It is a commonplace to say that the world has changed since the tragic events of September 11. This also holds true for those dedicated to humanitarian action—to the prevention of death and the alleviation of suffering during crisis and conflict, irrespective of any consideration other than need. The cause of the change for us, however, is not so much the attacks themselves or their vicious character. Sadly, such great loss of life and willingness to inflict death indiscriminately upon innocent civilians is nothing new, as those of us who have worked in areas of conflict know only too well.

What has changed is that, as a result of these attacks, the leading international power, the United States, has declared a new global war on terrorism. This war, as it has been defined, pits terrorism against freedom, and those who would imperil humanity against those who stand to defend it. While the main focus, thus far, has been on Afghanistan, the repercussions have swiftly embraced the entire planet. Like the Cold War, this is an open-ended, global fight defined to uphold both interests and values. Yet unlike the Cold War, it is one in which alliances are constantly shifting, the enemy consists primarily of an ill-defined set of nonstate actors as well as their purported state sponsors, and territorial control is not necessarily an aim.

The U.S.–led war on terrorism poses a number of challenges for independent humanitarian action and the principles that underpin it. First, it seeks to subordinate humanitarianism to its broader purpose, undermining the ability of humanitarian actors to impartially reach out to all victims. Second, by questioning the applicability of international humanitarian law, the antiterrorism campaign could well threaten the fundamental restraints on the conduct of warfare, thus weakening the protection and assistance to which civilians are entitled. Third, there is a shift in attention to conflicts worldwide, and the victims they generate, making it more difficult to respond to crises at the margins of current priorities.

Most Muslims now live in democracies—a fact that is rarely acknowledged. The Muslim world has also elected five women heads of state in the past decade. These two indicators are symbolic of the diversity within the Muslim world, and also of the direction in which that world is headed.

Few Muslims wish to be classified in a category that would prevent them from participating in the benefits of modernity. The pull of mass education, commerce, trade, and engagement with the world is strong. But these possibilities are openings that radical Islam is attempting to close off, which has led to an ideological civil war within Islam. In country after country, the middle class, the elite, and most of the poor are frightened by an austere version of theocratic Islam that has managed to gain political leverage. In order to sustain modern governments and access to the world in which they want to be active contributors, Muslims need an alliance with the West—not a confrontation.

The United States' foreign policy in Afghanistan has a long history of misguided plans and misplaced trust—a fact that has contributed to the destruction of the social and physical infrastructure of Afghan society. Afghans contend that after having fought as U.S. allies against the Soviet Union—with the price of more than two million dead—the United States swiftly walked away at the end of that bloody, twenty-three-year conflict. The toll of the war on Afghan society reflected in current statistics is so staggering as to be practically unimaginable: 12 million women living in abject poverty, 1 million people handicapped from land mine explosions, an average life expectancy of forty years (lower for women), a mortality rate of 25.7 percent for children under five years old, and an illiteracy rate of 64 percent. These horrific indicators place Afghanistan among the most destitute countries in the world in terms of human development.

The events of September 11 have forced institutions to reexamine their priorities and practices. Yet the first world war of the twenty-first century has left many wondering if there truly is a war, and what, if anything, different is demanded of them. The philanthropic sector in particular has not changed significantly, and it continues to struggle with fundamental concerns about its directions. If September 11 and its aftermath are to mean anything to philanthropy other than emergency relief, it must be a recognition that now is the time to tackle the problems and tensions that were ignored before the attacks. For nearly a year, philanthropy as a sector has not rallied behind this call for longer-term reform. Philanthropy should take up these tasks, no matter how daunting they may be, for if foundations do not lead the effort, it may be left to the governments and the militaries of the world to respond on their own.

