen Brief an Merkel. In dem Schreiben wird der Bundesregierung auch „eine rein virologische Sichtweise“ und ein „gefährliches Spiel mit den Zukunftschancen dieses Landes“ vorgehalten see: „Corona-Krise. Wirtschaft fordert Ende des Lockdowns“, in: tagesschau.de, https://www.tagesschau.de/wirtschaft/wirtschaft-deutschland-corona-101.html, last revision 02.05.2020, 09:35 Uhr (accessed 04.05.2020).
[2] Böckenförde, Ernst-Wolfgang: „Die Entstehung des Staates als Vorgang der Säkularisation“ in: Forsthoff, Ernst (Hg.): Säkularisation und Utopie. Ebracher Studien. Stuttgart/ Berlin/ Köln/ Mainz: W. Kohlhammer Verlag 1967. p. 87 The original German quote which I have roughly translated above reads: „Sicherung der Erhaltensbedingungen des bürgerlichen Lebens und Ermöglichung der Befriedigung der individuellen Lebensbedürfnisse durch die Bürger“
[3] Woodward, David; Smith, Richard D: „Global Public Goods and Health: concepts and issues“ in: World Health Organization. Trade, foreign policy, diplomacy and health, https://www.who.int/trade/distance_learning/gpgh/gpgh1/en/index9.html , last revision unkonwn (accessed 04.05.2020). p. 10
[4] Rid, Annette: „Just health: meeting health needs fairly“ in: World Health Organization. Bulletin of the World Health Organization, Volume 86, Nr 8, August 2008 https://www.who.int/bulletin/volumes/86/8/08-054601/en/ , last revision unknown (accessed 04.05.2020).
[5] Daniels, Norman: Just health. Meeting Health Needs Fairly. New York: Cambridge University Press 2007. p. 46
[6] Daniels 2007: p. 58
[7] Rawls, John: Justice as Fairness. A Restatement. Cambridge/ London: Harvard University Press 2001. p. 59
[8] Rawls 2001: p. 60; see also: Rawls, John: Political Liberalism (paperback ed.). New York: Columbia University Press 1995. p. 187–90
[9] Birnbaum, Robert; Ismar, Georg: „Bundestagspräsident zur Corona-Krise. Schäuble will dem Schutz des Lebens nicht alles unterordnen“ in: Der Tagesspiegel, https://www.tagesspiegel.de/politik/bundestagspraesident-zur-corona-krise-schaeuble-will-dem-schutz-des-lebens-nicht-alles-unterordnen/25770466.html, last revision 26.04.2020, 06:47 Uhr (accessed 04.05.2020). I have only roughly translated the german original quote which reads: Aber wenn ich höre, alles andere habe vor dem Schutz von Leben zurückzutreten, dann muss ich sagen: Das ist in dieser Absolutheit nicht richtig. Grundrechte beschränken sich gegenseitig. Wenn es überhaupt einen absoluten Wert in unserem Grundgesetz gibt, dann ist das die Würde des Menschen. Die ist unantastbar. Aber sie schließt nicht aus, dass wir sterben müssen.
[10] Raz, Joseph: The Authority of Law. Oxford: Clarendon Press 1979. p. 221
