Lisa Fuller

Citizens of liberal, affluent societies are regularly encouraged to support reforms meant to improve conditions for badly-off people in the developing world. Our economic and political support is solicited for causes such as: banning child labor, implementing universal primary education, closing down sweatshops and brothels, etc. But what if the relevant populations or individuals in the developing world do not support these particular reforms or aid programs? What if they would strongly prefer other reforms and programs, or would rank the various benefits that might be offered differently than seems reasonable to the Western, liberal supporters of these campaigns and organizations? What is the proper liberal response here? I argue that the proper liberal response is to support those programs and reforms that the global poor most value. The bulk of the paper is devoted to arguing against the popular liberal argument which states that we can safely disregard the preferences of the oppressed when they seem very unreasonable because these individuals suffer from “adaptive preferences.” This typically is taken to mean that their preferences are “not their own” in an important sense. I put forward various different proposals for why adaptive preferences can be safely dismissed, but ultimately argue that they are not persuasive. And if it is no longer legitimate to appeal to adaptive preferences as a basis for disregarding what oppressed people want, then I argue that to do so is straightforward paternalism, and so is unjustifiable in all but the most extreme cases. Finally, I argue for the following concrete recommendations: Given that resources are not infinite, we should (1) Support programs that give oppressed people increased access to information, such as access to technology, (2) support those reforms and aid programs that the oppressed themselves regard as most important, with special emphasis on those opportunities for education that they deem valuable, and (3) refrain from supporting coercive policies intended to thwart adaptive preferences.

Thomas Pogge and Andrew Kuper suggest that we should promote an ‘institutional’ solution to global poverty. They advocate the institutional solution because they think that non-governmental organizations (NGOs) can never be the primary agents of justice in the long run. They provide several standard criticisms of NGO aid in support of this claim. However, there is a more serious problem for institutional solutions: how to generate enough goodwill among rich nation-states that they would be willing to commit themselves to supranational institutional reforms. In the current international political climate, the implementation of such institutional reforms introduces several intractable problems, including difficulties of global coordination and enforcement. I defend the solution of NGO aid from the criticisms presented by Pogge and Kuper, and propose how it might be reformed. My main suggestion is that all practising NGOs should be required to be ‘accountable for reasonableness’ in the sense that Norman Daniels and James Sabin have outlined.

Recently theorists have demonstrated a growing interest in the ethical aspects of resource allocation in international non-governmental humanitarian, development and human rights organizations (INGOs). This article provides an analysis of Thomas Pogge's proposal for how international human rights organizations ought to choose which projects to fund. Pogge's allocation principle states that an INGO should govern its decision making about candidate projects by such rules and procedures as are expected to maximize its long-run cost-effectiveness, defined as the expected aggregate moral value of the projects it undertakes divided by the expected aggregate cost of these projects? I critique Pogge's argument on two fronts: (1) I demonstrate that his view is problematic on his own terms, even if we accept the cost-effectiveness framework he employs. (2) I take issue with his overall approach because it generates results which can undermine the integrity of INGOs. Further, his approach mis-characterizes the nature of INGOs, and this mistake is at the root of his problematic view of INGO priority-setting. Ultimately, I argue for a conception of INGOs in which they are understood as ?organizations of principle?, in the sense that they are independent moral agents and so should be permitted a fairly wide sphere of autonomy within reasonable moral constraints.

Non‐governmental aid programs are an important source of health care for many people in the developing world. Despite the central role non‐governmental organizations play in the delivery of these vital services, for the most part they either lack formal systems of accountability to their recipients altogether, or have only very weak requirements in this regard. This is because most NGOs are both self‐mandating and self‐regulating. What is needed in terms of accountability is some means by which all the relevant stakeholders can have their interests represented and considered. An ideally accountable decision‐making process for NGOs should identify acceptable justifications and rule out unacceptable ones. Thus, the point of this paper is to evaluate three prominent types of justification given for decisions taken at the Dutch headquarters of Médecins sans Frontières. They are: population health justifications, mandate‐based justifications and advocacy‐based justifications. The central question at issue is whether these justifications are sufficiently robust to answer the concerns and objections that various stakeholders may have. I am particularly concerned with the legitimacy these justifications have in the eyes of project beneficiaries. I argue that special responsibilities to certain communities can arise out of long‐term engagement with them, but that this type of priority needs to be constrained such that it does not exclude other potential beneficiaries to an undesirable extent. Finally, I suggest several new institutional mechanisms that would enhance the overall equity of decisions and so would ultimately contribute to the legitimacy of the organization as a whole.

