THE CROSS-CULTURAL IMPORTANCE OF SATISFYING VITAL NEEDS
bioe_1761486..496ALLEN ANDREW A. ALVAREZ
Keywords vital needs, basic healthcare,
health resource allocation, extreme scarcity,
basic agency, preintrinsic value
ABSTRACT
Ethical beliefs may vary across cultures but there are things that must be valued as preconditions to any cultural practice. Physical and mental abili-ties vital to believing, valuing and practising a culture are such precon-ditions and it is always important to protect them. If one is to practise a distinct culture, she must at least have these basic abilities. Access to basic healthcare is one way to ensure that vital abilities are protected. John Rawls argued that access to all-purpose primary goods must be ensured. Amartya Sen and Martha Nussbaum claim that universal capa-bilities are what resources are meant to enable. Len Doyal and Ian Gough identify physical health and autonomy as basic needs of every person in every culture. When we disagree on what to prioritize, when resources to satisfy competing demands are scarce, our common needs can provide a point of normative convergence. Need-based rationing, however, has been criticized for being too indeterminate to give guidance for deciding which healthcare services to prioritize and for tending to create a bottomless-pit problem. But there is a difference between needing something (first-order need) and needing to have the ability to need (second-order need). Even if we disagree about which first-order need to prioritize, we must accept the importance of satisfying our second-order need to have the ability to value things. We all have a second-order need for basic healthcare as a means to protect our vital abilities even if we differ in what our cultures consider to be particular first-order needs.
INTRODUCTION
The WHO Commission on the Social Determinants of Health recently lamented the tragic health inequities observed within and between countries.1 It laments the fact that girls born in Japan and Sweden can expect to live more than 80 years, while girls born in several African countries can expect to live only fewer than 50. The Com-mission asserts that ‘there is no necessary biological reason’ for this and that these inequities can be remedied
if the necessary social, political and economic actions are taken. The Commission advocates universal healthcare coverage that is not dependent on people’s ability to pay.2 The reason for trying to remedy health inequities need not only be the egalitarian moral intuition that individu-als should be regarded with equal concern and respect, as it is commonly held in the Western societies. Concern for equality is not the only reason to support universal access
1CSDH. 2008.Closing the gap in a generation: health equity through
action on the social determinants of health. Final Report of the Commission on Social Determinants of Health.World Health Orga-nization. Available at: http://whqlibdoc.who.int/publications/2008/ 9789241563703_eng.pdf [Accessed 28 Aug 2008].
2 While recognizing that health status is determined largely by other
social determinants, the Commission affirms that ‘maldistribution of health care – not delivering care to those who most need it – is one of the social determinants of health.’ It even states that ‘Health-care systems8 [preventive, curative and palliative interventions, whether directed to individuals or to populations] are a vital determinant of health.’ Ibid: 1, 94, 100.
to basic healthcare. There are other plausible reasons (that are non-comparative and enabling) for wanting to improve poor health status that merits support across cultures.
Every individual has a vital need3
to protect her basic ability to feel, desire, value, choose, and act on the choices she makes. People may differ on particular beliefs, values, and preferences but they have a common vital need to protect their basic abilities to have these dispositions. The importance of their common enabling vital needs precedes the importance of particular things they value since they won’t be able to do this in the first place without having basic abilities that vital needs satis-faction protects. The importance of vital needs satisfac-tion cannot be trumped by particular valued things within a culture without contradicting the need for the ability to value such things. We can disagree about the rightness or wrongness of particular cultural practices but we cannot disagree about the fundamental impor-tance of the ability to practise a tradition, especially the ability to evaluate it as wrong or right. The practice of culture and its evaluation both require some basic physi-cal and mental abilities. It is pointless to ask which of our competing values are more important if the bases of our ability to value these are threatened by deprivation of our vital needs. We undermine the importance of our basic abilities when we pit the importance of our access to resources that satisfy our vital needs against resources we need only to satisfy our preferences relative to our own cultural values. The importance of vital needs satisfaction cannot be trumped by particular preference-based needs shaped by particular cultures. It must be given a special place in discussing ethics of health resource allocation that can be appreciated even when the discussants come
from different cultures. This we must do if we are to avoid the inconsistency of prioritizing what we will not be able to enjoy when we set aside vital enabling needs. This is what I mean when I refer to the idea of cross-cultural importance of satisfying vital needs. To explore this idea, I proceed as follows. First, I discuss why I think the idea of the importance of vital needs satisfaction is different from the much discussed and often discredited account of the moral force of basic needs. I situate the discussion in the context of health resource allocation and distributive justice. I argue that the difference depends on whether the needs in question are assumed to be above the bottom floor of vital enablement or not. The vital-needs account stipulates a definite universal level of needs satisfaction that must be achieved first before one could value other needs, desires and preferences. Secondly, I discuss what vital needs satisfaction means, its relation to basic agency, and the value it affords in relation to valuing itself. Then finally, I suggest what role vital needs satis-faction can play in developing a cross-cultural framework for discussing the ethics of health resource allocation, especially in countries that suffer from extremely tight health budgets. For example, such framework can provide multicultural societies, such as the Philippines,4 with a point of consensus that proponents of competing values can support.
WHAT IS THE DIFFERENCE BETWEEN
BASIC NEEDS AND VITAL NEEDS?
It is difficult to decide which needs, in general, are legiti-mate because needs tend to be dependent on the value of what they are needed for.5
Another difficulty is that the value of health as a need depends on the satisfaction of other more basic needs, without which health matters
3 I use the term ‘vital needs’ to emphasize what is necessary for basic
agency. The term has been used extensively in environmental ethics to emphasize the kind of human needs that are strong enough to trump needs of other life forms. Knut Erik Tranøy, in his 1975 article, con-trastsvital needswith non-vital butlegitimate needs. The very title of Tranøy’s article, especially the word ‘can’, apparently implies that ‘vital needs’ is related to basic agency. See K.E. Tranøy. Ought’implies ‘can’: A bridge from fact to norm? Part II.Ratio1975; 17: 147–175. Tranøy writes that ‘prolonged or definitive frustration’ of vital needs ‘kills or
disables[emphasis added]’ (p. 155) suggesting that human basic ability is undermined whenever vital needs are not satisfied. David Wiggins explicitly makes a distinction between basic and vital needs: a need is basic ‘just if what excludes futures in whichyremains unharmed despite his not havingxare laws of nature, unalterable and invariable environ-mental facts, or facts about human constitution’; a need is vital if it is urgent, grave, entrenched, and non-substitutable. D. Wiggins. 1998.
