Access to Medicines

PUBLIC HEALTH ETHICS VOLUME 1 • NUMBER 2 • 2008 • 73–82 73 Access to Medicines Thomas Pogge∗ , Centre for Applied Philosophy, Canberra ∗ Corresponding author: Professor Thomas Pogge, Professorial Fellow, Centre for Applied Philosophy, LPO Box 8260, Canberra. Tel.: +61 261255485; Email: . I would pay three million to go into space, says the banker to his attorney. — I wouldn’t go if you paid me, the latter laughs, for me the French Riviera is quite exciting enough. Markets are highly efficient mechanisms for ensuring that outcomes track people’s different preferences. This is illustrated by the first story, which suggests how markets can achieve a miraculously apt match-up of people to vacations or, more generally, commodities. Markets can be similarly efficient in achieving an apt match-up of people to jobs. But markets can be problematic, too, as the second story suggests. Channary rents out her body for a few dollars, often suffering violence and abuse. She will be HIV positive in a few years and, unable to afford advanced AIDS medicine, she will die in her early twenties. The tourist will enjoy quality medical care in his home country and will have quite a few extra years beyond his parents’ life expectancy. Though fifty years older than Channary, he will outlive her by a decade. Some see no moral problem here. They may judge that, when Channary is renting out her body, she is choosing her most preferred option. If she lacked this opportunity, she would be worse off. And if she rents out her body while knowing the risks, then why should others have to bail her out later when, like so many girls before her, she gets sick? But consider the situation, seven years after their encounter, when he gets his coronary bypass while Channary is losing her battle with AIDS. The cost of his surgery is 200 times that of an annual supply of the antiretrovirals she needs. It is wonderful, of course, that he can be given more healthy years of life. But is it right that she is left to waste away, and to die at 23? There are two related points here. Looking to the future, we might ask whether the market-produced outcome tracks what matters. At $150 per year (Rimmer, 2008), Channary cannot afford the antiretrovirals she needs to survive. Does her access to this medicine really matter less than all the other things on which such an amount, or more, is actually spent? Is an extra year of life for her really less important than my jet ski rental or my dinner at the revolving restaurant? Looking to the past, we should question the economic distribution that conditions decisions and market allocations. Channary indeed prefers to rent out her body seeing her younger siblings cry for food and her mother from despair. But how come she is trapped in such an awful set of options? She was born into a poor family in a country that had suffered decades of devastation. Cambodia was drawn into the Vietnam War, which ended in 1975 with a victory for Pol Pot and the Khmer Rouge. Having killed about one-fifth of the population in four years, they were ousted by Vietnamese forces in 1979, but, with support from China, the US, the UK and the UN, the Khmer Rouge continued to wage a devastating civil war that left Channary’s family in perpetual destitution. None of this can be viewed as her responsibility. It is hard to find fault even with her parents, who worked hard all their lives to get by. They did have five children, to be sure, but with high infant mortality and the lack of social security for old age, one can hardly fault them for that. And they could not have foreseen, of course, her father’s early death from typhoid fever. A market system can put poverty to good uses. It is a good thing that those who, for whatever reason, tend to use resources poorly should become poorer as a result and thus get fewer resources to waste. This is good because more scarce resources will then be controlled by people using them well. And it is good also because, under such a system, people have incentives to improve their performance. But these thoughts must be balanced against two other considerations. The penalty should not be hugely disproportionate. The man who wasted heating oil last year, and the woman who overspent her credit card—let the market constrain them to cut back their spending. But this should not lead to their freezing or starving to death or doi: 10.1093/phe/phn023 Advance Access publication on 19 June 2008  C The Author 2008. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org Ah, I would pay a million for an extra year of life, the elderly tourist effusively tells his lover. — We have never had even a hundred dollars, the Cambodian teenager replies, we are a large family. 74 • POGGE tional civil servants, and the general public—if not yet among affluent governments—that human rights impose not merely negative duties not to violate these rights, but also positive duties to protect and promote them. The second route has also been alluded to already. Channary’s situation grows out of an historical process in which we are deeply entangled: the Vietnam War, the establishment of Lon Nol, the continued support for the Khmer Rouge. We may have no share of responsibility in any of this; so reparation for past wrongs is not at issue here. The point is rather that the situations and prospects of all of us are deeply shaped by one common history that has given some of us a start like Channary’s and others vastly superior options and opportunities. Perhaps such huge inequalities could have come about without injustice. But, in fact, they did not. Our common history is deeply pervaded by the most grievous wrongs. And these wrongs taint the huge inequalities this history has resulted in. To be sure, it makes no sense to say that we inherit responsibility for crimes others have committed, even if they were our ancestors and even if they acted for our benefit. But if we rightly disown responsibility for such historical wrongs, then how can we lay claim to the fruits of these wrongs? How can we accept and forcefully defend the great advantages from birth that an unjust historical process has arbitrarily bestowed upon us without addressing the severe deprivations this same unjust process has arbitrarily imposed upon others? The third route will be further discussed in what follows. Historically accumulated, the huge inequalities of the present manifest themselves also in the rules that govern our interactions. The most advantaged have both the power and strong incentives to shape these rules so as to entrench and expand their advantage. This phenomenon is plainly visible in many countries—in the United States, for instance, where contributions to political campaigns can buy legislative outcomes. Such laws, structuring the US economy, have between 1979 and 2005 expanded the national income share of the top 1 percent of the population from 10 to 22 percent (Saez and (...truncated)