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S. Muller (2017)The economics and philosophy of the brain drain: A critical perspective from the periphery
South African Journal of Philosophy, 36
(2015)citation_publisher=Oxford University Press, New York; Debating Brain Drain: May Governments Restrict Emigration?
Kieran Oberman (2013)Can Brain Drain Justify Immigration Restrictions?*
Sabine Hohl, Dominie Roser (2011)Stepping in for the Polluters? Climate Justice under Partial Compliance
Analyse & Kritik, 33
Eszter Kollar, A. Buyx (2013)Ethics and policy of medical brain drain: a review.
Swiss medical weekly, 143
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Human Resources for Health, 10
R. Goodin, Christian Barry (2014)Benefiting from the Wrongdoing of Others
Journal of Applied Philosophy, 31
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J. Mcmahan (2010)Humanitarian Intervention, Consent, and Proportionality
C. Hobden (2017)Taking up the slack: The duties of source state citizens in the brain drain crisis1
South African Journal of Philosophy, 36
Gillian Brock, M. Blake (2014)Debating Brain Drain: May Governments Restrict Emigration?
D. Owen (2016)Refugees, Fairness and Taking up the Slack: On Justice and the International Refugee Regime
Moral Philosophy and Politics, 3
Catherine Lu (2018)Responsibility, Structural Injustice, and Structural Transformation
Ethics & Global Politics, 11
Yusuf Yuksekdag (2017)Health Without Care? Vulnerability, Medical Brain Drain, and Health Worker Responsibilities in Underserved Contexts
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Peter Cane (2016)Role Responsibility
The Journal of Ethics, 20
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Kieran Oberman (2016)Emigration in a Time of Cholera : Freedom, Brain Drain, and Human Rights
Economics & Human Biology, 9
G. Collste (2014)Global Rectificatory Justice
Gillian Brock, M. Blake (2016)What should be done to address losses associated with ‘medical brain drain’?
Journal of Medical Ethics, 43
David Miller (2013)Justice for Earthlings: Essays in Political Philosophy
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Luis Cabrera (1970)Migration, the 'Brain Drain', and Individual Opportunities in Gillian Brock's Global Justice
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Jeremy Snyder (2009)Is Health Worker Migration a Case of Poaching?
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Journal of Medical Ethics, 34
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Zofia Stemplowska (2016)Doing more than one’s fair share
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Javier Hidalgo (2012)The active recruitment of health workers: a defence
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(2013)citation_publisher=Cambridge University Press, Cambridge; Justice for Earthlings: Essays in Political Philosophy
Abstract One of the ways to address the effects of skilled worker emigration is to restrict the movement of skilled workers. However, even if skilled workers have responsibilities to assist their compatriots, what if other parties, such as affluent countries or source country governments, do not fulfil their fair share of responsibilities? This discussion raises an interesting problem about how to think of individual responsibilities under partial compliance where other agents (including affluent countries, developing states, or other individuals) do not fulfil their fair share of responsibilities. What is fair to expect from them? Taking health worker emigration as a case in point, I discuss whether the individual health workers’ fair share of responsibilities to address basic health care needs decreases or increases when the other parties do not fulfil their share. First, I review the responsibilities that different stakeholders may hold. Second, I argue that there are strong reasons against increasing or decreasing health workers’ fair share of responsibilities in a situation of partial compliance. I also argue that it is unfair for non-complier states to enforce health workers to fulfil their fair share or take up the slack. Introduction The mass exodus of skilled workers from under-served and resource-poor countries in the world has the potential to diminish capacity building for the institutions that provide for the basic needs of the citizens. The effects of emigration of skilled workers from developing countries continue to be a matter of concern, especially for Sub-Saharan African (SSA) countries where there are critical shortages of skilled workers and, more specifically, health workers (Brock and Blake, 2015). One of the policy proposals to address the effects of skilled worker emigration from under-served countries is to restrict the movement of skilled workers. Such exit restrictions have many ethical implications on individuals’ interests and human rights (Brock and Blake, 2015; Oberman, 2016). Nevertheless, let us suppose that individual skilled workers have responsibilities to assist in the basic-need satisfaction of their compatriots. Skilled workers, or some of them, benefit from the use of public funds for their tertiary education. They also benefit from public goods throughout their lives and, based upon reasons of reciprocity, one could argue that they have a duty to stay and serve their compatriots (Brock and Blake, 2015; Brassington, 2012). Arguably, there is prima facie nothing wrong in the state’s restriction of their emigration. Having said that, one might find it unfair to burden individual skilled workers. It is the affluent countries after all who cultivate most of the benefits in recruiting skilled workers. One could argue that regardless of their causal role in diminishing basic needs delivery