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This article seeks to contribute to debates on the political economy of global health by offering a ‘planetary’ perspective. We initially sketch contestations concerning improvements, inequalities ...

Globally, there is inequitable access to healthcare. Despite efforts to promote universal access to healthcare, the political and economic conditions that give rise to this are unlikely to be resolved. While a minority of wealthy countries enjoy unlimited privately purchased healthcare, for most, there are limits to what can be accessed. In the few successful high-income, public healthcare systems, limited rationing results mostly in treatment delays or restriction of novel expensive treatments. For the majority of people globally though, there are severe restrictions, and some form of rationing is not so much by design as by default. Given these different levels of healthcare, even defining universal approaches to rationing becomes difficult. While efforts should be made to narrow the wealth gap, the COVID-19 pandemic has highlighted that all populations are vulnerable and that rapidly overwhelming disease pandemics can threaten even the wealthiest of countries.

As the COVID-19 pandemic rages through the world, all aspects of life globally are being disrupted by mounting death rates and governments' responses The first ethical lesson has been the realization that the increasing instability of the world, characterized by diverging trajectories of health and well-being, with a minority (25%) benefiting from spectacular human development and progress, and a majority (75%) suffering from inadequate human and social development, is amplified in South Africa as a failing state, with its even wider disparities and continuing, pervasive poverty, hunger, unemployment and heavy burden of disease The second lesson relates to the complexity of the challenge for the government and people of a middle-income country seeking a balance between efforts to: mitigate and control the pandemic for long enough to prepare already inadequate overall health facilities to save as many lives as possible, and prevent severe damage to our fragile and crumbling economy in order to avoid deaths from starvation and other neglected health needs Here, Benatar discusses the ethical challenges highlighted by the pandemic

Medical practice has changed profoundly over the past 60 years. Many changes have also been made in medical education, often with a view to countering adverse aspects of highly specialised, commercialised and bureaucratised modern medical practice. Regardless of the state of the world today and of the variety of changes that may occur in the years ahead, excellence in the application of bedside skills and technological advances, accompanied by excellence in humanistic aspects of caring for patients as people, will remain preeminent goals at the heart of medical practice. Powerful social forces that negatively influence practice cannot be counteracted through changes in medical education alone and need to be addressed directly within health systems. Shifting healthcare towards a valued social service is arguably essential for improving both public and individual health through more widespread universal access to high quality and effectively integrated health care.

Much current global debate – as well as a great deal of political rhetoric – about global health and healthcare is characterised by a renewed emphasis on the goal of universal access throughout the world. While this goal has been achieved to varying extents in the United Kingdom, Canada and many countries in Europe, even within those countries where national health systems have long been in place, the pervasive shift in emphasis from health as a social value to health as a commodity within a capitalist market civilization is eroding the commitment to equitable access to healthcare. Against this background the challenge is much greater in low- and middle-income countries that lag behind – especially if aspirations to universal access go beyond primary care. The challenges of achieving greater equity in access to health and in health outcomes, in a middle-income country like South Africa, illustrate the magnitude of the tensions and gaps that need to be traversed, given the vast differences between healthcare provided in the private and public sectors. Understandably the concept of National Health Insurance (NHI) in South Africa has widespread support. The strategies for how a successful and effective NHI could be implemented, over what time-frame and what it covers are, however, very controversial issues. What tends to be ignored is that sustainable improvement in health in South Africa, and elsewhere, is not determined merely by medical care but more especially by social structures intimately linked to deeply entrenched local and global social, economic and political forces and inequalities. While seldom openly addressed, some of these forces are explicated in this article to supplement views elsewhere, although most have elided emphasis on the pervasive effects of the global political economy on the provisioning and practising of health and healthcare everywhere on our planet.

This article seeks to evaluate the ethical underpinnings of neoliberalism and its associated power relations, and to illustrate the influence of such relationships on the health of people and the planet in the so-called era of the Anthropocene. We seek to reveal the current ethical standing of neoliberalism, and to identify other ethical positions and power relations that could be more conducive to promoting peaceful progress in an era during which all future life on our planet will be increasingly threatened by several organically inter-linked, human-caused crises, including that of the Earth’s biosphere. We conclude that on a planet close to many tipping points, beyond which irreversible entropy may ensue, a shift is needed away from neoliberal and anthropocentric belief systems towards a more ecologically aware perspective on life. Fostering the ethics of greater cooperation, mutual respect, deeper democracy, solidarity and enhanced social justice could facilitate the development of sustainability as a maxim of wisdom and praxis. Ultimately however, such progress requires the transformation of political power, as well as policies that are grounded in new ethical commitments.