Needs, values, truth: essays in the philosophy of value. Oxford: Clarendon Press: xii, 14–17, 22–23, 39–40. Cf. D. Wiggins. 1985. Claims of Need. InMorality and objectivity: a tribute to J L Mackie.T. Honderich, ed. London: Routledge and Kegan Paul: 149–202. Although I share the priority Tranøy and Wiggins give to vital needs versus other needs, my emphasis is on characteristics of vital needs that make agency possible. Cf. A. Sen. 1999.Development as freedom. Oxford: Oxford University Press.
4A.J. Romualdez. 2008. State of the Nation’s Health. Available at: http://centennial.lectures.upm.edu.ph/UP_Centennial_Lecture_Series/ romualdez.html [Accessed 24 Nov 2008]. Since annual health expendi-tures in the Philippines fall below the 5% of GDP minimum set by the World Health Organization (WHO), scaling up basic healthcare provi-sion to a level sufficient to satisfy vital needs would enable many poor Filipinos to contribute to the economic and political life of the country. Such policy could also work in other countries, especially in these times of global economic crisis. Expanding universal health insurance cover-age in the US, for example, could stimulate the economy because it has been found to increase spending on other consumer goods. J. Gruber & A. Yelowitz. Public Health Insurance and Private Savings.J Polit Econ
1999; 107: 1249–1274: 1271. If people spend more on healthcare, they won’t be able to spend for other consumer goods anymore. Provision rather than deprivation of vital needs is the way to enable people to contribute in solving the causes of scarcity. Cf. J. Gruber. Universal
Health Insurance Coverage or Economic Relief – A False Choice.N
Engl J Med2009; 360: 437–439.
less.6
Also, although it seems easy to claim that needs have priority over mere preferences, needs in general are too indeterminate to provide guidance in choosing what must be prioritized when resources are scarce.7
When needs are used to determine what healthcare should be provided, it tends to impose limitless demands for resources.8These worries may be relevant to basic needs that are shaped by particular cultures, but not to vital needs that are universally enabling across cultures. While the basic needs required for the practice of a particular culture may not be as basic in other cultures, vital needs are so fundamental that their deprivation will disable persons from practising any cultural tradition, even the least demanding ones. Moderate scarcity may allow us to satisfy basic needs that are not vital, but extreme scarcity could undermine our capacity to satisfy even our vital needs.
Some objections to the moral force of needs
Brian Barry wrote a series of brief notes on needs where he argues that the value of needs is derivative and that needs don’t have independent justification. Needs always occur in the derivative formula:Aneedsxin order toy.9 The justification of the need for x is derived from the importance of what comes after the phrase ‘in order to’. This formula implies that needs are important only if the purpose for needing it is important. My response to this is that even if most needs have derivative value, it is not necessarily the case with needs that arevital. The impor-tance of the vital need for protection from ability-harming or agency-ability-harming conditions (e.g. physical and mental infirmities) is not necessarily derivative. Satisfaction of vital needs,ceteris paribus, is a precondi-tion to having ends to value.10 However, Barry further argues that although claims connected with ‘core’ basic human needs do not usually demand that the purpose be stated (as it is with needs in general) ‘. . . it is still deriva-tive and the only interesting questions arise in connection
with the ends.’11
But we may ask, ‘Whose ends should it be?’ Is it not the case that it only makes sense to talk about ends when they are owned by someone (whether the owner herself or her proxy)? By recognizing that purpose must be owned, we reveal that Barry’s insistence, that even ‘core’ basic needs (or vital needs) are derivative, involves an assumption that the vital needs of purpose owners have already been sufficiently satisfied for them to be able to have ends in the first place. If Barry does not assume such vital needs satisfaction, then he must at least assume that there are others, say evaluators,12 who already have the ability to conceive and value ends as a proxy owners of the need in question. Even a proxy has a vital need for the ability to conceive and value ends. Vital needs satisfaction is a precondition13to having ends. All evaluators of ends have a vital need for the ability to have ends, so that when the one in need is not able, another evaluator should be able to talk about such connection between need and the supposed end it serves.14In short, for Barry to be correct that even ‘core’ basic needs have derivative value, someone needs to have at least the ability to make the connection between that basic need and the purpose from which its value is derived. This viciously leads to requiring an enabled evaluator for every level of derivation. To avoid this viciousness, we could just simply recognize that satisfaction of vital needs is a precondition to having the vital ability to have ends. If we must refer to protecting our ability to have ends as an end, we must not classify it as atypeof end belonging to the same set of ends we are able to have. Otherwise it would imply that we could choose between valuing the ability to have ends and valuing the ends that we are enabled to have as if these ends were of the same type. Thus, it is not correct to say that all needs are derivative because we must differentiate the importance of vital needs from the importance of non-vital needs that depend on specific ends to be valuable. Vital needs are those that must be satisfied in order to have ends in the first place. The idea of derivative importance does not apply yet to the vital need for ‘the ability to have ends’ as it does to needing something for ‘a particular end’ that we already have.15 The non-derivative value of the vital need to
6 J. Griffin. 1986.Well-being: its meaning, measurement, and moral
importance. Oxford: Oxford University Press: 52.
7 E.J. Emanuel. 1991.The ends of human life: medical ethics in a liberal
polity. Cambridge, Mass.: Harvard University Press: 110. 8 Ibid: 110–112.
