Solomon Benatar advocates for a paradigm shift in conceptions of health and Bioethics.
It has long been known that poverty strongly influences the prevalence and mortality rates of diseases like tuberculosis. This remains true today – the Ebola epidemic emerged and raged in three of the world’s poorest countries. Yet only recently has it been widely and publicly acknowledged that health more generally is significantly determined by social circumstances.
Dramatic advances in diagnostic techniques (including sophisticated scanning methods) and in various therapeutic aspects of health care (for example, keyhole surgery and new drugs) have generated considerable optimism for narrowing health disparities and achieving convergence of global health status within a generation. This optimism is unjustified, however, because there has been relatively limited social progress within broader contexts. For example, defining severe poverty as living on less than $2 per person per day, shamefully underestimates what it means to be poor. It also portrays unrealistic interpretations of what is required to achieve healthier and longer lives for more people.
The shift from pre-modern, non-scientific medicine to modern, highly scientific, technically oriented and personalized medicine required a new paradigm of thought. So too a shift in attention from individual health to population health requires new ways of thinking, including an expansion of the current Bioethics discourse.
Almost 50 years ago, the looming environmental threats to health from vastly expanding (and wasteful) consumption of non-renewable resources led to a proposal that Bioethics be defined as the study of the ethics of human life, inclusive of our interactions with the biosphere. However, this idea was unattractive to those with greater interest in making scientific advances that benefit a limited number of people. Bioethics’ initial thrust towards scholarly work and debates on the nature of power relations in medical practice, subsequently embraced dilemmas posed by exciting biotechnological medical advances.
In the early 2000s the SARS epidemic, together with renewed concern about socio-political and environmental threats to life and health, ignited interest in ethical dilemmas inherent in public health and global health, and in the notion of developing sustainability in the 21st century. The term global health ethics was coined as a stimulus to debates and actions that might improve prospects for human health and planetary sustainability.
While ideas about global health ethics were shared by some, ethical dilemmas associated with individual patient care and with the use of emerging biotechnologies have continued to eclipse bioethical scholarship on macro ethical dilemmas.
In recalling the chaos that characterized the world 100 years ago when the first World War was in full swing, we should understand that today’s world is analogously in a state of major disequilibrium. Characteristic features of our current global crises include the instability of a fraudulent global economic system; wide disparities in health, disease burdens, human well-being and suffering; continuing emergence of new infectious diseases; antimicrobial drug resistance; climate change; and environmental degradation with profound loss of species diversity due to human induced extinctions. The interlinking nature of these crises, mired in the aggressive (often fraudulent) competition for resources, is further aggravated by multiple civil wars, and other forms of conflict that result in the displacement of millions of people who are destined to suffer as long-term refugees.
In the context of such major looming threats to health that go beyond biomedical considerations to include the potential for collapse of our civilization, we need to examine how true we are to our allegedly shared values: individual freedoms, democracy, faith in science and the market. Arguably, our unbalanced dedication to hyper-individualism, our embrace of distorted versions of freedom and of human rights, pursuit of anemic forms of democracy, excessive faith in science with neglect of social solutions and domination of a heavily consumerist-oriented market undermine our values.
The magnitude of the task of changing deeply entrenched behavior patterns associated with current ways of life, to which the most privileged people feel entitled, should not be underestimated. But, nor should the potential for human ingenuity. Bioethics should be at the forefront of endeavors to address problems that flow from the misguided quest for endless consumption, economic growth and new technologies that benefit only a few among us.
A recently published book provides a comprehensive and penetrating introductory account of how Bioethics could be extended to become Global Bioethics. This book’s ambitious and visionary ethical and multidisciplinary discourse, together with previously described insights and actions, offers a bridge towards sustainable improvement in the health of people and our planet. The survival of our species is arguably dependent on the vision of turning the seemingly unlimited ingenuity of human kind to such activities.
Solomon Benatar is an Emeritus Professor of Medicine at the University of Cape Town and Adjunct Professor in the Dalla Lana School of Public Health, University of Toronto.