Background The field of bioethics has evolved over the past half-century, incorporating new domains of inquiry that signal developments in health research, clinical practice, public health in its broadest sense and more recently sensitivity to the interdependence of global health and the environment. These extensions of the reach of bioethics are a welcome response to the growth of global health as a field of vital interest and activity. Methods This paper provides a critical interpretive review of how the term “global health ethics” has been used and defined in the literature to date to identify ethical issues that arise and need to be addressed when deliberating on and working to improve the discourse on ethical issues in health globally. Results Selected publications were analyzed by year of publication and geographical distribution, journal and field, level of engagement, and ethical framework. Of the literature selected, 151 articles (88%) were written by authors in high-income countries (HIC), as defined by the World Bank country classifications, 8 articles (5%) were written by authors in low- or middle-income countries (LMIC), and 13 articles (7%) were collaborations between authors in HIC and LMIC. All of the articles selected except one from 1977 were published after 1998. Literature on global health ethics spiked considerably from the early 2000s, with the highest number in 2011. One hundred twenty-seven articles identified were published in academic journals, 1 document was an official training document, and 44 were chapters in published books. The dominant journals were the American Journal of Bioethics (n = 10), Developing World Bioethics (n = 9), and Bioethics (n = 7). We coded the articles by level of engagement within the ethical domain at different levels: (1) interpersonal, (2) institutional, (3) international, and (4) structural. The ethical frameworks at use corresponded to four functional categories: those examining practical or narrowly applied ethical questions; those concerned with normative ethics; those examining an issue through a single philosophical tradition; and those comparing and contrasting insights from multiple ethical frameworks. Conclusions This critical interpretive review is intended to delineate the current contours and revitalize the conversation around the future charge of global health ethics scholarship.

The authors draw on their many decades of combined experience with medical students, observing their maturation into practice in widely differing contexts, to reaffirm some of the essential goals of medical education. They briefly review curricular changes in medical education over the past 100 years, then focus on the dynamic tension in undergraduate medical education (UME) resulting from new pedagogy. Specifically, these tensions arise from the differing trajectories and directions of the 3 traditional pillars of academic medicine: clinical excellence, state-of-the-art education, and cutting-edge research. The authors highlight the role of generalism as an essential foundation of UME, as well as the dilemma of a shrinking cadre of medical students choosing a generalist career path. To address challenges stemming from pedagogical changes, the authors offer 4 observations. First, a more condensed approach to faculty development may be to ensure that bringing teachers up to speed on the new curriculum is not excessively burdensome. Second would be a more gradual introduction of the proposed changes. Third, some discussion about medical education pedagogy and curricular development ought to have a place in UME to prepare the next generation of physicians for ongoing changes in accreditation and in approaches to education. Finally, more appropriate funding of medical education would alleviate some of the burden and anxiety by acknowledging its nonmaterial value.

Ilona Kickbusch’s thought provoking editorial is criticized in this commentary, partly because she fails to refer to previous critical work on the global conditions and policies that sustain inequality, poverty, poor health and damage to the biosphere and, as a result, she misreads global power and elides consideration of the fundamental historical structures of political and material power that shape agency in global health governance. We also doubt that global health can be improved through structures and processes of multilateralism that are premised on the continued reproduction of the ecologically myopic and socially unsustainable market civilization model of capitalist development that currently prevails in the world economy. This model drives net financial flows from poor to rich countries and from the poor to the affluent and super wealthy individuals. By contrast, we suggest that significant progress in global health requires a profound and socially just restructuring of global power, greater global solidarity and the “development of sustainability.”

