Justified commitments? Considering resource allocation and fairness in Médecins sans Frontières-Holland

Developing World Bioethics

Volumn 6, Issue 2, 2006, Pages 59-70

  Fuller, Lisa ^a  

^a UNIVERSITY OF TORONTO   (Canada)

Author keywords

Distributive justice; Justification; NGOs; Resource allocation; Special obligations

Indexed keywords

COMMUNITY; CONFERENCE PAPER; DECISION MAKING; HEALTH CARE DELIVERY; HEALTH CARE ORGANIZATION; HEALTH PROGRAM; HEALTH SERVICE; MEDICAL RESEARCH; NETHERLANDS; PRIORITY JOURNAL; RESOURCE ALLOCATION; RESPONSIBILITY;

ANALYTICAL APPROACH; BIOMEDICAL AND BEHAVIORAL RESEARCH; DOCTORS WITHOUT BORDERS; HEALTH CARE AND PUBLIC HEALTH;

COMMUNITY-INSTITUTIONAL RELATIONS; COOPERATIVE BEHAVIOR; DELIVERY OF HEALTH CARE; DEVELOPING COUNTRIES; HEALTH SERVICES NEEDS AND DEMAND; HEALTH SERVICES RESEARCH; HUMANS; INTERNATIONALITY; NETHERLANDS; ORGANIZATIONS; PHYSICIANS; POLICY MAKING; PROGRAM EVALUATION; PUBLIC HEALTH; REFUSAL TO PARTICIPATE; RELIEF WORK; RESOURCE ALLOCATION; SOCIAL JUSTICE; WORLD HEALTH;

EID: 33645503675     PISSN: 14718731     EISSN: None     Source Type: Journal    
DOI: 10.1111/j.1471-8847.2006.00139.x     Document Type: Conference Paper

References (37)

1. The Sphere Project. 2004. The Sphere Project: Humanitarian Charter and Minimum Standards in Disaster Response. Geneva: The Sphere Project. Available at: http://www.sphereproject.org/ [Accessed 3 Feb 2006].
2. A. Ebrahim. Accountability in Practice: Mechanisms for NGOs. World Development 2003 31 821.
3. A somewhat different version of this paper was printed for distribution within MSF in 2004. I also benefited from an opportunity to present it at the Joint Centre for Bioethics (University of Toronto) in April of that year.
4. I should note, however, that this precise division of labour is currently undergoing some changes since many partner sections have become quite large and are the source of significant expertise.
5. More information on specific projects can be found at any one of the many MSF websites, including: http://www.msf.ca/ ; http://www.msf.org.au/ ; http://www.msf.org/.
6. See L. Fuller. 2003. Many Missions, One Voice: Justice and Integrity in MSF Operational Choices. Amsterdam: MSF. The output of this first visit was the above policy report in which I analyzed the meaning and importance of MSF principles and their relation to practice.
7. I would like to express my sincere thanks to all participants, as well as to MSF-H's Public Health Department for its role in facilitating this research. In particular, I would like to thank Richard Bedell and Lucie Blok for all their help and advice. Without their considerable support, this project would not have been possible. I would also like to thank L. Wayne Sumner for supporting my proposals to do field work, and my reviewers for their helpful comments.
8. It ought to be noted that mechanisms of procedural fairness do not, on their own, guarantee the production of a fair outcome in every case. I recognize that such procedural mechanisms might benefit from additional substantive criteria that define what can count as an acceptable outcome, thus eliminating at least the most obvious cases of unfairness. I do not suggest any such criteria here, however.
9. N. Daniels & J. Sabin. 2002. Setting Limits Fairly. Oxford: Oxford University Press: 44.
10. Of course, there is no doubt that such a project is also instrumentally valuable.
11. For a much more in-depth discussion of the intrinsic goods embodied by MSF projects, see Fuller, op. cit. note 6.
12. S. Scheffler. 2001. Boundaries and Allegiances. Oxford: Oxford University Press: 100. The underlying assumption here is that relationships of solidarity and trust have intrinsic value, but I do not argue for that claim here, since such an argument would constitute a significant digression.
13. Ibid: 100.
14. Ibid: 104.
15. Ibid: 92.
16. Ibid: 85.
17. Ibid: 93.
18. Another very important constraint is MSF's mandate or mission, but this is recognized as such by MSF-er's and so will be addressed in the next section as its own mode of justification.
19. I owe this formulation of the problem to Nicholas Stockton.
20. It is worth noting here that simple non-abandonment might be a good because it expresses solidarity. The importance or weight of this will vary with the situation of the population.
21. The intrinsic value generated by a particular project could take the form of acts of protest, compassion or non-abandonment, for instance.
22. Of course, it is not always easy to determine exactly whose opinion represents the view of the community. Certainly the opinions of authority figures should not be the only ones considered. At the very least, the people most affected by the presence of MSF should place some value on their efforts.
23. Scheffler, op. cit. note 12.
24. This is, admittedly, merely a slightly more radical version of what already goes on.
25. A note about the word 'mandate'. Officially, MSF doesn't have a rigidly defined, written mandate. They prefer not to because this allows for more flexibility and growth. However, having an informal mandate or mission of this kind only makes the problem of how it can function as a constraint or justification more acute, rather than less.
26. See Fuller, op. cit. note 6.
27. The fact that these goods have substantive value is what justifies directing action towards their realization in the first place. Their value is a sufficient reason to choose them, since it is unreasonable to expect that any organization will be able to take on all the goods that would be worthwhile pursuing.
28. Daniels & Sabin, op. cit. note 9, p. 48.
29. 'History' and 'integrity' are Dworkin's terms, rather than Daniels' (see Ronald Dworkin. 1986. Law's Empire. Cambridge, MA: Belknap Press.) However, they are a nice shorthand way of referring to the two elements of justice which both philosophers are concerned to incorporate into decision-making, namely, procedural justice and substantively just outcomes.
30. Daniels & Sabin, op. cit. note 9, p. 48.
31. Scheffler, op. cit. note 12, p. 107.
32. Ibid: 106.
33. The idea that the mandate can and should be constrained by factors outside the organization might seem unusual or objectionable to some. It is often thought that the giver of 'charity' is free to decide to whom s/he will give, how much, and when. This approach seems unduly dismissive of the interests of recipients since it suggests that they are not entitled to a say in actions that greatly affect them. Indeed, for similar reasons this prevalent view also does not express sufficient respect for the beneficiaries as the moral equals of the NGO decision-makers. Finally, it is important to note a significant difference between the case of the isolated, private giver and the situation of an NGO. It seems much more plausible to argue that 'if you are in the ongoing business of providing aid, then you ought to do so in an accountable and ethically justifiable manner' than it is to argue that private individuals ought to be held to such standards (although perhaps this argument could be made). The institutional character of NGOs, coupled with the significant effects they have on a large number of people provide presumptive reasons in favour of more stringent ethical requirements for them.
34. Unless, of course, certain consequences were altogether unforeseeable, and then we do no typically hold anyone responsible for them. We do, however, still take into account the degree of uncertainty people were facing when they made the decision, and evaluate whether or not it was a wise one under the circumstances.
35. While this division of labour between field and headquarters might be a bit artificial, it does seem to have some intuitive appeal. Clearly though, what is important is that both perspectives ultimately be represented in the decision-making process.
36. Of course, this needs to be done in conjunction with other MSF sections as well.
37. T. Christiano. Knowledge and Power in the Justification of Democracy. Australas J Philos 2001 79 202.