9 Barry,op. cit.note 5, pp. 47–49, lxiv–lxix. Barry asserts this about needs to avoid the ‘danger of treating it as an independent justificatory principle’ (p. 49). This view is similar to Alan White’s position in A.R. White. 1975.Modal thinking. Oxford: Blackwell: 102–123.
10 Barry counters that it is not the case that everybody’s welfare is
valuable. If the welfare of evil individuals like Hitler is disvalued, the duty of Hitler’s physician to meet his needs becomes weaker. See Barry,
op. cit.note 5, p. lxvii. Barry seems to dismiss the physician’s duty to do no harm without justification. Even without saying thatprimum non nocereis beyond argument, it must be shown to be false before it can be dismissed in favor of other values.
11 Ibid: 49.
12 Or perhaps, ideal rational observers.
13 I use the term ‘precondition’ as Len Doyal and Ian Gough used it in
explaining their idea of survival as ‘precondition for human action and interaction’. L. Doyal & I. Gough. 1991.A theory of human need. New York: Guilford Press: 50–55.
14 That second evaluator (when not able herself) will in turn need
another evaluator to talk about her own need-end connection, so on and so forth.
15 Some needs and ends have instrumental/derivative value with respect
protect basic abilities that make having valued ends pos-sible gives moral force to the necessity of its satisfaction.
James Griffin16
claims that health is an example of a need that can matter less when deprivation of other needs (e.g. liberty and minimum material provision) makes life not worth living. He contends that the importance of health as a basic need depends ‘upon the level of satisfac-tion of other basic needs; if my needs for liberty and minimum material provision are not met, and are so unlikely ever to be met that life is not worth living, then health must matter less too.’17 It seems that Griffin assumes that ‘health’ refers to a physical condition that is better than normal and not the kind of normal condition that material provision and liberty enable. But if he means that an agent will not be able to value anything in life without the satisfaction of her basic needs, then it is strange that he thinks health would matter less. It should have been the opposite. Health as having basic abilities should matter more, not less, because basic health is nec-essary to enable anyone to do basic things, e.g. provide for oneself, acquire liberty, defend one’s freedom, or acquire more freedom. The point of Griffin’s broader argument is, roughly, that an agent’s informed desire determines her good. He may be correct in pointing out that satisfaction of some basic needs is important for what basic needs enable. Its effectiveness is indeed affected by satisfaction of other needs. He is not quite correct, however, in citing health as an example of a basic need that depends on other basic needs. It cannot be that even health must matter less than desires when the pos-sibility of having desires depends of the fact that one is at least healthy enough to desire things. Health to Griffin – in certain respects – seems to be merely a kind of physical fitness that is a result of exercising,18 so that its impor-tance diminishes when life is no longer worth living.19He argues that it would be ‘far too strong’ a claim to set aside the desires for libraries or schools in favour of the need for exercise equipment for keeping oneself fit. It is cer-tainly far too strong in the case of exercise equipment but
not in the case of health or healthcare. The demands for education and health are not mutually exclusive. The fact is, not having either of these two can affect the other. It is not uncommon to see evidence showing that receiving education improves health.20
But in order to receive edu-cation one must at least have the necessary ability to study. One must be ‘healthy’ enough to go to school or receive education.21The one who desires to be educated can only benefit from going to school if she is at least healthy enough to study, i.e. if she has a sufficient level of mental and physical health that would enable her to enjoy the benefits of attending universities or going to libraries. The more flexible conception of need Griffin proposes22 must apply only to needs that are not vital. It should not apply to the vital need for health as a broad category of abilities that include the ability to desire and value. Apparent basic needs can only be trumped by apparent mere desires when the latter are actually vital needs (e.g. the desire to be healthy). The value of health, if under-stood in a more fundamental way, makes avoidable deprivation of vital needs unacceptable. It is always important to satisfy the vital need for health precisely because it is needed for enabling persons to live a human life.
Ezekiel Emanuel worries that the idea of providing everything we need to restore normal functioning could justify ‘unlimited demands on social resources’, if so, it is ‘ipso factounacceptable’.23
This worry need not lead to rejecting the use of any conception of need. He is right to qualify that ‘deviations from normal human functioning and wholeness . . . are not medical needs for matters of justice’ and that treating ‘some diseases is more urgent than treating others’ because ‘not every medical need is a citizens’ need.’24 Society is only obliged to provide the most urgent minimum of basic healthcare needed by its citizens. Still, Emanuel worries that the idea of minimum basic healthcare ‘cannot specify the particular services that are actually covered and those interventions that are excluded’ and such indeterminacy is again ‘likely to lead to unlimited demands for resources’.25In the end, citizens
with final or intrinsic value. To claim that vital needs arenotderivative (contrary to what Barry claims about all needs) does not mean that these needs have intrinsic value. The value of vital needs has a different sense of fundamentality, thus I refer to such value as preintrinsic. 16 Griffin,op. cit.note 6, p. 52.
17 Ibid. This view has some similarity to Abraham Maslow’s view that
unless the more basic needs in the hierarchy of needs are met, there won’t be any cognitive drive for the higher needs (as there won’t be a Griffinian desire for higher needs), thus, life won’t be worth living (because the agent won’t be driven to live that life in the absence of potent desire). Griffin implies that the basic need for liberty and minimum material provisions must be satisfied first before higher needs for [above normal] health will become desirable.
18 He compares the need for physical fitness (as health) with the desire
for constructing libraries or universities (as non-need), then claims that desires are sometimes more important than needs. See his discussion on pp. 45–46 concerning books versus exercise equipments. Ibid. 19 Ibid: 49.
20 M. Marmot. Achieving Health Equity: from Root Causes to Fair
Outcomes.The Lancet2007; 370: 1153–1163. See especially Figure 3, p. 1154, where it is shown that life expectancy in Russia increased as higher levels of education were attained.