Freedom of speech and academic freedom are widely recognized prerequisites for the maintenance of national and international freedom to communicate with colleagues in the relentless, objective, scholarly pursuit of knowledge and the advancement of the human condition. The debate on freedom of speech and academic freedom at universities in South Africa is complicated by the cultural and ideological diversity that characterizes a society in which racial discrimination has been entrenched for so long (Benatar The Lancet 335, 1576- 1578 1990a). It is perhaps not surprising that in this context the ‘language’ used does not necessarily have the same meaning to all the participants in the debate. These differences in ‘realms of discourse’ which seem to threaten freedom of speech and academic freedom are in part a reflection of the different ideologies from which they arise and also highlight the challenge to universities in South Africa to become ‘Africanized’. This essay is an attempt to analyze and discuss some of the overt, covert and intertwined strands of thought and the different ‘realms of discourse’, woven into the debate on academic freedom (and academic boycott) with a view to identifying, and briefly describing, the various concepts which influence and determine differing positions and which in part derive from diametrically opposed ideological value systems. The complexity of the issues involved precludes provision of comprehensive arguments for or from each position. I shall endeavor to sketch the basis for conflicting opinions, and illustrate that the difficulty in reaching consensus on ‘rational’ grounds is hampered by the contrasting basic value systems from which reasoned debates may proceed. Without recognition and acknowledgement of these fundamental differences, it is difficult to understand discussions in which the same words are used to describe different concepts and values, or to embark on the de-alienation and negotiation processes required to peacefully reach compromise solutions to the complex challenges facing society and universities in South Africa.

In many settings, the dedication of healthcare workers (HCWs) to the treatment of tuberculosis exposes them to serious risks. Current ethical considerations related to tuberculosis prevention in HCWs involve the threat posed by comorbidities, issues of power and space, the implications of intersectoral collaborations, (de)professionalization, just remuneration, the duty to care, and involvement in research. Emerging ethical considerations include mandatory vaccination and the use of geolocalization services and information technologies. The following exploration of these various ethical considerations demonstrates that the language of ethics can fruitfully be deployed to shed new light on policies that have repercussions on the lives of HCWs in underresourced settings. The language of ethics can help responsible parties get a clearer sense of what they owe HCWs, particularly when these individuals are poorly compensated, and it shows that it is essential that HCWs' contribution be acknowledged through a shared commitment to alleviate ethically problematic aspects of the environments within which they provide care. For this reason, there is a strong case for the community of bioethicists to continue to take greater interest both in the micro-level (eg, patient-provider interactions) and macro-level (eg, injustices that occur as a result of the world order) issues that put HCWs working in areas with high tuberculosis prevalence in ethically untenable positions. Ultimately, appropriate responses to the various ethical considerations explored here must vary based on the setting, but, as this article shows, they require thoughtful reflection and courageous action on the part of governments, policy makers, and managers responsible for national responses to the tuberculosis epidemic.

The Lancet–University of Oslo Commission Report on Global Governance for Health provides an insightful analysis of the global health inequalities that result from transnational activities consequent on what the authors call contemporary “global social norms.” Our critique is that the analysis and suggested reforms to prevailing institutions and practices are confined within the perspective of the dominant—although unsustainable and inequitable—market-oriented, neoliberal development model of global capitalism. Consequently, the report both elides critical discussion of many key forms of material and political power under conditions of neoliberal development and governance that shape the nature and priorities of the global governance for health, and fails to point to the extent of changes required to sustainably improve global health. We propose that an alternative concept of progress—one grounded in history, political economy, and ecologically responsible health ethics—is sorely needed to better address challenges of global health governance in the new millennium. This might be premised on global solidarity and the “development of sustainability.” We argue that the prevailing market civilization model that lies at the heart of global capitalism is being, and will further need to be, contested to avoid contradictions and dislocations associated with the commodification and privatization of health.

While debate remains about the definition and goals of work on global health, there is growing agreement that our moral starting point is the reality of unjust inequalities in the distribution of the conditions necessary for human health and well-being. With the growth of multi-jurisdictional and multicultural global health partnerships, the adequacy of the prevailing bioethical paradigm guiding the conduct of global health research and practice is being increasingly challenged. In response to ethical challenges and conflicts confronted by decision-makers in global health research and practice, we propose an innovative methodology that could be developed to bridge the gap between polarized systems of ideas and values (metaphysical, epistemological, moral, and political). Our inter-philosophies methodology provides the potential to construct a new, shared paradigm for global health ethics, thereby increasing the capacity for solidarity and shared decision-making in global health research and practice.