in under-served regions, affluent countries should have duties of assistance (Brock, 2009; Ruger, 2009). Rather than fulfilling this duty, they even benefit from the situation by recruiting skilled workers from resource-poor regions (Hooper, 2008). Why should we expect from individuals to ‘take up the slack’ by staying when affluent countries1 do not fulfil their fair share? The same goes for source country governments and their responsibilities. The vulnerabilities of people in under-served regions can be partly due to the failure of source country governments. No doubt, these failures are themselves partly caused by global inequalities and by the (morally questionable) actions and omissions of governments in affluent countries and of international institutions (Hobden, 2017). However, lack of accountability, corruption and violation of human rights are considered some of the push factors. Elsewhere, I have argued that the states in SSA countries are responsible for addressing the background conditions (poverty, infrastructure, illiteracy, etc.) that make people vulnerable and dependent, and if the state fails in this regard, it is unfair to expect, for instance, local health workers to ‘take up the slack’ (Yuksekdag, 2018). Therefore, a necessary condition for health workers’ having responsibilities to assist the health needs of the population is that the state fulfils its responsibilities (Yuksekdag, 2018). One might object that this line of reasoning goes a little too far. In general, it seems plausible that people can have moral duties to do things they would not have to do if other agents had fulfilled their duties. Suppose I walk past a child who is drowning in a pond because the local or the international community failed to put up a fence to prevent such accidents, or because the child’s parents failed to look after her properly. I still have a duty to save the child—even though the only reason she ended up in the pond is that other agents neglected their duties.2 Some might even claim that the reason for the risk of harm, be it a misfortune or a wrongful act, should not matter in the instantiation of a duty to take up the slack (McMahan, 2010). This discussion raises an interesting problem about how to think of individual responsibilities under non-ideal circumstances, i.e. circumstances where other agents (including the affluent countries, developing states or other individuals) do not fulfil their fair share of responsibilities. Call this the issue of partial compliance. How should we assess this issue? How should we think of the responsibilities of local skilled workers against the background of partial compliance? Is it fair to expect them to solely fulfil their fair share or even take up the slack? Or is it unfair to even expect them to do anything at all? These questions concern the unfairness between different duty-bearers when one does not do her fair share (Stemplowska, 2016). Interestingly, this issue is not sufficiently addressed in the literature discussing the ethics of skilled worker emigration. The primary aim of this article is to discuss whether it is fair to place burdens on individual skilled workers in a situation of partial compliance. Thus, this discussion assumes that individual skilled workers have responsibilities to assist their compatriots in addition to the responsibilities of their governments, and the affluent countries and their citizens. However, there is a merit in reviewing the potential sets of responsibilities of each actor to address the effects of skilled worker emigration or diminishing basic-need delivery in general. The first part of the article serves that purpose by providing a sketch of each actors’ fair share of responsibilities. I use health worker emigration as a case in point. In the second part of the article, I discuss the reasons for and against health workers’ responsibilities in a situation of partial compliance: (i) doing nothing or less than their fair share, (ii) fulfilling their fair share, or (iii) taking up the slack. I argue that there are good reasons against (i) and (iii). I also argue that to ask (ii) or (iii) from health workers, the agent (e.g. the source country) that enforces the responsibility should also fulfil its fair share. Responsibilities to Address Skilled Health Worker Emigration and Health Care Delivery Deprivation The normative discussion on skilled worker emigration from under-served and resource-poor contexts and its putative effects on capacity-building and basic needs satisfaction has largely focussed on delineating which parties, on what grounds and to what extent hold responsibilities to address this very concern. In this part of the article, I review the literature that discusses the responsibilities of different stakeholders (e.g. developed countries and recruiting agents, the source countries and individual skilled workers)—with a focus on health worker emigration. A note is needed at this point to elucidate the effects of health worker emigration and basic health care delivery deprivation in under-served and resource-poor regions. The negative effects of health worker emigration on health care delivery has been greatly problematized in the last decade (Eyal and Hurst, 2008; Hooper, 2008; Kollar and Buyx, 2013; Brock and Blake, 2017). Notably, there are accounts shedding light on the positive developmental effects of skilled worker emigration in general (Clemens, 2013). Emigrant health workers might also benefit from better remuneration and working conditions in the destination countries. However, in the short-term, critical shortages of health workers might render the under-served populations vulnerable to ill-health and higher rates of mortality (WHO, 