The Global Bioethics Blog has two interesting posts recently, touching on the relations between first-world and third-world healthcare systems and patients. They raise some interesting questions about the obligations the medical haves bear towards the have-nots, and the extent to which the pursuit of our own interests in a globalized medical marketplace dooms others in far reaches of the world.

One article touches on recently-raised immigration quotas for licensed nurses from other countries. Congress has increased the quota in this special category of skilled worker, in response to a perceived nursing shortage here and in anticipation of greater needs as the baby boomers enter their declining years. This creates a couple of problems, however:

This week’s editorial in The Lancet criticizes the provision as unjust, both in its effects on health care systems in the developing world and its role in maintaining the status quo of underpaying nurses in the United States. The shortage of nurses in developing countries is exponentially greater than that of the United States, and ‘in-sourcing’ nurses from resource-poor countries just perpetuates the domestic trend of underpaying nursing staff.

By enticing nurses to leave their home countries, the practice of hiring foreign nurses into the US has devastating effects on primary care provision in impoverished regions, many of whom have virtually no doctors, and a ratio of nurses to population that is already grievously low. In addition, this policy is entirely employer-profit-driven: it would certainly be possible to hire as many nurses as were needed if nursing were a more attractive field for prospective college students, which is to say if nurses were paid better. (The effect of raising nursing salaries would not be immediate, but would be felt within 4 years as student nurses emerged from college programs. That is well within time to respond to demand from the boomer population.) The nursing immigration program is nothing more than a guest-worker program aimed at keeping domestic professionals’ salaries low.

Another issue has to do with the tremendous mismatch of medical-research resources and priorities with global need. Most published research is at the cutting edge of exciting scientific fields, and the most-prestigious journals exclusively publish this high-tech science. But the practical medical needs of underdeveloped countries have more to do with the affordability and accessibility of already-proven treatments in areas with little medical infrastructure. Major advances in treating underdeveloped populations have included rehydration packets to fight dysentery, heat-stable vaccines that do not require refrigeration, and cheaper AIDS drug regimens – not very sexy technological issues, but of overwhelming importance to large percentages of the world’s population. Because solving these problems does not entail cutting-edge science or major research breakthroughs, however, and likely because they only address the needs of the world’s least influential people and least profitable markets, the amount of research effort devoted to them is pitiful relative to the size of the population at need.

[In] 416 issues of the NEJM [the New England Journal of Medicine; one of the most prestigious medical journals in the world] over an eight year period, from January 1997 to December 2004, . . . less than 3% of the articles were relevant to developing countries. Just when people are starting to become familiar with the 90/10 gap — that 90% of health research expenditures worldwide are devoted to diseases afflicting only 10% of the earth’s population — now we have a 97/3 gap in health research publishing and the NEJM is its unfortunate poster child.

Again, this is an example of the first world catering to its own interests while other parts of the world remain in need.

It is easy to see the problems caused when part of the world – or, let’s face it, one big self-absorbed and economically dominant country – behaves without regard for the effects of its actions on others. But what are the obligations of the better-off to others globally?

In a way, this is a variation on the familiar argument about the obligations of the rich to the poor. In some ways, in fact, the response to the two inquiries is the same as well: the rich cannot act with indifference because they are part of, and benefit hugely from, the community to which the poor contribute so much. Just as the rich in the US benefit from depressed labor costs, and from social goods such as the transportation system, the US as a whole benefits from depressed labor costs worldwide, as well as, in the medical realm, the use of biomaterials from developing countries for research and the production of medicines, research on third-world patient populations, overseas markets for US drug companies, and in other ways. Add to that the legacy of colonialism and present-day meddling in foreign politics, and the US has a lot to answer for in respect of other countries’ poverty and their lack of healthcare resources. This suggests an obligation to help now, but it is not a fully satisfying argument (because it rests on these contingent facts of history, and not a more general principle requiring assistance).

Making a general argument that the research and treatment resources of economically powerful countries should be significantly redeployed toward meeting the needs of citizens of less-able governments requires a general principle of obligation. In this, that argument is somewhat like that supporting universal healthcare: that everyone is bound together in the social enterprise, and there are certain aspects of that collective undertaking that should not be contingent on individual circumstances, still less market forces. Making the argument across national boundaries requires universalizing that notion of collective entreprise – it requires moving the argument from the national to the global level.

There are lots of reasons to be skeptical of such a move. It is hard to envision the social contract as a global principle: there certainly seem to be many parts of the world in which that contract is not operative, and in many cases they are the same areas that have greatest medical need. (Though in this context one is reminded again of Gandhi’s remark about Western civilization: “I think it would be a good idea.”) But perhaps this is too pessimistic. What every part of the world does share is a desire for settled life: outside the Bush administration, you don’t find many open advocates of feudalism these days, let alone nomadic barbarism or even monarchy. Without getting all Francis Fukuyamic, there is a general consensus in favor of civilization (in the sense of a stable, organized society under a recognized governmental system), which is to say that the social contract has been ratified worldwide, whether or not it is always adhered to. And if so, then, just as much as we want other parts of the world to calm down and quit causing trouble, we must acknowledge that we are bound to them by obligations also.

The conclusion that those obligations include expending our own resources for others’ healthcare takes more effort, but I think there is an argument to be made there. It is strengthened by the ways in which we have taken advantage of the third world for our own healthcare, some of them mentioned above.

At any rate, the point is that we are in a planet-sized lifeboat with regard to scientific and medical resources, and we have got to realize that and start taking seriously our membership in a community large than just those who happen to be sharing our seat cushion.