All wars—and the current war on terrorism is no exception—provide serious tests for the rule of law. The demands of armed conflict, with its instantaneous decisions of life and death, do not lend themselves easily to legal constraint. It is thus not surprising that the United States, which has been outspoken historically on matters of human rights, would become less attentive to those concerns after coming under deadly attack. For Human Rights Watch (HRW) and other human rights organizations, the primary concern since September 11 has been to demonstrate that upholding fundamental rights, whether on the battlefields of Afghanistan or in the detention facilities at Guantánamo Bay, is not only consistent with fighting international terrorism, but is, in essence, what the war is all about. The unwillingness of the Bush administration to embrace this idea bodes ill for the protection of rights as the war on terrorism reaches across the globe.

Most work in medical ethics across the last twenty-five years has centered on the ethics of clinical medicine. Even work on health and justice has, in the main, been concerned with the just distribution of (access to) clinical care for individual patients. By contrast, the ethics of public health has been widely neglected. This neglect is surprising, given that public health interventions are often the most effective (and most cost-effective) means of improving health in rich and poor societies alike.

In this essay I explore two sources of contemporary neglect of public health ethics. One source of neglect is that contemporary medical ethics has been preoccupied—in my view damagingly preoccupied—with the autonomy of individual patients. Yet individual autonomy can hardly be a guiding ethical principle for public health measures, since many of them must be uniform and compulsory if they are to be effective. A second source of neglect is that contemporary political philosophy has been preoccupied—in my view damagingly preoccupied—with the requirements for justice within states or societies, and (until very recently) has hardly discussed justice across borders. Yet public health problems often cross borders, and public health interventions have to measure up to the problems they address.

Everyone wants to be healthy, but many of us decline to act in healthy ways. What bearing, if any, should these choices have on the ethics of clinical practice and health policy? Should risk-takers have the same claim on scarce resources, such as organs for transplant, as those whose plight is due to no choices of their own? And is there any reason not to impose fees and taxes on risk-takers, be they smokers or mountain climbers, to defray the added expense of the care they may need? In health resource allocation aimed at reducing the burden of disease, should we regard certain burdens as individual responsibilities: for example, dealing with stigma, or caretaking for family members?

Socioeconomic status (SES) and health expectancy are strongly linked. To the extent that this results from risk-taking by the poor, is reduction of SES-linked health inequalities a morally important social goal? International public health aims at improving health on a population level. The World Health Organization has been criticized for failing to distinguish genuine health risks from personal lifestyle choices, as when it speaks of a tobacco-related “epidemic” as if cigarette use were a contagious disease like malaria. Should personal responsibility for health be taken into account in setting the agenda for global public health, and in measuring progress by countries in improving health. This paper addresses applications of the notions of personal and social responsibility for health. It also looks at the vulnerability of the notion of personal responsibility for health to intentional manipulation by self-interested parties in health policy debates.

There is no cure or vaccine for HIV/AIDS. The only life-prolonging treatment available is antiretroviral (ARV) therapy. WHO estimates, however, that less than 5 percent of those who require treatment in developing countries currently enjoy access to these medicines. In Africa fewer than 50,000 people–less than 2 percent of the people in need–currently receive ARV therapy. These facts have elicited strongly divergent reactions, and views about the appropriate response to this crisis have varied widely.

The intensity of the debate concerning access to life-prolonging medicines for the treatment of HIV/AIDS, and the heated rhetoric with which they are often conducted, suggest that these disagreements may be rooted in deeper disagreements of value. It is not obvious, however, what disagreements of value are at stake in this debate. By analyzing the statements of scholars, public officials, activist organizations, and private sector representatives, each of whom may endorse very different policy recommendations on access to HIV/AIDS drugs, we have identified and created a typology of the different sources of disagreement in the debate. We conclude that the central disagreements concerning access to medicines arise from competing understandings of how responsibilities for bringing remedy to hardships should be allocated to different agents and institutions. A central lesson that emerges from our analysis is that thinking about “health equity” must extend beyond the explanation and justification of goals, values, and ideals, and engage more honestly with the difficult question of how responsibilities for bringing remedy to health crises should be allocated in complex social contexts.