2013). It is important to be wary of the negative effects of health worker emigration on the most underprivileged groups in a country (Muller, 2017). The World Health Organization (WHO) has set a target of 4.45 health workers3 per 1000 of the population as part of the Sustainable Development Goals (SDGs). For the WHO, this figure is an indicator of the minimum number needed to meet the demand for health workers (WHO, 2016). In 2015, the African Region had 1.3 health workers per 1000 of the population on average (WHO, 2017). Furthermore, affluent countries and private agencies continue to recruit health workers from under-served countries. Active recruitment of health workers is even labelled by some as a form of poaching (Snyder, 2009). The concern is that affluent countries and private recruiting agencies benefit from recruiting trained health workers without giving consideration to the financial and developmental effects of the recruitment on the source countries. Responsibilities of Affluent Countries There are many unfavourable background conditions that under-served regions suffer from, such as: critical shortages of health workers, poverty, lack of medical equipment, health illiteracy, and insufficient infrastructure (Schneider et al., 2006; Bhargava et al., 2011). All these aspects can be partially attributed to recruitment policies or past injustices committed by the citizens of affluent countries. One might argue that the recruiting countries and their citizens have largely benefited from health worker emigration and they should be held responsible for the effects of critical shortages in under-served regions (Goodin and Barry, 2014). It is also plausible to expect the fulfilment of rectificatory duties by affluent countries that would aim to compensate for the effects of past injustices on the current levels of health deprivation (Collste, 2015). Notably, it is challenging to delineate to what extent citizens of affluent countries should be held accountable, if not causally responsible, for the health deprivation in resource-poor countries (Goodin and Barry, 2014). However, the responsibilities of affluent countries and their citizens can be argued for regardless of the causal links between their actions/omissions and the effects of health worker emigration on the basic need satisfaction of individuals residing in the source countries. For example, the responsibilities to assist or aid might be derived from the principles of global distributive justice. In her account of global justice, Gillian Brock (2009) argues that individuals should not be deprived of basic needs and rights on the basis of morally arbitrary factors such as one’s birthplace. This implies global duties for every individual and country to distribute certain resources in order to provide certain basic needs.4 More particularly, health needs of individuals around the world might be highlighted. Focusing on global health justice, Jennifer Prah Ruger (2009) argues that there is a general duty to prevent premature mortality. Global health justice requires upholding the responsibilities of global, national, and local communities as well as individuals to address health deprivations via global health governance (Ruger, 2009). The implication is that global actors including the affluent countries and intergovernmental organizations should support and enable health promotion (Ruger, 2009). In particular, and especially in the short-term, it can be plausibly expected from affluent countries and their citizens that they provide resources and medical equipment, transfer know-how, and offer debt-relief strategies—regardless of their role in past injustices. As Ruger (2009) emphasizes, global health promotion also requires efforts of national authorities and individual agents. Responsibilities of Source Country Governments The governments in under-served and resource-poor contexts also have responsibilities towards their citizens. The state and its members have reciprocal duties towards each other and also to individual health workers (Brock and Blake, 2015). State and state officials hold the primary responsibility in enhancing individuals’ capability to be healthy (Ruger, 2009). For instance, the state (the community in general and the state officials) should be responsible for ameliorating the background factors that enhance health delivery deprivation such as poverty, insufficient infrastructure and corruption. States also have the responsibility for establishing decent, equitable and affordable public structures and health delivery institutions (Ruger, 2009). The developing states should respect basic interests, human rights and working conditions of the health workers as well as their citizens in general. It is possible that the state and state officials are sometimes unable to fully achieve, for instance, decent working conditions, sufficient sanitation or adequate living conditions. As such, it would be plausible for them to, at the least, show good-faith efforts that they are working towards meeting sufficient working and living conditions (Brock and Blake, 2015). State officials, in particular, should be considered to have individual responsibilities to be accountable and transparent. These responsibilities can be argued for in different forms, for instance, by referring to an account of role responsibility that the state officials should hold on the basis of their institutional authority and power (Cane, 2016). Individual Health Worker Responsibilities The responsibilities of other stakeholders nonetheless do not necessarily negate the individual responsibilities of health workers given the worrisome short-term effects of critical shortages in health care delivery systems. The