The editors of the special section on Global Health Fieldwork, Ethics and Human Rights are to be lauded for making visible some of the ethical challenges that arise in global health fieldwork within a context of human rights. The issue provides thought and concrete proposals on how to bring an ethical analysis into global health practice. The invisibility and neglect of ethics has been problematic in global health practice.
Many years ago, as a health and sanitation coordinator for a non-government organization (NGO) in Bolivia, I was confronted with a cholera outbreak, a failed potable water project, and endemic neglected tropical diseases. This experience of witnessing the effects of a poorly designed project riddled with power imbalances, together with the unnecessary deaths from a disease which is treatable, and easily preventable, sparked in me what Paul Farmer calls, road angst, an angst which has shadowed me to this day, more than 28 years later. ‘The ethical darkness of global health’ as described by Richard Horton is real. Unfortunately, it is not limited to the area of global health but is found throughout international development and humanitarian aid.
The proposed Framework Convention on Global Health states, ‘The world fails nearly 20 million people every year, and fails billions more people whose lives are shattered by want and deprivation.’ In the 21st century, there are still millions of children, women, and men whose rights to clean running water, a safe and secure supply of food, education, and other basic conditions are not fulfilled. This is a failure of states to fulfil their international legal obligations, and it is also a moral and legal failing of institutions involved in aid and humanitarian responses.
In response to David Miliband’s claim that we are living in an age of impunity, Horton states that ‘non-intervention has become the norm, irrespective of the scale of the atrocity. The 21st century is being defined by diminished outrage and accountability.’
David Ross, in an attempt to increase the ethical rigor of global health fieldwork proposes ethical reviews for all global health fieldwork proposals. This may provide fruitful gains, but to lighten the ethical darkness, structural changes are needed in the global economic and political order. To make these changes we need to understand the situation we are in today, and how we got here. There is a risk that by pushing an ethical focus into global health, that ethics becomes just another buzzword and checkbox to complete. The challenge is to ensure a philosophically rigorous underpinning of ethics.
The value of philosophy
As acknowledged throughout the special section, global health is interdisciplinary and complex, requiring insights and integration of several disciplines, including importantly, philosophy. Through challenging assumptions (implicit and explicit) and clarifying concepts, philosophy helps identify and understand the complex societal constructs that maintain global health inequalities and inequities. Central to the essence of philosophy is analysis and critique, including a moral dimension.
To think ethically means to consider the good and harm that can result from individual, institutional and state action. This harm is not limited to that done to individuals, but also to communities and nations. Barriers to equitable global health include power imbalances at all levels. One way of thinking about this is to consider ethics at two levels: the ethics of global health; and the ethics in global health. These two levels are inter-related and interdependent.
The ethics of global health is concerned with the macro level: the ethical issues that may arise with the policies and programs implemented at a global level, such as the Sustainable Development Goals. But is also concerned with the responsibility, obligations, and accountability of institutions, as well as states towards their populations and the rest of the world. The ethics in global health is more relevant to global health professionals in the field; from making decisions about priorities of actions; dealing with cultural relativism; differing worldviews, values and attitudes, data sharing, and so on. Both levels are important and cannot be addressed nor understood separately.
Understanding and addressing ethical issues is not easy. To be able to respond to such challenges requires skills in the analysis and reasoning of these complex dilemmas which is where a philosophical training can contribute. Philosopher Stephen Toulmin suggests that in medicine and criminal justice, specialists such as psychiatrists, lawyers and judges, can benefit from philosophers. Health professionals are not generally trained in ethical theory and many do not have the adequate analytical skills to evaluate ethical situations effectively. An understanding of ethical theory, ethical analysis, and reasoning is essential to good ethical practice.
Introductory courses in ethics are helpful, but not sufficient to enable health professionals to be competent in ethical analysis. Higher level ethics courses offered in postgraduate programs in global health and public health would also be helpful. Such postgraduate ethics courses should bridge ethical theory with the practice of global health, applying theoretical frameworks to case studies.
Global health ethics
The ethics of global health is broader than medical ethics and research ethics. Ethical principles used in bioethics are beneficence, non-maleficence, autonomy, justice, veracity, and fidelity. In global health these principles are still important but also necessary are considerations of global health equity, political responsibility, pragmatic solidarity, and maybe others.
With ethics comes responsibility: assuming the responsibility for one’s actions but also for the consequences of these actions, intended and unintended. This may include calling out the harms that those who wield power directly and indirectly visit upon much of the world’s population, and holding them accountable for their actions.
To understand ethical challenges, there is a need to understand and address flagrant injustices and inequities. This includes, for example, the imbalance of power between richer and poorer countries reflected in the prioritization of national interests over global interests (such as food aid policies) and a global economic order intended to benefit richer countries over poorer. Philosophy and philosophers, along with the social sciences, can promote a better understanding of the causes of global injustices.
One of the underlying problems which contributes to the ethical darkness in global health is the way some lives are valued less than others, described by Judith Butler as the grievability of lives. This serious ethical issue imbues global health fieldwork at all levels. Ethical cowardice evident today is not only of those who violate ethical principles but also of those who remain silent in the face of unethical treatment of communities and individuals. Impunity should not be tolerated.
As someone who used to work in global health fieldwork but now teaches philosophy and global health/global ethics courses, I see the incredible worth of philosophical thinking but also am cognizant that this requires skill development. We do ethics an injustice and dilute its significance by reducing it to an empirical and subjective tool. If we are serious in wanting to address global health inequities, then we require professionals well-trained in ethics, otherwise there is a risk of breeding complacency and reducing ethics to token gestures.
It is undeniable that the need to implement an ethical dimension in all global health fieldwork is urgent; to work towards health as a human right also needs ethics. The challenge lies in ensuring that a philosophically rigorous form of ethics is upheld; one where the ethics of global health, as well as the ethics in global health are integral parts of global health theory and practice.
Anna Malavisi, PhD, is assistant professor, Department of Philosophy and Humanistic Studies at Western Connecticut State University, USA
 Paul Farmer, To Repair the World, (Oakland, CA: University of California Press, Oakland, 2013).
 R. Horton, Offline: The ethical darkness of global health, The Lancet, Volume 394, Issue 10194, P200, July 20, 2019
 Health for All: Justice for All. (The FCGH Manifesto) (2012). Available at: https://www.jalihealth.org/documents/manifesto.pdf
 Horton, see note 2
 D. Ross. Institutionalizing ethical review in global health practice: A modest proposal, Health and Human Rights, 21/1, pp 45-47
 G. Priest, What is Philosophy, Philosophy 81, 2006, p-189-207.
 S. Toulmin. “The Recovery of Practical Philosophy,” American Scholar, 57, 3 (1988), pp. 337- 352
 J. Butler, Frames of War, (Verso, 2009).