This chapter analyses the political influences that shaped reform of healthcare service provision and financing during four decades of neoliberal capitalist dominance, with its emphasis on individualism, consumerism, competitiveness, and the capitalist market in determining social needs and healthcare priorities. New financing sources and market competition, which shaped adoption of reforms, are contrasted with earlier reform efforts that were premised on the socialisation of risk and the universalisation of healthcare provision on an equitable basis for all. Transformation of state forms promoted the market and substantially weakened capacities to provide for basic needs. Controversy over these outcomes has coincided with astounding increases in global inequality, particularly since the 2008 global financial meltdown, with devastating and unequal effects on the health of populations. The chapter concludes by returning to the quest for universal health coverage by reaffirming the “Health for All” principles of social justice and solidarity within a ‘post-Washington consensus’.

A new context for ethics and ethics education is evident in a rapidly changing world and our threatened planet. The current focus on considerations of inter-personal ethics within an anthropocentric perspective on life should be extended to embrace considerations of global and ecological ethics within an eco-centric perspective on global and planetary health. The pathway to understanding and adapting to this new context includes promoting shifts in life styles from selfish hyper-individualism and wasteful consumerism towards cautious use of limited resources within an increasingly interdependent world in which the equal moral worth of all and sustainability are valued. Critical scholarly approaches to global politics and to the global political economy could facilitate such change and encourage iterative interactive processes instead of seeking conclusive definitive ‘scientific’ solutions to all problems. Hopefully this shift in perspective could be achieved firstly through sensitization to new and increasingly challenging ethical dilemmas, and then by encouraging rational thinking and action based on global and ecological considerations rather than on false economic dogma and the distorted workings of a market civilization. Moving ahead with these activities must begin with promotion of education, learning and self-reflection to foster the widespread development of a global state of mind. Such a shift would require an expanded ethical discourse, with consideration of ethical dilemmas beyond human inter-personal relationships. These should include intra-institutional and inter-institutional relationships, as well as relational ethics between nations in a post-Westphalian world, and between humans and nature in an era now called the Anthropocene, to ensure survival on a planet undergoing entropy.

Health and access to health care vary strikingly across the globe, and debates about this have been pervasive and controversial. Some comparative data in Canada and South Africa illustrate the complexity of achieving greater equity anywhere, even in a wealthy country like Canada. Potential bi-directional lessons relevant both to local and global public health are identified. Both countries should consider the implications of lost opportunity costs associated with lack of explicit resource allocation policies. While National Health Insurance is attractive politically, Canada's example cannot be fully emulated in South Africa. Short- and medium-term attempts to improve equity in middle-income countries should focus on equitable access to insurance to cover primary health care and on making more use of nurse practitioners and community health workers. In the longer-term, attention is needed to the economic and political power structures that influence health and health care and that ignore the social and societal determinants of sustainable good health locally and globally. This long-term vision of health is needed globally to achieve improvements in individual and population health in a century characterised by limits to economic growth, widening disparities, continuing conflict and migration on a large scale and multiple adverse impacts of climate change.

The improvement of health globally is arguably one of the most significant health policy and global strategic issues of the twenty-first century. What resources should be allocated to improve health and access to health care is contentious. Resource allocation choices are inevitable and those choices are complex, difficult, and morally problematic. Distributive justice, a primary moral concern of health systems, requires that the benefits and burdens of health-related services be prioritized according to morally relevant criteria. Knowing what resource allocation decisions to make would be quite simple if we could agree on both the need to do so and the criteria to guide allocations. However, examination of international experience has shown that there is no consensus about what and how allocation decisions should be made.

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the 'Accountability for Reasonableness' (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.

Striking disparities in access to healthcare and in health outcomes are major characteristics of health across the globe. This inequitable state of global health and how it could be improved has become a highly popularized field of academic study. In a series of articles in this journal the roles of power and politics in global health have been addressed in considerable detail. Three points are added here to this debate. The first is consideration of how the use of definitions and common terms, for example ‘poverty eradication,’ can mask full exposure of the extent of rectification required, with consequent failure to understand what poverty eradication should mean, how this could be achieved and that a new definition is called for. Secondly, a criticism is offered of how the term ‘global health’ is used in a restricted manner to describe activities that focus on an anthropocentric and biomedical conception of health across the world. It is proposed that the discourse on ‘global health’ should be extended beyond conventional boundaries towards an ecocentric conception of global/planetary health in an increasingly interdependent planet characterised by a multitude of interlinked crises. Finally, it is noted that the paucity of workable strategies towards achieving greater equity in sustainable global health is not so much due to lack of understanding of, or insight into, the invisible dimensions of power, but is rather the outcome of seeking solutions from within belief systems and cognitive biases that cannot offer solutions. Hence the need for a new framing perspective for global health that could reshape our thinking and actions.

