International Justice and Health: A Proposal

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In the ten healthiest counties in the United States, white men have a life expectancy above 76.4 years. By contrast, in the ten least healthy counties, African-American men have a life expectancy of between 61 (Philadelphia) and 57.9 years (District of Columbia). (1) The difference is staggering. Not only that, but in the absence of some very special explanation, it seems manifestly unjust. Some famous remarks of John Rawls resonate distinctly here: "Intuitively, the most obvious injustice of the system of natural liberty is that it permits distributive shares to be improperly influenced by these factors so arbitrary from a moral point of view." (2) What factors could be more arbitrary than the color of one's skin or the county of one's residence?

In other contexts, however, a fifteen-year difference in life expectancy can seem like small potatoes. In 2000 male life expectancy at birth in Malawi, for example, was 37.1 years, as compared to 73.9 years for the United States. (3) That is a difference of almost thirty-seven years--a factor of two--and the United States is far from being top of the table. Even in comparison to average life expectancy worldwide, the differences are substantially worse in the international context. Combining male and female rates, global life expectancy at birth was 64.5 years in 1999. (4) Twelve countries, all in sub-Saharan Africa, had both female and male life expectancies at birth that were twenty years or more below the global average in 1999; and a further eighteen countries, all but one in sub-Saharan Africa, were fifteen years or more below the global average, again for both females and males. (5) The global average is itself some sixteen years below the top.

International differences in life expectancy are so outrageous that it may seem beside the point to inquire into the basis in justice for condemning them. Presumably, few would disagree that in this respect, not to mention others, our world is grossly unjust. Still, at least until recently, anyone who did so inquire was bound to be disappointed, sorely and surprisingly. Theories of justice have had precious little to say about the requirements of international distributive justice. For the most part, philosophers have confined themselves to articulating the requirements of justice as it applies to a domestic society under ideal circumstances. Rawls's celebrated two principles of justice, for example, apply only to the basic structure of a society that is both "a closed system isolated from other societies" and also "well-ordered." (6) Yet, if present-day differences in life expectancy among nations offend against any moral precept, they presumably offend against justice--specifically, international justice. Principles restricted to the domestic case simply do not reach the issue.

More recently, philosophers have begun to attend to the subject of international distributive justice. Their point of reference, by and large, has been Rawls's principles and framework for the domestic case. (7) For example, Charles Beitz argues that the principle of justice governing the distribution of resources among nations is simply Rawls's difference principle, applied globally. (8) Rawls himself has now gone on to elaborate his own extension of his framework to the international case, (9) albeit one that signally, and somewhat ironically, lacks a principle of distributive justice. So there has been progress of a kind, even if much work plainly remains to be done.

But while it has become more common for theorists of justice to relax the restriction to the domestic case, the second of the traditional simplifications remains more or less firmly in place. The ambition continues, that is, to be a prescription for ideal circumstances. This is not, of course, because anyone thinks that the world as we know it is actually well-ordered. Rather, the idea is that a fully just arrangement is, in some important sense, theoretically prior. …