21 Exercise equipment, of course, is not something that one needs in
order to be healthy enough to study. It is therefore not something that can be considered a vital need as are basic healthcare and proper nutri-tion. Furthermore, having libraries may be something that is merely desirable but not the need for education that libraries and universities could satisfy. There are no strong reasons to exclude the benefit of education provided by universities and libraries from the category of basic needs.
22 Griffin,op. cit.note 6, pp. 51–55. 23 Emanuel,op. cit.note 7, pp. 110–114. 24 Ibid: 112.
have to choose particular conceptions of the good life that will be deliberated upon in society and that this deliberation will hopefully produce a reasonable consen-sus that will guide their decisions about what to include or exclude in the list of basic healthcare they will collec-tively guarantee.26The variety of conceptions of the good may be daunting but the necessity of enabling people to develop conceptions, engage in public debate, and nego-tiate and implement the results of social and political agreements, is inescapable. We may not be able to provide every kind of healthcare that may be needed to protect all abilities, but we must at least provide the most basic healthcare that is vital for protecting the basic ability of citizens to participate in the political process. If not, then we will be left to rely on a few sufficiently able legislators to deliberate what should be good for the many and what basic healthcare services must be guar-anteed. This is not a legitimate process if we agree that citizens have to make their own choice. We must there-fore, at least, allow satisfaction of vital needs that is essential in sufficiently enabling the most number of citi-zens to participate.
Vital need satisfaction is a precondition to being able to have valued ends that general needs are instrumental for. In saying this, it seems that objections to the moral force of general needs do not apply to the importance of vital needs because such objections presuppose that those in need already have the vital ability to have ends and the vital ability to value such ends. When vital needs are deprived, vital abilities are diminished. The account of the cross-cultural importance of vital needs that I propose makes the need for vital enablement explicit. Vital needs satisfaction is a prerequisite to a coherent discussion of the value of particular ends. A person must at least be healthy enough to be able to value particular things in life before particular values can even be debated. The positive thesis I wish to defend is that satisfaction of vital needs will enable persons to be agents that have the vital ability to feel, value, choose, and pursue a cultural practice. The reason for claiming this is that human persons can only be moral agents above a definite bottom floor of enabling satisfaction of vital needs. To deprive satisfaction of vital needs undermines vital abilities to think and act, including the important ability to value things in life. My negative thesis pertains to what the importance of vital needs implies to the problem of health resource allocation when resources are scarce: distribu-tive schemes presupposing that resources for health are only moderately scarce are not appropriate in extreme scarcity. To use a distribution scheme based on presumed moderate scarcity, even when resources are extremely scarce, would only result in deprivation of the vital needs of the losers in the distribution game. This will also be
unjustly legitimized by the wrong assumption about the kind of scarcity in effect. A distribution scheme is unjust if it avoidably deprives losers of their vital needs. It is unjust because to deprive people of their vital needs would cause their preventable disablement. Such depri-vation and disablement is unjust no matter how legiti-mate the distribution scheme might seem.
Needs, moderate scarcity, and extreme
scarcity
There are several contending solutions to the problem of scarcity of resources for health. Such scarcity is usually conceived in terms of competing health needs in moder-ate scarcity, so that under an ideally optimal distribution scheme all vital healthcare needs would be met even though other non-vital needs might be deprived. The contending solutions include: (1) distributing resources equally to meet health needs or trying to mobilize health resources to achieve equality of health status among populations, (2) prioritizing those who are worse off, (3) allocating and spending health resources to the most cost effective health programs that produce the best outcome per resources spent, and (4) if there are intractable dis-agreements about which distributive scheme should be followed or how resources should be properly distrib-uted, resorting to fair procedures that guarantee equality of opportunity. Consider the case of distributing resources based on the ideal of equality under moderate scarcity. When access to health resources for one is more than enough and for another is only slightly below the bottom threshold of sufficiency, optimal redistribution of resources under such condition results in sufficient access to health sustenance and protection for all. Sufficient access to health resources would probably improve the health status of the previously worse off individual more than when access is insufficient. Resources are extremely scarce when vital needs of at least some individuals are deprived, no matter how resources are distributed. Again consider the case of the equality based distribution scheme under extreme scarcity. When access to health resources for one is only barely sufficient and the access for another is way below the bottom threshold of suffi-ciency, redistributing resources from the well off to the worse off to achieve equality results in both individuals falling below the threshold, with one individual remain-ing under the threshold and the other gettremain-ing worse. This is because the total resources available are not enough for all to have their vital needs satisfied and achieve sufficient health.27
26 Ibid: 144–154.
27 Distributing equally in extreme scarcity can only make recipients
Standard solutions to the problem of allocating health resources tend to presuppose some kind of moderate scarcity and thus may miss out on some important moral considerations when dealing with the allocation problem in extreme scarcity. One important weakness is the pre-supposition that access to vital enabling resources is secure, so that the result of any distribution scheme is legitimate and morally acceptable. Most standard solu-tions miss out the fact that in extreme scarcity, any dis-tribution scheme would result in shares that fall below the bottom floor of vital enablement. Such distribution schemes cannot function to legitimize depriving out-comes in extreme scarcity, as it does in moderate scarcity, because of the disabling results it tends to tolerate.