The corrections for four minor errors are shown below. In the paragraph at the top of page 6 the words (mathematical calculation of the most economical means to ends, and loss of the sense of sacredness), should be bracketed as shown below and the quotation marks around the words total freedom for the wolves meant death for the lambs should be removed.

It is clear that the World Bank definition of poverty is outdated and requires revision. A brief review of how poverty and income levels are defined is offered to provide insight into the shortcomings of such definitions and into what ‘eradicating poverty in all its forms’ would mean if considered within more realistic boundaries.

The health of whole populations within nations and globally and the implications of climate change are two of the most important challenges facing humanity in the 21st century. Both are components of a complex global crisis that must be acknowledged and addressed. Here we draw the attention of health professionals to some emerging threats and insights from key works of environmentalists in the hope that these may catalyze reflection on the broader challenges facing human health at a time of deep planetary malaise.

The Ebola epidemic in West Africa is not merely a biomedical problem that can be seen in isolation and dealt with only through emergency medical rescue processes. The ethical dilemmas surfaced by this epidemic are also not confined to the usual micro-ethical problems associated with medical care and medical research. The pandemic, as one of many manifestations of failed human and social development that has brought the world to dangerous ‘tipping points’, requires deep introspection and action to address upstream causal processes.

In the 12 years since publication of the previous issue of this volume, the world has changed significantly. In addition to further widening of many of the disparities in health previously described, the impact and implications of the still evolving global economic crisis and of climate change have led to increasing recognition of how the ‘development’ agenda has failed, and that global health is one of the major challenges for the twenty-first century (Benatar and Brock, 2011). World population has increased to 7 billion people, half of whom continue to live in severe poverty (on less than US$2–3 a day), most in constant hunger and under squalid conditions, with little prospect of significant improvement unless new solutions are envisaged. This article discusses the health of citizens of very poor countries and the global interdependence of the health of all peoples, including the privileged.

1 Lawn JE. The child survival revolution: what next? Lancet 2014; 384: 931–33. 2 Barros AJ, Ronsmans C, Axelson H, et al. Equity in maternal, newborn, and child health interventions in Countdown to 2015: a retrospective review of survey data from 54 countries. Lancet 2012; 379: 1225–33. 3 Wang H, Liddell CA, Coates MM, et al. Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 957–79. 4 South Centre. Capital fl ows from South to North: A new dynamic in global economic relations. Geneva: South Centre; 2008. 5 Klein N. This changes everything: capitalism vs the climate. New York: Simon & Shuster; 2014. 6 Bensimon CM, Benatar SR. Developing sustainability: a new metaphor for progress. Theor Med Bioeth 2006; 27: 59–79. 7 Horton R. Offl ine: Why the Sustainable Development Goals will fail. Lancet 2014; 383: 2196. issues in the next 15 years—namely inequity and climate change. Reduction of the neonatal mortality rate, for example, from 70 to 30 might be achievable through biomedical interventions, technological changes coupled with health systems change, female education, and nutritional interventions. Decreasing it further however, is going to depend less on these factors and issues of governance than it does on paradigm shifts in global political and economic thinking. The global system is driven by inequity, by capital outflows from low-income countries that dwarf infl ows by more than six to one, and a global system with increasing numbers of what Klein calls “sacrifi ce zones” (poor out of the way places that are being destroyed by the consequences of global warming). Biomedical and health system change will not aff ect these “sacrifi ce zones” and as such, are likely to hinder further improvements in child survival in the coming decades. This has particular resonance in view of the imminent release of the Sustainable Development Goals for the post-2015 era. The very phrase ”sustainable development” has been criticised as unachieveable when development is defined in economic terms (in the context of hyper consumption and depletion of the earth’s resources), and there is a need to think about ”developing sustainably”. If we link this to the six dimensions of sustainability outlined by Horton (wellbeing, capability, intergenerational equity, externalities, resilience, and strength of our civilisations) and, more specifi cally, the last one, we have to then situate ourselves firmly in the realm of the political. Location of future gains in child survival squarely within what has gone before, largely biomedical and for the most part apolitical, runs the risk of simply doing business as usual and masking the real social and societal changes that are needed to achieve ambitious goals.

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the 'Accountability for Reasonableness' (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible.