Mountains Beyond Mountains Study Guide
Mountains Beyond Mountains cover


Moral Obligation in Mountains Beyond Mountains

By Professors Sara Goering, Philosophy, and Audrey Young, Medicine, University of Washington

 What can you learn from this topic?

  • What do philosophers say about why, and how much, an individual should help strangers in need?
  • What are your own moral obligations to help others; what are the limits of your obligation?
  • Do some individuals bear greater moral obligation than others?

► DO WE HAVE MORAL OBLIGATIONS TO STRANGERS? If so, what grounds such an obligation? Paul Farmer clearly believes we do. In Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, Farmer and Jim Kim tell each other, “Some things were plenty black and white…areas of moral clarity, which they called AMC’s” (101).

Argument: There is no moral obligation to strangers. Poverty, malnutrition, and poor health are common in many parts of the developing world. Some may argue that these conditions are not a problem of justice, but merely a terrible misfortune to those who suffer them. Such suffering may motivate wealthier or luckier individuals to supererogatory action (i.e., action that goes beyond the requirements of duty) in the form of charity, but their efforts are not considered to be morally required.

Readings: Jan Narveson “Is World Poverty a Moral Problem for the Wealthy?” The Journal of Ethics 8(4): 397-408, 2005; Francis Snare “Misfortune and Injustice: On Being Disadvantaged” Canadian Journal of Philosophy 16: 39-61, 1986.

Argument: There is a moral obligation to strangers. Others have argued that the great inequalities of health and welfare between the developed and the developing world are clearly a matter of justice, and that we are morally required to lend our assistance. For instance, philosopher Peter Singer famously argued that everyone ought to give away significant portions of his/her income/wealth in order to eliminate hunger in places such as Bangladesh, where famine has threatened a huge portion of the population. He reasoned on the basis of the moral theory of utilitarianism, which says that consequences of actions are what matter morally, focusing on the relative balance of happiness over unhappiness. On this view, individuals all count equally, and we are to treat each individual impartially (without special favor to those we happen to know or love). Singer pointed out how commonly those of us in the wealthy parts of the world waste money on movies, fancy dinners, and other luxury items. (Similarly, Farmer notes that he could do much for Haiti merely with what Parisians spend on dog-grooming.)

In more recent work, Thomas Pogge has argued that addressing these inequalities is a matter of moral obligation for developed nations (and their citizens) not simply on utilitarian grounds, but because of the intimate links between our country’s policies, our own relative wealth, and the extreme poverty in such places. He argues that we have a particular moral obligation to individuals (and their countries) we have causally harmed. This ties in with Farmer’s ideas about structural violence.

Readings: Peter Singer “Famine, Affluence and Morality” Philosophy & Public Affairs 1: 229-243, 1972; Thomas Pogge “Responsibilities for Poverty-Related Ill Health” Ethics & International Affairs 16(2): 71-79, 2002; Peter Unger Living High And Letting Die: Our Illusion of Innocence Oxford University Press, 1996.

WHAT IS THE EXTENT OF OUR OBLIGATION TO STRANGERS? Paul Farmer’s sense of obligation to the poor seems limitless. This makes Kidder personally uncomfortable. Kidder writes: “I’d feel sorry that so many Haitian children still died of measles … but I’d also feel that I could never be sorry enough to satisfy him [Farmer]”(29). Farmer’s view of moral obligation is expressed in his term, ‘Comma,’ which “was always directed at third parties, at those who felt comfortable with the current distribution of money and medicine in the world. And the implication, of course, was that you weren’t one of those. Were you?” (24).

Some believe that we should each sacrifice to the point that everyone lives at an equal material level, as Paul Farmer almost seems to do. Others believe that everyone should have access to basic needs such as food, shelter, and medical care, and beyond this individuals should retain their personal material comforts. Singer suggests that giving 10 percent of one’s salary is a starting point for sacrifice, but that this may not be enough.

Each of these ideas imply that the wealthy have a greater moral obligation to strangers than those who are poor themselves. What do you think? Is an individual’s moral obligation in any way affected by what other people are doing? Should you do more if someone else isn’t doing her part?