responsibilities of the health workers from under-served and resource-poor regions are discussed both in the context of skilled worker emigration and also particularly in discussions concerning health worker responsibilities. The first reason why skilled workers in general may have a responsibility to assist, is in virtue of reciprocity for the benefits skilled workers enjoy in the society, including the state-funded tertiary education they receive (Brock and Blake, 2015). Second, it can be argued that skilled workers should support vital institutions in their countries, including the medical institutions that aim to satisfy the basic needs of the population (Brock and Blake, 2015). Third, and more particularly for health workers, elsewhere I argued that under-served populations are rendered more vulnerable to their actions and omissions (Yuksekdag, 2018). In under-served contexts, where the risk of harm is ill-health and mortality, individual health workers should assist with the promotion of basic-health needs of their compatriots (Yuksekdag, 2018). These accounts that discuss individual health worker responsibilities provide reasons why it is fair to expect health workers to provide a temporary service after their graduation. Some developing countries have already instituted compulsory service programmes, where the state-funded tertiary education is conditional upon the provision of 2–3 years of mandatory service by health workers after their graduation (Chen et al., 2012). Notably, the responsibilities I review address a non-ideal situation that is shaped by many unfavourable conditions. Similar to the discussions on CO2 emission or refugee protection, the fair share of responsibilities can be assessed considering the unfavourable conditions and then distributed assuming full compliance by all the agents (Hohl and Roser, 2011; Owen, 2016). In the scope of this article, I merely review the responsibilities of different stakeholders. Undoubtedly, more demanding responsibilities of affluent countries and their citizens can be argued for. Arguably, if affluent countries substantially contribute to prevent the harms in question, then we would not have the problem in the first place. However, there is no magic button that will make everything better by making epidemics disappear, health literacy adequate, infrastructure well-functioning and remuneration more than sufficient. Especially in the short-term it is plausible to expect a 2–3 years long health service5 by health workers in under-served and resource-poor regions (Brock and Blake, 2015). The main question of this article is that, regardless of what affluent countries’ responsibilities are, if they do not fulfil their share, would it still be fair to expect health workers to do a 2–3 years health service? In the next part, I discuss whether health workers should stay in their respective under-served countries for 2–3 years to promote basic health needs satisfaction—even if the other responsible parties do not fulfil their share. I argue that there are strong reasons against health workers doing less or more than 2–3 years health care delivery service. In addition, I argue that it is not fair for non-complier governments to enforce health workers to fulfil their fair share, let alone to do more. Individual Health Worker Responsibilities in Partial Compliance Imagine that either affluent countries or local authorities, or both, do not fulfil their fair share. What should health workers do? What would be a fair course of action? For example, doing less than what their fair share is? Is it fair that they fulfil their fair share and serve in the country for 2–3 years? Should they take up the slack and do even more? Two explanatory notes are needed. First, what is slack taking? It means doing some or a partial equivalent of the non-complier’s fair share on top of one’s fair share (Stemplowska, 2016). However, what would that imply for health workers? It is much more straightforward to highlight slack taking in reducing CO2 emissions or in giving protection to additional numbers of refugees. Simply put, if one country does not give protection to 10,000 refugees, taking up the slack ceteris paribus would mean other countries equally share the 10,000 refugees. Nonetheless, if a source country government does not ameliorate the infrastructure to address background conditions of vulnerability, it would be counter-intuitive to expect from individual health workers in particular6 to build roads. It is more fitting to delineate that slack taking implies extending health workers’ burdens due to the omissions of non-compliers. For instance, this could lead to an extension of the mandatory service duration to 3–4 years and/or with longer working hours. Second, what does fulfilling one’s fair share imply in partial compliance? When one party does not fulfil its duty, what other compliers are supposed to do in order to fulfil their fair share might change. Liam Murphy (2000) argues that while what exactly one has to do to fulfil one’s share might change, the net burden should stay the same. Suppose that an affluent country does not assist with a distribution of medical equipment or know-how necessary for adequate health care delivery. Then, fulfilling one’s fair share might imply conducting different forms of service or more administrative work without extending the service duration in terms of years or work hours. Doing Less than One’s Fair Share: Less or No Service One of the objections to placing burdens on individual health workers is that it would not be viable to promote basic health care delivery even if health workers would stay in the country for 2–3 years or take up the slack and stay even longer. What would