Many people in the developing world access essential health services either partially or primarily through programs run by international non-governmental organizations (INGOs). Given that such programs are typically designed and run by Westerners, and funded by Western countries and their citizens, it is not surprising that such programs are regarded by many as vehicles for Western cultural imperialism. In this chapter, I consider this phenomenon as it emerges in the context of development and humanitarian aid programs, particularly those delivering medical treatment, nutrition and access to clean water. I argue that in order to avoid contributing to cultural imperialism, INGOs have a duty to ensure that they do not offer services in a way that requires their beneficiaries to choose between accessing essential health services and violating or otherwise undermining traditional norms and practices which have significance for their beneficiaries. Following Onora O'Neill, I argue that offers requiring such a choice are effectively “unrefuseable” and so coercive. INGOs therefore, must avoid making such offers, and can accomplish this by means of an iterated process of reciprocal negotiation under conditions of equality, in which both the INGOs’ and the beneficiaries’ deep values and concerns play a role. In essence, I claim that employing such a process is a requirement of procedural justice, given the non-ideal conditions in which INGOs must operate.

Following John Rawls, nonideal theory is typically divided into: (1) “partial-compliance theory” and (2) “transitional theory." The former is concerned with those circumstances in which individuals and political regimes do not fully comply with the requirements of justice, such as when people break the law or some individuals do not do their fair share within a distributive scheme. The latter is concerned with circumstances in which background institutions may be unjust or may not exist at all. This paper focuses on issues arising in transitional theory. In particular, I am concerned with what Rawls’ has called “burdened societies," that is, those societies that find themselves in unfavorable conditions, such that their historical, social or economic circumstances make it difficult to establish just institutions. The paper investigates exactly how such burdened societies should proceed towards a more just condition in an acceptable fashion. Rawls himself tells us very little, except to suggest that societies in this condition should look for policies and courses of action that are morally permissible, politically possible and likely to be effective. In this paper I first try to anticipate what a Rawlsian might say about the best way for burdened societies to handle transitional problems and so move towards the ideal of justice. Next, I construct a model of transitional justice for burdened societies. Ultimately, I argue for a model of transitional justice that makes use of a nonideal version of Rawls’ notion of the worst-off representative person.

Joan McGregor argues that “colleges and universities should adopt as part of their core mission the development of skills of civil discourse” rather than engaging in the practice of restricting controversial speakers from making presentations on campuses. I agree with McGregor concerning the need for increased civil discourse. However, this does not mean universities should welcome speakers to publicly present any material they wish without restriction or oversight. In this paper, I make three main arguments: (i) Colleges and universities have a duty to protect members of the campus community from the harm and exclusion resulting from hateful or harmful speech, in the same way that they must protect them from sexual assaults and concussions. (ii) In the vast majority of cases, this duty can be fulfilled by holding speakers to standards of discourse that prevail in academic debate, and insisting on a number of procedural requirements. (iii) We should be wary of conservative arguments framed in terms of free speech, because they can be deployed to undermine important functions of the university in a democratic society, namely, to teach students how to be discerning citizens, and to protect thinkers willing to be critical of the government and the ruling classes.

Prisoners are legally categorized as a vulnerable group for the purposes of medical research, but their vulnerability is not limited to the research context. Prisoner-patients may experience lower standards of care, fewer options for treatment, violations of privacy, and the use of inappropriate surrogates as a result of their status. This case study highlights some of the ways in which a prisoner-patient’s vulnerable status impacted the care he received. The article argues the following: (1) Prisoner-patients are entitled to the same quality of care as all other patients, and healthcare providers should be vigilant to ensure that the stigma of incarceration does not influence care decisions. (2) Options for treatment should reflect what is most medically appropriate in the hospital or other healthcare setting, even when not all treatments would be available in the correctional setting. (3) The presence of guards at the bedside requires that additional measures be taken to protect the privacy and confidentiality of prisoner-patients. (4) When endof-life decisions must be made for an incapacitated patient, prison physicians are not well placed to act as surrogate decision makers, which heightens the obligations of the healthcare professionals in the hospital to ensure an ethically supportable process and outcome. Therefore, healthcare professionals should provide extra protection for those prisoner-patients who do not have decision-making capacity, by utilizing a robust process for decision making such as those used for incapacitated patients without surrogates, rather than relying solely on prison physicians as surrogates.

Healthcare ethics consultation is therefore one of the most consequential, institutionally accepted, and widespread forms of public philosophy in the United States. In this chapter, the authors begin with an overview of the development of healthcare ethics and its emergence as a concrete practice embedded in healthcare settings. They then describe the core ethical principles that inform the everyday practice of ethics consultations and the generally accepted steps involved in conducting a consultation. The authors discuss the role of clinical ethicists in medical education and policy development. Finally, they conclude with some remarks on the distinctive contributions made by those with philosophical training to these endeavors and the importance of continued engagement by philosophers in this important public work.