VITAL NEEDS SATISFACTION AND
BASIC AGENCY
Substantive approaches to health resource allocation in moderate scarcity lack relevance in extreme scarcity because the problem of securing the basic abilities of people through the satisfaction of their vital needs is not taken seriously. Even procedural approaches tend to overlook the fact that procedural solutions also require a significant amount of resources (e.g. those needed for educating citizens, equipping institutions, etc.). The resources that procedures require seem too demanding for societies with extremely scarce resources. In con-trast, an approach that pays attention to agency, enabling the satisfaction of vital needs can be useful in both moderate and extreme scarcity because it differen-tiates the level of abilities required for achieving ends: from the very basic to the most complex. Those who barely live at the level of subsistence are enabled (or disabled) in significantly different ways compared with those whose vital needs are secure. They differ not only in the variety of choices available to them but also in the sufficiency of means relevant to having preferences above mere survival. There are inevitable disagreements that arise when deciding which among various needs (even those instrumental to the most valuable ends) must be given moral priority. Nevertheless, the primacy of vital needs satisfaction that enable agency should be basic. Unless the disablement of a person’s basic agency is irreparably terminal, there are no consistent reasons to refrain from protecting, repairing, or sustaining such basic agency within a reasonable lifetime. Basic agency is a necessary component of experiencing and valuing
things. Anything, be it desire, happiness, or pleasure, can only matter for a person when she has the vital ability to experience and value such things.28
Depriving a person of the means to sustain her basic agency as an outcome of rationing is tragic. Resources for basic enablement should be made available to secure at least sufficient protection of vital abilities. Minimal access to goods and services that secure vital abilities should not be taken away from those who already enjoy them. Only resources in excess of what has been allocated for the satisfaction of vital needs should be up for distribu-tion. A threshold-sensitive approach to health resource allocation – that involves prioritizing and incrementally improving access to the most basic health services – is a more relevant way to deal with extreme scarcity.29 Needs beyond subsistence are important but they can only begin to matter when people are at least minimally healthy and posses the basic ability to need them.30
If ought implies can,31then mutual moral obligations of persons in society imply a corresponding basic collec-tive duty to provide sufficient means to the obligated so they can carry out what they are obligated to do. People may disagree as to what must be the manner and extent of such enabling provision. Provision could be as minimal as being sufficient for physical health with enough mental ability to make basic decisions. Provision could be as extensive as enabling optimal participation in social life, even flourishing or perfection. The necessity of a particu-lar amount of enabling provision depends on how demanding the ends to be pursued are. Some ends are more demanding than others.32 Lists of basic needs usually consist of both physiological and social needs from nourishment needs and health needs to needs for
threshold of the satisfaction of their vital needs. This is not the case in moderate scarcity. Resources are moderately scarce when optimal dis-tribution results in sufficient satisfaction of the vital needs of everyone. For a more detailed discussion see A.A.A. Alvarez. Threshold Consid-erations in Fair Allocation of Health Resources: Justice Beyond Scar-city.Bioethics2007; 21: 426–438.
28 I recognize that in extreme cases one can beunwillinglymade to give up basic agency, with or without the expectation of getting something else in its place (perhaps, to be relieved from pain). Basic agency is given up only because the alternative is expected to be better than having basic agency. Admittedly, a painful feeling could be so unbearable that one is forced to give up all ability to feel anything altogether just to be relieved from suffering, as if in the absence of all ability to feel, one could still retain her ability to feel relief from pain. In contrast, what I claim simply is that one cannot consistently value other things more than the very ability to value those things.
29 Among the two ways to construe thresholds: provision threshold
(upward) and deprivation threshold (downward), I focus ondeprivation thresholdsince my account deals with setting limits to deprivation in extreme scarcity. It pertains to deciding the extent of deprivation that we may morally allow. In contrast, limit setting viewed upward, perhaps in affluence, concerns deciding what extent of provision should be given so that resources are put to maximum use.
20 Here, we can include rational/informed desires as needs but the same
reasoning applies: rational/informed desires only matter when people have, at least, the basic ability to desire and be informed.
31 As suggested by the title of Tranøy’s paper. Tranøy,op. cit.note 3. 32 Perhaps the more complex ends and required enabling provisions are,
self respect and social participation. What is missing, however, in most accounts of basic needs is the explicit recognition of the vital abilities required to make the listed needsneedable.33
For example, for education34 to be a need the student-to-be must at least be able to study, i.e. she has to have the sufficient mental and physical powers that make learning possible; or for happiness35 (or welfare, or well-being) to be a need, one must have suffi-cient physical and mental ability to experience happiness, pleasure, or wellness. Being well educated is desirable and it can promote well-being aside from enabling a person to have better opportunities in life. However, we can only have these complex abilities (e.g. being able to secure better opportunities) when we at least have basic abilities (e.g. desiring, choosing, valuing) because our vital needs are satisfied.36
Basic and complex agency
A rough way to distinguish basic agency from complex agency and the kind of abilities and resource demands they each entail is to illustrate them as a tree of ends with the main trunk representing ‘survival’ and the branches as ‘ends’ that an agent can create and pursue (see Diagram 1). Basic agency is situated where an agent is basically enabled to pursue primitive ends (E1, E2, E3, . . . , En). Complex agency is situated where the
achievement of primitive ends leads to the possibility of pursuing emergent ends (e1, e2, e3, . . . , en) that in turn
may lead to the possibility of pursuing other emergent ends.37Emergent ends in complex agency may be created only upon achieving the primitive ends that make them possible. We begin to realize the relative value of emer-gent ends upon experiencing which ends lead to more efficient results, after which we realize which ends are merely instrumental to achieving emergent ends that are of intrinsic value (i5, i7, i11, . . . , in).38Emergent ends have
33 Exceptions to this are Len Doyal and Ian Gough’s recognition that
minimally autonomous actors must at least ‘have the intellectual capacity to formulate aims and beliefs’ and Alan Gewirth’s point that agents must not be deprived of ‘generic goods’ that are ‘necessary to all actions’ or essential to agency itself. See Doyal & Gough,op. cit.
note 13, pp. 62–63; A. Gewirth. 1981.Reason and morality. Chicago: University of Chicago Press: 77–82. We should also include John Rawls’ idea of all-purposeprimary goodsand fundamental interests that are prior or even preconditional to pursuing different conceptions of the good. See J. Rawls. 1971.A theory of justice. Cambridge, Mass.: The Belknap Press of Harvard University Press, especially section 15. Of course, Rawls confine his account to needs of citizensquacitizens of democratic societies. My account of vital needs that enable basic agency is more general and holds true even beyond democratic soci-eties. In contrast with Rawls’s citizen-focused account, vital needs refer to things human beings need to protect basic abilities [qua
human beings].
