Mountains Beyond Mountains Study Guide
Mountains Beyond Mountains cover

STUDY NOTE

Are We Responsible for the Suffering of Others?

By Professor Nancy S. Jecker, Medical History and Ethics; Adjunct Professor, Philosophy; Adjunct Professor, Law, University of Washington
Email: nsjecker@u.washington.edu

What You Can Learn from this Topic

  • How can we understand the term “justice” and distinguish justice questions from other ethics questions we may ask?
  • What are the different justice perspectives people hold?
  • How do these different justice perspectives help us to think about Paul Farmer’s view that the rich and poor are interconnected?
  • To what extent are disease and suffering personal vs. social responsibilities?

Understanding Justice

Justice is distinct from other areas of ethics because it deals with what people deserve or have a right to, not simply what it would be nice to give people. Philosophers usually distinguish between justice, on the one hand, and charity, on the other. Charity has to do with what would be the most kind or compassionate action, while justice refers to giving people what they are owed. When we respect someone’s rights by not trespassing on their property, for example, we are not doing them a favor or being nice, but giving them what they are due.

In reading Mountains Beyond Mountains: The Quest of Dr. Paul Farmer, A Man Who Would Cure the World, it is useful to think about a particular kind of justice, which has to do with the distribution of scarce resources. Distributive justice addresses the fair distribution of burdens and benefits among different individuals or groups in society. For example, the distribution of influenza vaccine in the United States is just if and only if different individuals and groups, such as the young and the old, or the sick and the well, are treated fairly.

Understanding Different Justice Perspectives

He gave a lot of speeches, sometimes several in one day, and in every one I heard, he talked about the dam.

It stops up Haiti’s largest river, the Artibonite. . . .The U.S. Army Corps of Engineers had planned it. . . . and no doubt some of the people behind its creation believed it a gift to Haiti. But no one seems to have given much thought to the peasant farmers who lived in the valley upstream.

Old-timers talked longingly…about the days before the water rose, when families lived on farms beside the river and everyone had enough to eat and something left over to sell…. One of the old people of Cange remembered seeing the water rising and suddenly realizing that his house and goats would be underwater in a matter of hours….Families had hurried away, carrying whatever they could save of their former lives, turning back now and then to watch the water
drown their gardens and rise up the trunks of their mango trees. For most, there was nothing to do but settle in the steep surrounding hills, where farming meant erosion and widespread malnutrition, tending nearer every year toward famine.

Tracy Kidder, Mountains Beyond Mountains, 37-38

One approach to distributive justice emphasizes the distribution of scarce health care services. For example, we might ask according to what criteria organs should be distributed among potential organ recipients. Some hold that organs, such as livers, should be given first to people with the greatest likelihood or quality of benefit. Others argue that those who have a more urgent medical need should have the highest priority for receiving a liver transplant. There is also debate about whether factors such as a patient’s alcohol consumption, which may have contributed to liver damage, should influence the distribution of resources.

An alternative approach, which Farmer emphasizes, focuses on the distribution of risk for disease and suffering. Rather than taking the need for health care as a given, Farmer underscores the fact that disease and suffering are not entirely random events, but involve human agency. Farmer uses the term “structural violence” to refer to economically and political driven violations of human rights that lead to poverty, disease, and human suffering. For example, the flooding of the Artibonite Valley in Haiti created “water refugees” who were at risk for poverty, malnourishment, suffering, and disease. When their farmlands flooded, water refugees had no means of livelihood and many became some of Farmer’s poorest patients. According to Farmer, such suffering is not a random event, but instead is the consequence of human decisions. According to Farmer, “violence” is often structured in a manner that systematically disadvantages certain groups of people, based on their race, sex, poverty, or lack of political representation.

Understanding Individual vs. Social Responsibility

A simple epidemiological map, a map based on what makes people sick and what kills them…could be coded in two colors. One would stand for populations who tend to die in their seventies, mainly from illnesses that seem like inevitable accompaniments to the aging of bodies. The other color would stand for groups who, on the average, die ten and even forty years earlier, often from violence and hunger from infectious diseases that medical science knows how to prevent and to treat, if not always to cure….The map of the United States…would depict a healthy nation speckled with disease. In Boston’s Mission Hill neighborhood, right next to the Brigham, for instance, infant mortality is higher than in Cuba. In New York City’s Harlem, a famous study from 1990 showed, death rates for males between the ages of five and sixty-five were higher than in Bangladesh.

Tracy Kidder, Mountains Beyond Mountains, 125

Our answer to the question, “Who is responsible for the suffering of others?” may depend in part upon how one believes that suffering came about.

One perspective holds that if a distribution of resources came about in a blatantly unfair way, for example, through stealing, enslaving, defrauding, exploiting, or otherwise coercing people, then the distribution is unjust (Nozick, 1974). When a distribution is unjust in this way, we should rectify it by creating the distribution that would come about if the unfair process had not occurred. According to this approach, great inequalities may, in principle, be tolerated, provided that goods were acquired and exchanged fairly.

