by Volnei Garrafa and Mauro Machado do Prado

Advances in scientific and technological development have been bitterly exclusionary. The benefits of the discoveries of the past century are inaccessible to more than two-thirds of the world's population. While the citizens of Sierra Leon and Malawi barely reach the age of 40, residents of Japan, North America, and most of Europe now live to 75 or 80. Similarly, investment in research on malaria, which killed some 2 million people in 1999, was 50 times less than for AIDS, which caused a similar number of deaths the same year.

If differences in interests and social needs between North and South were great before the advent of economic globalization, today they are disturbingly more so. Priorities in constructing public health systems are not based on the demands or needs of the world's people, but on the exigencies of the market and the interests of its strongest players. We let the global market--and the balance of power resulting from it--determine how people are born, live, and die; who should live longer and who should die younger. As the concentration of power grows day by day, the rules of the game provide ever more protection for the richer countries.

Aristotle asserted 24 centuries ago that life is the greatest good, and its main objective is to seek happiness. No one since has managed to convincingly contradict him. Yet with modernization, we have failed morally to reconcile the Aristotelian ideal of happiness with the modern agenda of autonomy.

The resulting ethical paradoxes are not only cause for moral indignation; they are politically unsustainable in the long run. This should leave no doubt about the need for a change in economic and scientific paradigms, principally in terms of social commitments and responsibilities. As theologian Hans Küng has written, "We must move from...a technocracy which dominates people to a technology which serves the humanity of men and women...from a legal democracy that is but a formality to a real democracy that reconciles freedom and justice."

The search for practical and ethical responses that emphasize the needs of those who have been excluded from the development process has become a priority for the countries of the Southern Hemisphere. We need a new critical framework directly linked to the needs of the majority. In such a framework, the dilemmas routinely confronted by public health specialists and bioethicists in the less-developed world would be addressed with greater objectivity. Outcomes would not, as now, invariably be prejudicial to the most vulnerable.

In the North, bioethics has been distorted and reduced to a neutral methodological tool used simply for reading and interpreting conflicts. True bioethics must leave room for indignation and intervention. At the next World Congress of Bioethics, in Brasilia next October, we will present a proposal for a debate on what we call "hard bioethics," a "bioethics of intervention." This is a peripheral (non-North-centric) perspective on the ethical theories traditionally espoused by the bioethics of the North. Its underlying principle is consequentialist utilitarianism: the greatest good, as a final outcome, for the greatest number. In the public, social sphere, this means the prioritization of policies and decisions should favor the greatest number of people for the longest possible time, even when this may adversely affect individual situations (with certain exceptions to be discussed). In the private, individual sphere, it means the search for viable, practical solutions to conflicts identified in their own social and cultural contexts.

What is needed is a truly democratic and concrete alliance with the historically most vulnerable sectors of society, and from that vantage point, a reanalysis of key dilemmas, among them: autonomy vs. justice/equity, individual vs. collective benefits, individualism vs. solidarity, universality vs. specificity.

Fundamental to our hard bioethics is a clear understanding of the meaning of equity, which is not the same as equality. Equity is the starting point; equality is its desired result. Through equity--the recognition of differences and the different needs of different social actors--we can begin to attain universal human rights, among them the right to a life with dignity. In the context of bioethics, this should mean the possibility of access for all to health and other goods that are indispensable for human survival in the contemporary world.

This bioethics approach goes beyond simple denunciation and utopian appeals. It is based on respect for citizenship and democracy and views bioethics as an important methodological tool for discussing and mediating problems. Interventionist bioethics can and should be an additional tool for finding effective political and social solutions to the entrenched problems of global inequity in health.

Mauro Machado do Prado is on the board of directors of the Brazilian Society of Bioethics and is a professor at the Federal University of Goiás, Brazil.

A new bioethics...
or "biopolitics"?

by Naomar Almeida Filho and Ichiro Kawachi

To reduce inequity in today's globalized world--particularly in the area of health--many people have called upon governments, enterprises, institutions, and professionals to become more ethical and humane. But an impassioned call for more ethics in politics or in health may not be the best response to the issues of social injustice. That risks ending up being just another way to depict political-structural processes as if they were the result of voluntary actions.

The failure to see health policy as part and consequence of health politics has indeed been a major obstacle for the pursuit of equity in health. To seriously consider the issue of health inequity, it is equally important to be critical and realistic. But first, we need an analytical framework capable of addressing the roots of the problem. Along this lines, we suggest a different approach, one that incorporates biology, history, and culture.

Society is an evolutionary feature of the human species that has guaranteed survival. Politics and the state are similarly historical outcomes of the social evolution of humankind. The economy, in turn, is a human invention to organize, manage, and distribute resources needed for the achievement of survival. Seen this way, the ultimate ends of economic and human development must include the improvement of the human condition.

As an evolutionary stage of humanity, contemporary societies have had to grapple with the issue of equity in health and the provision of health services. In general, they have developed two pathways to meet the commitment: indirectly, through economic development and the distribution of wealth; and directly, through the organization of national health systems.

In the former case, the state has increasingly withdrawn from the arena of social responsibility, leaving more room for laissez-faire. The rationale is that, by doing so, ground is left open for more economic development fueled by private initiative. In this approach, more wealth means more purchasing power in the hands of consumers, who supposedly will be able to buy more services, acquire better health, and live a longer and happier life. The issue of equity then becomes a matter of redistribution of income--not a simple question at all, particularly in those societies marked historically by segregation and social exclusion.

In the latter case, the governments of countries we generally call "welfare states" have taken on the responsibility for promoting and protecting their citizens' health. They have also taken charge of the organization, management, and/or provision of health services, in the best cases on an equitable basis.

The political and ethical challenge is of course even greater for the poorer countries of the South. To pursue the "neo-liberal" pathway, the political issue of unfair international trade terms, the economic issue of reduced surplus, and the managerial issue of prioritizing scarce resources pose major obstacles to the goals of economic development and income redistribution. In the second pathway, that of the welfare state, such countries must establish, cultivate, and consolidate strong governmental institutions. History and political economy have proven how difficult this can be.

Whatever the obstacles, this analysis suggests that health equity is not just a matter of ethics. It does not make sense to rely on the good will and good intentions of precisely those--countries, enterprises, institutions, and social groups--who profit from the status quo. Recent financial scandals and brutal economic competition have demonstrated that the blend of profit and ethics, though theoretically viable, can easily become a problematic matter.

Equity in health, even more than in other realms of human life, can only be achieved by giving voice and power to those who at present are voiceless and lack access to political systems and economic structures. This can be achieved through the many possible forms of citizenship and democratic participation in the management and government of public health systems. To our understanding, any market solutions for health care inevitably lead to more inequity in health. And in the end, the answer to health equity is less likely to be found in a "new bioethics"--whatever its philosophical foundations--than in a "new biopolitics," one that truly empowers those who have heretofore been powerless.