34 Tranøy lists education as a vital need along with oxygen, food, water,
sleep, health self, respect, security and love. Tranøy,op. cit.note 3, p. 156.
35 Lennart Nordenfelt proposed to define vital goals in relation to the
happiness they produce. See L. Nordenfelt. 1995. On the nature of
health: an action-theoretic approach. Dordrecht Kluwer: 88ff. 36 Interestingly, Lennart Nordenfelt defines health as the ability to
pursue vital goals. See L. Nordenfelt. 2000.Action, ability, and health: essays in the philosophy of action and welfare. Dordrecht: Kluwer. Rod Sheaff defines health as generic means to satisfy rational desires that comprise the bodily means to pursue one’s end painlessly, having natural drives, capacity to work up historical drives, and critical capacity to know and desire what one needs. See R. Sheaff. 1996.The Need For Health Care. London: Routledge. Emphasis on basic enabling as vital needs vis-à-vis basic needs avoids the charge of making a moral theory of needs too narrow and inflexible so that it automatically trumps legitimate informed desires (as what basic-needs-prioritarianism does). See for example the arguments for a more flexible needs account presented by James Griffin in Griffin,op. cit.
note 6, pp. 40–55. Emphasis on vital need for basic enabling is not susceptible to the charge that it is too narrow and too inflexible. Any particular person’s valuing of anything, whether the so-called basic needs or informed desires, especially when her actual happiness or well-being is at stake, depends on her basic ability to value or enjoy anything – without which any valuing, enjoying or being happy would not matter at all. In other words, if that person is not healthy enough to experience valuing (desiring?) or the most basic ability to enjoy or be happy, these things won’t matter to her.
37 Parallel to this, Tranøy earlier suggested that the emergence of
other legitimate needs (cf. emergent ends) presupposes satisfaction of vital needs (cf. achievement of primitive ends). Tranøy,op. cit.note 3, pp. 155–156. Upon learning to read (E2), one realizes that she can go to school (e4). After finishing school, one realizes she can take a job (e10). After getting a job, one realizes she can climb the corporate ladder, and so on until nothing more can be achieved but happiness or other intrinsic ends (i15). The crucial distinction between basic agency and complex agency is that the first realization that something else can be pursued occurs after reaching an initial primitive end in complex agency. However, it is the basic ability to reach primitive ends in basic agency that makes the emergence of new ends in complex agency possible.
38 After experiencing the emergence of ends and comparing the relative
values of these ends, we then begin to reflect upon what Rawls’s referred to as higher-order versus lower-order interests. Higher-order interests
intrinsic value when we can no longer have further ends to achieve upon reaching them. Emergent ends have instrumental value when we only pursue them so as to achieve other ends that we value. The desire to pursue ends emerges when our vital needs for having basic abili-ties are satisfied. We can only pursue primitive ends when our vital needs are satisfied and we are enabled to con-ceive and fulfill our further ends and further extend our abilities, say, through enhancing basic health and enhancing basic mental abilities. If one does not have the vital ability to move, she cannot engage in physical activi-ties (a primitive end) to develop her body in order to engage in sports (an emergent end) that involve more complex movements. If one does not have the basic ability to sense things, think about ideas, represent ideas into symbols and manipulate these symbols for commu-nication, she will not be able to study (as a primitive end) and go to school to pursue basic and higher education (as an emergent end) that involve more complex thinking skills. The value of learning or enjoying knowledge as ends can be intrinsic, but the value of satisfaction of the vital need for basic cognitive abilities to pursue and enjoy such intrinsic good is preintrinsic.
Having at least the ability to reach primitive ends must be ensured if we are to consider a person to be an agent at all. The normative force of the requirement to have, at least, basic agency is a point where reasonable agreement should be expected. Of course people could still disagree about how basic agency is to be effectively attained, say, whether through ensuring provision of basic income or through a highly efficient free market system that tend to distribute welfare equitably. Rea-sonable disagreement about which of the emergent ends should be pursued is expected, especially when the needed resources for these are only moderately scarce and basic agency is already widely achieved. We may tolerate such disagreements and even the distributive decisions that could result from our negotiations. When resources are scarce and we must deprive some demands to satisfy others, the bottom floor of deprivation must at least allow sufficient provision of what is vitally
needed to secure basic agency.39
Basic agency consists of: (1) the ability to sustain sufficient physical and mental health through a reasonable period of time (say, a normal life span), (2) the ability to feel, value, and use things and ideas that will allow oneself to conceive goals/ends worth pursuing, make informed/reasoned choice between goals/ends, pursue chosen goals/ends (and possibly succeed). Satisfaction of vital needs that enable and sustain basic agency should be secured if moral agency and obligations are to hold in any soci-ety.40 Basic agency enablement should be sufficient for persons to further enhance their agency so as to make society more stable and conducive for the basic agency of its members to flourish.
Basic agency and vital needs
Some need theorists41have cited Immanuel Kant’s idea of autonomy with the idea of basic needs as precondition to human action (and interaction), in particular the idea that physical and mental capacity are essential to the possibility of human action. Survival and mental compe-tence are obviously needed for humans to be able to act on their goals, indeed to even act at all. Even the concep-tion of goals depends on the satisfacconcep-tion of these basic needs. Autonomy or freedom can be conceived as one of the higher levels of abilities and the most basic level as the
are interests about things that make lower-order interests possible. For example, the higher-order interest to develop the moral capacity for a sense of justice (the ability and desire to conduct oneself in accordance with justice) makes it possible to pursue lower-order interests (e.g. a career, higher education, etc.) by creating a stable society conducive to such particular pursuits. The higher-order interest to develop the moral capacity for a conception of the good makes the lower-order interest of pursuing a particular conception (e.g. a religious life, an advocacy) possible. Likewise, primitive ends of basic agency make the derivative ends of complex agency possible. The primitive end of developing the basic ability to communicate makes the derivative end of successful participation in a debate possible. Debating requires complex agency involving knowledge, listening skills, strategic skills, persuasive skills, etc.