Farmer justifies stealing drugs and microscopes from the Harvard Brigham hospital with the belief that Haitians ought to receive the same standard of medical care as Americans (90). He is pushing the limits of acceptability in order to fulfill what he believes are his moral obligations. Do you think taking microscopes is morally acceptable in this case? Would you do the same?

Readings: Singer (see above); G. A. Cohen “Political Philosophy and Personal Behavior” in G.A. Cohen, ed. If You’re an Egalitarian, How Come You’re So Rich? pp. 148-179, Harvard University Press, 2000; Liam Murphy “The Demands of Beneficence” Philosophy & Public Affairs 22(4): 267-292, 1993.

Is Farmer a moral role model? Farmer significantly curtails his family time in order to address global health inequalities. People close to him question his choices, as Kidder points out: “I saw a sign taped to a wall [of the PIH office] which read, ‘If Paul is the model, we’re golden.’ When you looked closely, though, you saw that the word golden was written on a strip of paper. Lift up the strip and you saw that the original read, ‘If Paul is the model, we’re fucked’” (243-44) .Farmer’s sense of moral obligation runs so deep that it affects his personal life. As Ophelia notes on declining Farmer’s marriage proposal, “the qualities I love in you – also cause me to resent you: namely your unswerving commitment to the poor, your limitless schedule and your massive compassion for others. [A]s your wife, I would place my own emotional needs in the way of your important vision” (66). Farmer’s frantic travel and work schedule set the stage for his life-threatening hepatitis and routinely prevent him from spending time with his wife and daughter.

Most people feel that they just cannot emulate Farmer’s example, often for highly personal reasons. Think about how your obligations to family and friends affect your obligations to strangers. Is impartiality towards other human beings a realistic and/or desirable goal for any person? Does it make sense as a moral requirement?

On page 213, Farmer relates his attempt to love all children as he loves his own daughter, remembering an instance when a Haitian newborn died and he wept, thinking of his newborn daughter.

I thought I was the king of empathy for these poor kids, but if I was the king of empathy, why this big shift because of my daughter? It was a failure of empathy, the inability to love other children as much as yours. The thing is, everybody understands that, encourages that, praises you for it. But the hard thing is the other [loving them all equally]. … All the great religious traditions of the world say, Love thy neighbor as thyself. My answer is, I’m sorry, I can’t, but I’m gonna keep on trying, comma.”

Gender can play a significant role in determining our obligations to strangers. For example, mothers typically take primary responsibility for raising their children. Do mothers have different moral obligations than others? Would you consider it beyond the limits of moral obligation for a mother to leave her own children in order to help children starving in Haiti? What about when a Haitian mother leaves her own children to care for wealthy children in the first world, as a way to send support back for her family?

Readings: Nick Hornby How to Be Good Riverhead Trade, 2002; Susan Wolf “Moral Saints” Journal of Philosophy 79(8): 419-439, 1982; Catherine Wilson “On Some Alleged Limitations to Moral Endeavor” Journal of Philosophy 90(6): 275-289, 1993; Bernard Williams “A Critique of Utilitarianism” in J.C.C. Smart & Bernard Williams, Utilitarianism: For and Against, esp. pp. 82-117, Cambridge University Press, 1973; Shelee Colen “’Like a Mother to Them’: Stratified Reproduction and West Indian Childcare Workers and Employers in New York” in F. Ginsburg & R. Rapp, eds. Conceiving the New World Order: The Global Politics of Reproduction University of California Press, 1995.

Do some individuals have greater obligations than others? Some people have special moral obligations; often these obligations accompany their chosen professions. Almost everyone would agree, for example, that airline pilots are obliged to abstain from alcohol while flying. But this is an obligation to not do something. Many feel that the nursing and doctoring professions bring special ‘positive’ moral obligations. Farmer quotes Virchow: “Medical education does not exist to provide students with a way of making a living, but to ensure the health of the community” (61). For example, nurses and doctors are professionally obligated to treat those with communicable disease such as Severe Respiratory Syndrome (SARS) and anthrax, even at substantial risk to themselves. The Hippocratic Oath states that nurses and doctors must treat the sick regardless of their ability to pay. Do you agree? Should certain individuals bear this additional responsibility? Are business executives who run highly profitable corporations responsible to people who can’t afford their products?

Some might say that certain people have a special moral obligation because of their ethnic or cultural background. For example, Haitian doctors may have special obligations to help fellow Haitians. Some even view as morally questionable the ‘brain drain’ that leads Third World professionals to seek personal wealth and security in the First World. Do you think that members of an impoverished ethnic or cultural group have a special responsibility to other members of their group?

Reading: Edmund Pellegrino & David Thomasma. Virtues in Medical Practice. Oxford University Press, 1993.

WHERE SHOULD WE START? How should we prioritize the distribution of benefits owed to strangers in need? There are many places and populations that lack the basic goods of food, shelter, and medical care. Farmer is interested in Haiti because it is the most impoverished country in the Western hemisphere. Later he becomes selectively involved in Peru and Russia in response to personal appeals. The question thus becomes, how should we distribute our efforts once we recognize that moral obligation exists? Is there such a thing as justice in the distribution of services? Though Farmer is devoted to his patients in Haiti, he might do more for world health if he gave up the one-on-one visits and concentrated his energies on larger scale health programs (e.g., AIDS in southern Africa, or malaria around the world) (see Kidder, p. 181).

Argument: Our greatest obligation is to those whom we have personally harmed, (or whom our government has harmed through its policies). Like Farmer, Pogge makes a case for our causal responsibility for poverty and ill health in many parts of the world. Any moral obligation we have should start with their needs.

Reading: Pogge (see above); Jim Yong Kim et al., eds. Dying for Growth: Global Inequality and the Health of the Poor. Common Courage Press, 2000.

Argument: Our greatest obligation is to those who are the neediest. It doesn’t matter what has made them needy. This fits with Farmer’s adoption of the phrase from liberation theology regarding a “preferential option for the poor.” Liberation theology calls for justice in this world (not waiting for an afterlife), recognizes the significance of structural as opposed to individual sin, and emphasizes a religious commitment to struggling for and with the poor.

Readings: Paul Farmer Pathologies of Power University of California Press, 2005; Gustavo Gutierrez A Theology of Liberation: History, Politics and Salvation Orbis Books, 1988; Marcio Fabri Dos Anjos “Medical Ethics in the Developing World: A Liberation Theology Perspective” Journal of Medicine and Philosophy 21(6): 629-637, 1996.

Argument: The best use of our moral obligation is to those who are nearest to us or who share allegiances with us (fellow citizens, residents of our city, neighbors, family members, etc.). Our obligations to them may not only be met more efficiently (compared to circumnavigating the world to provide aid, as Farmer does), but they may also deserve priority on the basis of already existing relationships or the relative feasibility of forming such relationships. Should we help the homeless in Pioneer Square or those suffering in Darfur? Is this choice a personal preference or an issue of justice?

Readings: Frances Kamm “Famine Ethics: The Problem of Distance in Morality and Singer’s Ethical Theory” in Dale Jamieson, ed. Singer and His Critics, pp. 162-208, Blackwell Publishers, 1999; Andrew Mason “Special Obligation to Compatriots” Ethics 107(3): 427-447, 1997; John Cottingham “Partiality, Favoritism and Morality” Philosophical Quarterly 36: 357-373, 1986.

WHAT MOTIVATES AN INDIVIDUAL TO ACT ON BEHALF OF STRANGERS? After all, acknowledging a moral obligation to strangers does not mean acting to fulfill those obligations.

Reasons not to help others. Think about why some individuals don’t act to help others, even when they identify a moral obligation. Learning about the vastness of human suffering around the globe can foster a sense of hopelessness. An individual may feel he or she is too small to make a difference (especially given the structures of poverty and violence); even Farmer, who gives just about everything he can, still feels that what he does is too little. The difficulty of having to choose where to give can be emotionally overwhelming. Our culture has developed socially acceptable means of attending to obligations to the poor, such as black-tie fundraising dinners and tax deductions in exchange for charitable donations; these practices make an abstraction of the idea that other humans are suffering. Kidder notes, “The world is full of miserable places. One way of living comfortably is not to think about them or, when you do, to send money” (8). But Farmer does not want people to feel comfortable about the fact of poverty.

Farmer disparages “sustainability” as a key to international service work. But for many individuals, sustainability is a real issue. People can become fatigued while attempting to fulfill their moral obligations to others, particularly if they feel that their efforts don’t go very far.

Guilt as a motive for action. Some may be moved by the immediacy of another suffering human being, especially in settings or situations that feel familiar, such as Hurricane Katrina. Some may act in response to strong emotions like guilt and remorse. Farmer is all for guilt: Tom White, one of his donors, “said he thought it was a useless emotion. On the contrary, Farmer said, it could be quite helpful. What he endorsed, he said, was the guilt some rich people felt toward the poor, because it could cause them to part with some of their money” (93).

Virtue as a motive for action. Being moved by suffering is not the only means of generating action. Aristotle wrote that virtuous behavior is a learned trait; the Victorians believed that character was something that an individual developed himself or herself. In present-day society, action and service are expected components of some professions, as with lawyers who perform “pro bono” work. Do you think that moral virtues are consciously developed habits or are they inborn? What role does society and the media play in reinforcing ideas of virtue?

Readings: Ronald Dworkin. Sovereign Virtue: The Theory and Practice of Equality Harvard University Press, 2002; Aristotle: Nichomachean Ethics; David Rieff A Bed for the Night:Humanitarianism in Crisis Simon & Schuster, 2002.


Kidder, Tracy. (2003). Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, New York: Random House.

Suggested Courses

Below are some courses that will enable you to explore in more depth the topics raised in this study note.

PHIL 102 – Contemporary Moral Problems
Philosophical consideration of some of the main moral problems of modern society and civilization, such as abortion, euthanasia, war, and capital punishment.

PHIL 110 – Introduction to Social and Political Philosophy
An introduction to political theories such as conservatism, liberalism, and socialism and their treatment of select social issues.

PHIL 230 – Philosophic Issues in World Affairs
Moral problems that arise in connection with such topics as affluence, hunger, and overpopulation; global environmental degradation; war and weaponry; restructuring the international order.

PHIL 240 – Introduction to Ethics
Critical introduction to various philosophical views of the basis and presuppositions of morality and moral knowledge. Critical introduction to various types of normative ethical theory, including utilitarian, deontological, and virtue theories.

PHIL 242 – Medical Ethics
Introduction to ethics, primarily for first- and second-year students. Emphasizes philosophical thinking and writing through an in-depth study of philosophical issues arising in the practice of medicine. Examines the issues of medical ethics from a patient's point of view.

PHIL 338 – Philosophy of Human Rights
Theories of human rights and the bearing of these theories on issues of public policy such as legitimacy of war and terrorism, economic justice, and whether future generations have rights.

PHIL 345 – Moral Issues in Life and Death
Examination of such topics as war and murder, famine relief, capital punishment, high-risk technologies, abortion, suicide, and the rights of future generations.

PHIL 346 – Personal Values and Human Good
Examination of the idea of a good human life. Emphases differ from year to year. Typical topics include happiness and prudence, rationality and life plans, personal values and the meaning of life, autonomy and false consciousness, self-respect and self-esteem, honesty and self-deception, faith and "vital lies.".

PHIL 407 – International Justice
New course pending Winter 2007.

PHIL 410 – Social Philosophy
An examination of topics pertaining to social structures and institutions such as liberty, distributive justice, and human rights.

PHIL 411 – Justice in Health Care
Examination of the ethical problem of allocating scarce medical resources. Emphasis on fundamental principles of justice that support alternative health policies. Recommended: prior courses in philosophy or medical ethics.


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