Yet others believe that regardless of how a distribution came about, we should not tolerate inequalities of wealth, or inequalities in access to basic goods, such as health care or education. In support of this approach, it has been argued that if we were choosing distributive principles from behind a “veil of ignorance” (Rawls, 1971), and did not know how these principles would apply to us, we would try to make the position of the least well-off as good as possible. We would do this because we would consider the possibility that we ourselves could be one of the least well-off members of society.

These alternative perspectives carry important implications for how we think about our individual and collective responsibility to those who are less fortunate than ourselves. One does not need to travel to Haiti, Mexico, or Russia, as Farmer did, to find people living in poverty, or to find people who lack access to basic goods, such as health care. In the United States, about 46 million people do not have health insurance. People in this situation may see a doctor only when their untreated medical problems worsen to the point that pain becomes unbearable or serious complications set in. Farmer alludes to this problem in Mountains Beyond Mountains when he talks about the poverty just blocks away from the Brigham and Women’s Hospital in Boston.

Who is responsible to care for the uninsured? Farmer would argue that lack of regular access to basic services is a failure on society’s part to care for its most vulnerable members. At the same time, Farmer assumes personal responsibility for the poor, choosing the job of “being a doctor to the poor.”

Understanding Paul Farmer’s Point of View

Conventional readings of human rights violations have failed to draw on current understandings of the social determinants of a wide variety of ills, lending a random appearance to what is a highly predictable set of outcomes.

Paul Farmer, Pathologies of Power, 20

Farmer believes that the world’s poor are the chief victims of structural violence. For this reason, he concludes that the competition-driven market model of distributing resources is unjust and will not serve the poor well. Rather than viewing the individual as a self-sufficient and autonomous agent, as market approaches do, Farmer thinks of the world’s poor as victims of social structures that distribute risk for pain, suffering, and disease. Understood in this way, we are all responsible for the plight of the uninsured, and caring for the disadvantaged is both an individual and collective responsibility.

What Does This Topic Mean For You?

Understanding justice can help you think more critically about the scope and limits of your responsibility to care for those who are less fortunate than yourself. Understanding different justice viewpoints can help you to make sense of many current social and political issues, such as debates about reforming the health care system, caring for uninsured Americans, and rationing health care. Knowledge about the social and economic forces that drive risk for disease and suffering can help you enlarge your vision of individual power and responsibility.

Suggested Courses

HUM 201 Diagnosing Injustice: Ethics, Power, and Global Health
This course highlights the problem of global health disparities, and introduces students to conceptual tools from medical anthropology and medical ethics for critically analyzing health and illness in global, social, and ethical perspectives.

MHE 402 Ethical Theory (5)
Review of principal theories for normative ethical discourse, such as utilitarianism and deontology, and major metaethical commentary on those theories. Illustrated by classical and modern authors.

PHIL 410 Social Philosophy (5)
An examination of topics pertaining to social structures and institutions such as liberty, distributive justice, and human rights.

MHE 411 Introduction to Bioethics (3)
This course introduces students to bioethics as a field of scholarly inquiry. It accomplishes this primarily by working through specific ethical problems that arise in the clinical setting of medicine. By developing an appreciation of these problems, and of the methods of analysis used in their resolution, students will also learn about the methods and practice of bioethics.

MHE 417 Disease in History
This course will examine the impact of infectious and other diseases on Western society from antiquity to the present, the development of understanding of the causes of disease, and the application of that understanding to the prevention of disease through organized programs of public health.

MHE 474/PHIL 411 Justice in Health Care (5)
This course examines the ethical problem of allocating scarce health care resources. Our emphasis throughout is on fundamental principles of justice that support alternative health policies.

PHIL 102 Contemporary Moral Problems (3)
Philosophical consideration of some of the main moral problems of modern society and civilization, such as abortion, euthanasia, war, and capital punishment. Topics vary.

PHIL 110 Introduction to Social and Political Philosophy (5)
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 (3)
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 (5)
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 Introduction to Medical Ethics (5) I&S/VLPA
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 (5)
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.

Resources for Further Study

Books

Farmer, Paul. (2005). Pathologies of Power: Health, Human Rights, and the New War on the Poor. Berkeley: University of California Press.

Farmer, Paul. (1999). Infections and Inequalities: The Modern Plagues. Berkeley, CA: University of California.

Fleischacker, Samuel. (2004). A Short History of Distributive Justice. Cambridge, MA: Harvard University Press.

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

Nozick, Robert. (1974). Anarchy, State, and Utopia. New York: Basic Books.

Rawls, John. (1971). A Theory of Justice. Cambridge, MA: Harvard University Press.

Sered, S. & Fernandopulle, R. (2005). Uninsured in America: Life and Death in the Land of Opportunity. Berkeley: University of California Press.

Sterba, James. (2003). Justice: Alternative Political Perspectives, 4 th edition Belmont, CA: Wadsworth.

Shklar, Judith. (1990). The Faces of Injustice. New Haven, CT: Yale University Press.

Young, Iris Marion. (1990). Justice and the Politics of Difference. Princeton, NJ: Princeton University Press.

Websites

Robert Wood Johnson Foundation “Cover the Uninsured Week” Website
http://covertheuninsured.org/

Robert Wood Johnson Foundation
http://www.rwjf.org/index.jsp

Agency for Health Research Quality
http://www.ahrq.gov/

National Institute of Health
http://www.nih.gov/


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