39 David Wiggins tests the truth of need statements by surveying and
comparing the different levels of moral and political thresholds of acceptable deprivations and harms that result from such deprivations. Wiggins.op. cit.note 3, pp. 14–15.
40 Len Doyal and Ian Gough attributes this line of reasoning to Kant’s
idea of having a reason for acting as the basis of moral responsibility which is only possible if an individual has the physical and mental capacity to do so. Doyal & Gough,op. cit.note 13, pp. 52–53. Harry Lesser earlier wrote on survival as a basic need by stating that ‘the existence of moral agents is a necessary precondition of moral activity.’ R. Plant et al. 1980.Political philosophy and social welfare: essays on the normative basis of welfare provision. London: Routledge & Kegan Paul: 38. Following this Kantian line of reasoning, Barbara Herman wrote: ‘Ends . . . that are necessary to sustain oneself as a rational being cannot (on rational grounds) be given up. Insofar as one has ends at all, one has already willed the continued exercise of one’s agency as a rational being.’ B. Herman. 1993.The practice of moral judgment. Cam-bridge, Mass.: Harvard University Press: 55. Kant makes a stronger claim inThe Metaphysics of Morals:
When it is said that it is in itself a duty for a human being to make his end the perfection belonging to a human being as such (properly speaking to humanity) this perfection must be put in what can result from hisdeeds, not in meregiftsthat he must be indebted to nature; for otherwise it would not be a duty. This duty can therefore consists only incultivating one’s faculties(or natural predispositions), the highest of which is understanding . . . (Ak 6: 386.30-387.2)
point where human agency begins.42
Agency can be broadly defined as the ability to act but I will use the term here to refer to the vital ability of human persons to feel, to value, to choose, to conceive goals and to pursue those goals, among other things. Using means to pursue goals is a property of personal action and we only refer to non-person entities using means to ends as a manner of speaking, personifying them as it were. One cannot use means to achieve ends unless she is an agent, i.e. unless she has the vital ability to think and act as enabled by the satisfaction of her vital needs. It goes without saying that agency (or continuing agency) depends on continuing survival. The succeeding levels of abilities build on the preceding ones so that without basic agency, complex abilities are not possible. As one sustains basic agency through the sustained satisfaction of her vital needs, she can opt to develop her abilities further, say to interact with others thereby being further enabled to the level of sociability. After securing basic agency, some other needs remain important, such as being able to interact socially, being able to flourish, etc., depending also on how broadly human existence should be construed. The things necessary to achieve these higher abilities are basic needs but only those things necessary to achieve basic agency are vital needs.43
The ability to act and the ability to interact are important in defining human agency but they are not necessarily the end point of enhancing human abilities. One could further enhance her abilities so as to achieve some degree of autonomy. Basic agency is not necessarily autonomous as pointed out recently by feminist thinkers.44 Thus, it makes sense to talk about
autonomous agency as distinct from basic agency.45 Perhaps, flourishing and autonomous agency provide broader categories of abilities. I will mention these con-cepts as higher levels of abilities in the next diagrams that I will present.
To illustrate what satisfaction of vital needs could be, consider Diagram 2. Here, levels of human enablement are plotted against normal life years from birth to adult-hood. It starts from the most basic ability to act (basic agency), continues with abilities necessary for interacting with other persons (sociability) followed by a broad cat-egory of further expansion of abilities (flourishing) where abilities are further expanded, perhaps, even developing to full autonomous agency or perfection, as Kant calls it. Abilities normally develop through the course of normal human development. Diagram 2 illustrates how basic agency would ideally emerge from birth to childhood as vital needs are satisfied. The length of time for the emer-gence may vary from one individual to another but it should reach the level of basic agency as basic mental and physical abilities become sufficiently developed. The development of abilities ends in death after a full life has been lived within the length of time possible for humans. Basic agency marks the bottom floor of the least abilities
42 Andrew Jason Cohen refers to aninitial agential choicewhere the normativity of choice enters in. He also explicitly defends the claim that ‘the agentcanreject rationality and autonomy’ against Kant’s stronger claim that this is impossible. A.J. Cohen. Existentialist Voluntarism as a Source of Normativity.Philosophical Papers2008; 37: 89–129. 43 Soran Reader, in her defence of the basic needs approach against
criticism of its silence about the substantive content of positive ends, offers reasons that are useful for defending any basic agency-centered account of vital needs, namely: (1) ‘the substantive conception of the positive state beyond need is an essentially contestable matter for social negotiation. Any attempt to stipulate what its content must be will obstruct the process of political negotiation and prevent community-building consensus-formation from taking place, thereby imposing external values on the needy rather than helping them’; (2) ‘framework’ is intended to describe actions that are morally required . . . Once needs are met, although further ends might morally permissibly be sought, there is no obligation on agents of justice to seek them. There is no moral obligation to expand anything . . . Human beings are beings who naturally define and seek their own ends’. S. Reader. Does a Basic Needs Approach Need Capabilities?J Polit Philos2006; 14: 337–350: 341–342.
44 Some feminist thinkers talked about autonomous agency as not only
‘uncoerced but the circumstances that structure that choice are also free of the coercive dimension of oppression’. Susan Sherwin, for example, distinguishes agency from autonomy. Agency is used to refer to informed choice while autonomy is a more comprehensive notion of freedom ‘where not only is the immediate choice uncoerced but the
circumstances that structure that choice are also free of the coercive dimension of oppression.’ S. Sherwin, ed. 1998.The Politics of Women’s Health: Exploring Agency and Autonomy.S. Sherwin, ed.: Philadelphia: Temple University Press: 1–18:12, 19–47; C. Mackenzie & N. Stoljar. 2000.Relational autonomy: feminist perspectives on automony, agency, and the social self. New York: Oxford University Press. Bevir seems to affirm the distinction between basic and autonomous agency and yet, following Michel Focault, rejects the possibility of autonomous agency. M. Bevir. Foucault and Critique: Deploying Agency against Autonomy.Political Theory1999; 27: 65–84: 67.