In a democratic society, the social rules are imposed by all upon each. As “recipients” of the rules, we tend to think that they should be designed to engender the best attainable distribution of goods and ills or quality of life. We are inclined to assess social institutions by how they affect their participants. But there is another, oft-neglected perspective which the topic of health equity raises with special clarity: As imposers of the rules, we are inclined to think that harms we inflict through the rules have greater moral weight than like harms we merely fail to prevent or to mitigate. What matters morally is not merely how we affect people, but how we treat them through the rules we impose. While current (consequentialist and Rawlsian) theorizing is dominated by the first perspective and thus supports purely recipient-oriented moral conceptions, an adequate approach to social justice requires a balancing of both. Such balancing results in a relational conception of justice, which distinguishes various ways in which an institutional scheme may causally affect the quality of life of its participants.

This essay argues that the strength of our moral reason to prevent or mitigate particular medical conditions depends not only on what one might call distributional factors, such as how badly off the people affected by these conditions are in absolute and relative terms, how costly prevention or treatment would be, and how much patients would benefit from given treatment. Rather, it depends also on relational factors, that is, on how we are related to the medical conditions they suffer. It then discusses some implications of this view for understanding responsibilities for international health outcomes.

This paper discusses obligations of international distributive justice-specifically, obligations rich countries have to transfer resources to poor countries. It argues that the major seven OECD countries each have an obligation to transfer at least one percent of their GDP to developing countries.

The strategy of the paper is to defend this position without having to resolve the many debates that attend questions of international distributive justice. In this respect, it belongs to the neglected category of nonideal theory. The key to the strategy is to show that a significant amount of good would be accomplished by a one percent transfer, despite the fact that one percent is quite a small amount.

To make this showing, the paper takes health as a fundamental measure of individual well-being and examines the improvement in life expectancy that would likely result from devoting the one percent transfer to the major determinants of health. It adduces data indicating that substantial progress towards raising life expectancy in developing countries to the global average of 64.5 years can be expected from expenditures of $125 per capita, divided between health care, education, and basic nutrition and income support. A one percent transfer from the major seven is enough to cover expenditures on that scale for the poorest fifth of the world's population.

In the lexicon of rights, the concept of human rights can play a wide variety of roles. Human rights can be defined as substantive natural rights that transcend politics and culture or as the rights that underlie political and cultural differences. They can be defined narrowly as rights that could be asserted against enemies in war or, more broadly, as the aspirational goals to which governments are held accountable by their citizens and the world. Despite their lack of recognition in covenant and positive law through much of the twentieth century, human rights are increasingly asserted on the basis of such recognition. To some, human rights are simply the sine qua non (procedural? biological?) for asserting other rights, whatever these may be. In this paper I do not choose among these uses of the concept of human rights by propounding a single definition; neither do I defend or criticize human rights in general.

No serious student of victimhood and injustice can fail to appreciate their complicated origins and problematic legacies. For individuals and societies emerging from communal violence, oppression, and atrocity, the quest for moral regeneration–through acknowledgment, understanding, and transformation–is as difficult and perplexing as it is pressing. Challenging moral questions abound in the aftermath of human wrongs that admit no easy answers. Indeed, the ethics and politics of transition have been widely contested in theory and practice, by people who share the same basic moral/political concerns to redeem the suffering of victims and to forge a future that never again repeats the violations of the past.

Much of Catherine Lu's response resonates in tone and substance with my article. Like me, Lu speaks in the language of moral psychology and relies heavily on the later work of that preeminent moral psychologist among liberal theorists, Judith Shklar. She agrees, moreover, with both Shklar and me that victimhood (and the fear it produces) is morally damaging more often than not, and that the recent literature on human rights, which focuses on the relation of victim and perpetrator, tends to let the beneficiaries of systemic injustice off the hook. Lu and I, thus, share much common ground that other respondents might have contested, and I am grateful that her perceptive criticisms focus on points within my argument that I am pleased to elaborate.

This brief response cannot adequately address all of the challenging issues raised by Robert Meister in his reply, so I hope only to clarify our main points of contention that will likely continue beyond this exchange.