really make a difference in institutional capacity building is more effort coming from affluent countries and better coordination from the local and national governments (Hidalgo, 2013). This is an effectiveness objection. Be that as it may, in the short term, the efforts of individual health workers might still bring viable results in promotion of the basic health needs of the population. Furthermore, there might be situations where affluent countries do not fulfil their fair share while source country governments do. The question remains that even if it is effective to expect health workers to do nothing short of their fair share, is it unfair to expect them to? The argument in favour of doing less than one’s fair share in partial compliance is that it sustains ‘the horizontal equity’ between different stakeholders (Miller, 2013: 216). The idea is that it is fair iff no one does more than the others (Miller, 2013; Stemplowska, 2016). Indeed, in the debate over refugee protection, this has a pretty straightforward implication: if a country reduces the amount of refugees it is supposed to accept, then the other countries should reduce the amount proportionately. In the case of health worker emigration, it would be fair for health workers to do less than their fair share in proportion7 to the level of non-compliance of other agents. Moreover, it seems especially unfair to expect relatively more underprivileged parties to do more than other parties. Luis Cabrera (2011) suggests that it is implausible for individual health workers to hold such responsibilities given their relatively underprivileged status in comparison to physicians trained in the affluent countries. Affluent countries and their citizens are the ones that have arguably benefited the most from past injustices or the hitherto recruiting of health workers from resource-poor countries. If said affluent countries do not fulfil their fair share, it would be unfair for already underprivileged parties, such as health workers, to be expected to fulfil their fair share. The best we can expect from them is to contribute as much as the others or proportionately less than what others do. However, it is not clear why the equity argument or relative disadvantage would defeat health workers’ responsibility to remain in the country to promote satisfaction of the basic health needs of vulnerable populations (Hohl and Roser, 2011; Miller, 2013). Two reasons can be given against health workers doing less than 2–3 years of service. First, the addressee of the health workers’ responsibility is the vulnerable population. Even if health workers may be relatively disadvantaged in comparison to affluent countries and their citizens, the vulnerable populations occupy an even less-advantageous position. Second, an argument can be made that individual health workers are responsible for what their fair share is. Murphy (2000) asserts this line of reasoning by taking the example of the duty to aid. The duty to aid is a collective responsibility that falls on everyone who can help (Stemplowska, 2016). Since individuals are the ones who can act, each individual should be fairly assigned their fair share to contribute to this collective responsibility to aid people in dire need—assuming full compliance (Stemplowska, 2016). Regardless of how others act, one is responsible for her share in contributing to the collective duty to aid. What matters primarily to Murphy is the fairness among the duty-bearers and a substantively fair distribution of responsibilities in between the agents (Stemplowska, 2016). Similarly, if we delineate the responsibilities of different agents to address the basic health care needs of vulnerable populations, and if the responsibilities are fairly distributed, then it should be considered fair that health workers fulfil their share regardless of what other duty-bearers do (Miller, 2013). Moreover, when health workers do not fulfil their fair share, they would be responsible for the part of the harm they inflict on others—even if it is much less than the harms inflicted by other parties’ non-compliance (Miller, 2013). If health workers have a responsibility to remain in the country and serve their compatriots for 2–3 years, this responsibility is there in the first place to address a certain risk of harm incurred by contagious diseases, epidemics and shortage of health workers. Failing to fulfil this responsibility would contribute to the harm in question—unless there is nothing to be achieved by fulfilment of the health worker’s fair share (Miller, 2013). Fulfilling One’s Fair Share So far, I have depicted the reasons why individual health workers should fulfil their responsibilities, which they originally hold under full compliance and nothing more. The implications of this argument warrant a little more scrutiny. One implication concerns the potential extra costs of fulfilling one’s share in partial compliance. Health workers might remain in the country for 2–3 years to provide health care delivery. However, if the local authorities do not fulfil their fair share, there are certain extra costs incurred on health workers, such as lack of proper medical equipment, increasing risks to contract diseases and lower compensation (Tsolekile et al. 2015; Chikanda 2006). These aspects can be considered an issue of demandingness8 but not necessarily a matter of fairness (Miller, 2013). Health workers might be asked to incur certain reasonable costs to fulfil their duties even under full-compliance. Imagine that health workers are supposed to conduct their service in less-than-decent working conditions. They might also struggle due to inadequate equipment, administrative inefficiency, and less remuneration. Arguably, fulfilling