45 The idea that autonomy is a higher agential ability seems to be in line
with Kant’s idea ofone’s own perfection(eigene Vollkommenheit). See Ak 6: 386–387. Kant,op. cit.note 40, p. 150.
that one could possess; below this bottom floor, any ability to think and act is absent or severely diminished. One of the worst things that could happen is for a life of diminished abilities to end in untimely death (as shown in Diagram 3). It is very unlikely that people with dimin-ished abilities would be able to protect themselves from fatal risk of disease, especially if they lack access to inter-ventions that could save their lives and help them recover. Sufficient prenatal care, maternal care, and primary healthcare during childhood, among other things, are vital in overcoming such challenges.
Some people suffer a lifetime of extremely diminished agency way below the floor of basic agency (as shown in Diagram 4). It could be due to extreme deprivation of vital needs before being born or during childhood, or it could be the result of some unavoidable birth defects. It could be the result of the unhealthy lifestyle of parents like smoking, consumption of harmful substances,
maternal malnutrition, or it could also be the result of environmental pollution caused by avoidable human activities. In such cases basic agency has been, avoidably, extremely diminished. Many and most cases involve defi-cits in abilities that can be feasibly remedied.
Those who believe that every person should be treated with equal worth and respect would consider the predi-cament illustrated in Diagram 5 showing inequality between persons A1, A2, and A3 as a cause for moral alarm. However, another reason for finding this situation morally problematic is not merely the inequality that is evident but the fact that A2 and A3 have abilities falling short of basic agency. The solution to this moral problem is not to make them all equal but to raise the level of A2 and A3’s abilities above basic agency. This should be done without necessarily taking away resources that would make A1 fall below basic agency. Nevertheless, A1 may not take more resources to increase her abilities further up to higher levels. These should instead be set aside for redistribution. This would not harm A1 as it would if she were pulled down from the level already achieved as a result of redistribution. Diagram 5 illus-trates a situation of moderate scarcity.
The need to attend school is a first-order need. The vital need to be healthy enough to be able to study is a second-order need (i.e. a need for the ability to need) and is fundamental to enabling individuals to understand, feel, value, choose, and act. First-order needs arise only when second-order needs of individuals are satisfied, i.e. when they have been made physically and mentally healthy enough to be able desire and value things. It is also important for them to have secure access to resources that will satisfy their second-order need for protecting their basic abilities. No one can have first-order needs without at least being enabled by the satis-faction of their second-order needs. Basic health Diagram 3. Extremely diminished abilities
Diagram 4. Long term deprivation of vital needs
protection – as an enabling good – is important in the second-order sense of needing.
THE FUNDAMENTAL IMPORTANCE OF
VITAL NEEDS SATISFACTION ACROSS
CULTURES
The vital needs satisfaction account emphasizes the fun-damental importance of the second-order conception of need as criterion for health resource allocation. It shows what practitioners of culture need to protect their ability to practise their culture. It is also a standpoint from where first-order needs can be evaluated as to whether any of these first-order needs tend to undermine second-order needs.46Although the way vital needs are satisfied by health protection may vary across cultures, sufficient satisfaction of vital needs is of cross-cultural moral importance. Vital enablement is the universal base on which the practice and evaluation of culture is made possible.
There are two policy implications that the vital needs account engenders. First, resources for health in low-income countries should be mobilized to secure, at least, minimal access to goods and services that sustain and protect vital abilities. Second, minimal access to goods and services in low-income countries should not be taken away from those who already enjoy them because these goods and services protect and sustain their vital abilities. In the Philippines, as a lower middle-income country with health expenditures less than 5% of its GDP, these policy implications must take the form of increasing tax-based and insurance-based financing and resource allocation for health that benefits/enables the poor, to reduce their out-of-pocket health expenditures. This has been the kind of recommendation firmly held by those who have closely investigated and managed the national health system of low-income countries. For example, former health
secre-tary of the Philippines Alberto Romualdez claims that he is convinced that in the face of declining capacity of government to allocate resources to social services, even precisely because of this, increasing healthcare provision to the poor are ‘required and can catalyze further changes towards greater equity in health’.47
CONCLUSION
Even if people from different cultures do not share the value of equality, they should at least recognize the value of satisfying the vital needs on which their ability to practise any culture is based. The value of vital needs satisfaction is always consistent with any cultural tradi-tion even in cultures where people do not subscribe to egalitarian or liberal values. Vital needs satisfaction offers a relevant cross-cultural reason for wanting to remedy poor health status through improving access to basic healthcare. It can strengthen our call for global health equity regardless of whether or not we agree in invoking principle of equality.
Acknowledgements
I wish to thank the organizers of the 9thWorld Congress of Bioethics in Rijeka, Croatia for the opportunity to present an initial version of this paper in one of the sessions of the conference. I also thank those who have commented on the initial version as well as the anonymous review-ers of the journal. This paper was written while I was on a scholarship at the University of Bergen. Thanks also to Professor Reidar K. Lie for the help he extended in making my participation at the Rijeka IAB Congress possible.
Allen Andrew A. Alvarezis Assistant Professor of Philosophy at the University of the Philippines in Diliman and Research Fellow in Phi-losophy at the University of Bergen. His doctoral dissertation deals with the issue of ethics of healthcare rationing in extreme scarcity. He has written an encyclopedia entry on rationing and has published articles on empirical ethics, Filipino concepts of disease and illness, and research ethics.
46 The same reasoning is given in attempts to discount ethical relativism
by searching for universal criteria by which to evaluate cultural prac-tices. ‘If a cultural practice produces manifest suffering or produces lifelong physical disability, there are good grounds for judging that practice to be ethically wrong.’ R. Macklin. 1999.Against Relativism: Cultural Diversity and the Search for Ethical Universals in Medicine. New York: Oxford University Press: 24.