one’s fair share would be plausible as long as these costs do not reach the level of overdemandingness.9 However, how should unreasonable costs be assessed? Two alternative ways can be offered. First, we can assess if doing their own share would overly increase the costs and thereby infringe upon the interests and rights of health workers. The idea would be that extra costs should not reach to a level that they threaten the exercise of human rights or access to needs or capabilities (Brock, 2009). Alternatively, we can apply a certain test of proportionality and assess if these costs are substantially outweighed by what needs health workers address (e.g. basic health needs satisfaction). Taking up the Slack: Extending the Service The argument thus far is that once the responsibilities are delineated assuming full compliance, regardless of what others do, individual health workers should stay in the country for 2–3 years and address the basic health needs of the population. The extra costs of fulfilling their share should not be unreasonable and their service should be viable in that it is not compromised to the extent of ineffectiveness due to others’ omissions. Notably, the responsibilities to address or prevent harm are delineated assuming that everyone fulfils their responsibility. However, the situation under partial compliance is different than before (Stemplowska, 2016). Due to non-compliance by certain agents, the distribution of responsibilities might need to address the current situation where vulnerable populations’ health needs are at stake. If health workers have responsibilities, those responsibilities address remedying the potential harms and ill-health the populations might suffer from. Under such conditions, if there would be not any unreasonable costs, would it be unfair for individual health workers to also take up the slack if they can effectively do so? The problem with taking up the slack is twofold. First, there is a certain unfairness in addressing non-compliers’ fair share. Second, there is also an unfairness in incurring extra costs because of a non-complier’s omission10 (Hohl and Roser, 2011). Earlier I distinguished the fairness objection from the demandingness objection in favour of fulfilling one’s fair share even if that puts an additional yet reasonable costs on individual health workers. Suppose that the total costs of fulfilling one’s fair share and taking up the slack are proportional to what basic needs or human rights are served. However, the unfairness remains for (a) addressing others’ fair share, and (b) incurring additional costs as a result of, for instance, affluent countries’ omission. The unfairness lies in not only extending the years of service but also incurring more costs in doing so. The strength of the fairness objection then varies in relation to the costs of taking up the slack (Hohl and Roser, 2011). This becomes even more troubling when these extra costs such as indecent working conditions or less remuneration would be incurred by relatively less-privileged individual health workers because of more privileged agents’ non-compliance. As argued, I do not consider relative disadvantage of health workers plausible enough to defeat individual health workers’ fair share of responsibilities towards their compatriots who are also in a more underprivileged position. However, it is not fair to expect health workers to take up the slack and also incur more costs (even if the costs are reasonable) due to staying in the country for an extra 2–3 more years, because the more privileged agents do not fulfil their fair share. There is, however, still one way to argue for taking up the slack. Zofia Stemplowska (2016) asks that even if fairness among different duty-bearers is a significant value, why should it take ‘lexical priority’ over the value of helping those whose needs warrant responsibilities in the first place? Unfairness between different duty-bearers is not the only moral consideration in delineating how we should act. So this view does accept that taking up the slack might be unfair, yet the stakes are sometimes so high that addressing individual basic needs should outweigh the consideration of fairness in partial compliance. Miller (2013) accepts the intuitive appeal of this line of reasoning but asserts that taking up the slack should not be an enforceable duty. He makes a distinction between duties or duties of justice that can be enforced (if the enforcement is done in considerate and proportionate ways) and humanitarian duties that cannot be enforced (Owen, 2016: 149). Miller (2013) argues that taking up the slack should be considered a humanitarian duty that cannot be enforced. Nevertheless, in some cases, one might have an intuition that the parties should be enforced to take up the slack. Imagine that there are three surgeons attending a night shift in the emergency ward. Three different patients come in and they all require a much-needed operation to survive. Three surgeons fairly distribute the burdens and each takes up one patient. All of a sudden, one surgeon decides not to do the operation and goes home. What if the other two do not take up the slack?11 Many would intuitively think that the other two surgeons should also be subjected to a case of medical malpractice. If so, then we cannot treat taking up the slack in this case as a humanitarian duty, which cannot be enforced. However, two significant problems arise in the case of expecting health workers to take up the slack. Let us assume that the basic health needs of the population are strong enough to outweigh the considerations of fairness and, accordingly, health workers should extend their compulsory service. First, I am not sure if health workers would incur reasonable costs in taking up the slack in our case. Extending the service in a situation of partial compliance has many implications upon their basic needs, interests and basic liberties, such as the right to exit. Second, even if so, who would or could enforce such a duty? Even if the consideration of unfairness in taking up the slack is trumped by the dire needs of populations, there is another moral problem here about the enforcement. Is it ethically acceptable that non-complier parties will enforce health workers to take up the slack or even fulfil their fair share? Enforcing the Duties of Health Workers in Partial Compliance Let us start by further examining the enforcement of slack taking. As specified, in the case of health workers, slack taking would imply more years of service or working longer hours while incurring additional reasonable costs. Is it acceptable that non-complier source country governments enforce health workers to take up the slack? Suppose that a murderous person throws a child into a pond and I happen to pass by and witness the act. I would have a responsibility to save the child unless doing so would put me in an unreasonable risk of harm (e.g. the murderous person might still be there with a gun). What if said murderous person throws a child into the pond, and then forces me to save the child? There is something morally worrisome about this scenario. The worry here is not that I do not have a responsibility to fulfil my fair share or take up the slack, but that the party who imposes the situation for me to take up the slack is also the party who coerces me to do more. Similar concerns arise when considering how to enforce that health workers fulfil their fair share. Would it be fair that the source country governments who do not fulfil their fair share of duties (including their duties towards the health workers) enforce this duty? Remember that providing 2–3 years of service might bring about certain costs. I argued that as long as these costs do not reach the level of overdemandingness, it would be still fair that health workers do the service. However, the problem of enforcement is not about whether it is plausible to fulfil one’s fair share, but if it is plausible to be enforced to fulfil your fair share when the extra-costs (that are reasonable) exist partially because the enforcing party does not fulfil its duty. Then, under partial compliance, when affluent countries do not fulfil their responsibility, it would be permissible for source country governments to implement service programmes that require health workers to fulfil their fair share iff the source country fulfils its own share.12 Notably, the enforcement problem is not limited to source countries. It also extends to affluent countries. It has been discussed in the literature whether affluent countries should address the effects of skilled worker emigration by implementing immigration restrictions on skilled workers (Oberman, 2013). The enforcement problem would dictate that if they do not fulfil their fair share, it is not fair for them to enforce skilled workers to fulfil their responsibilities towards their compatriots. Finally, I would like to anticipate and respond to two potential objections or points. First one is a possibly counter-intuitive implication of my argument. What if affluent countries do fulfil their fair share while under-served countries do not? Would that give affluent countries a prerogative to restrict skilled worker emigration? First, this might lead to unforeseeable and unreasonable extra costs for health workers that should be accounted for. For instance, even if affluent countries transfer the necessary resources and know-how, if source country governments do not put them into an effective use, this would run into an objection of effectiveness or even demandingness. Second, if affluent countries do fulfil their fair share of responsibilities and ameliorate the working and living conditions in the source countries, this would likely motivate both source country governments and health workers to fulfil their fair share in the short-term, and in the long-term as the reason for restrictions would likely disappear. After all, the raison d'être of the discussion of this article is that the affluent countries do not fulfil their responsibilities. Second, it should be noted that the health worker responsibilities in partial compliance can be discussed explicitly by using different perspectives such as global luck egalitarianism or the concept of structural injustice. No doubt, the extent of fair distribution of responsibilities for different actors, one’s potential responsibilities in partial compliance, or the ways in which the enforcement is justifiable might diverge depending on one’s model of responsibility. Take the example of structural injustice approach where individuals are collectively held morally responsible for engendering certain socio-economic conditions or taking part in structures that render some more vulnerable to objectionable harms even if they are not directly liable for the said harm (Lu, 2018: 45). One may find more compelling reasons for individual health workers’ responsibility to assist that would then aim at eliminating the vulnerabilities produced by the socio-political structures in which they participate (Lu, 2018). Regardless, the question would still remain when and in what way it should be considered fair and reasonable for some agents to take up the slack, and this article lays the groundwork for alternative ways of discussing this question. Conclusion In this article, I discussed whether health workers in under-served and resource-poor regions should fulfil their fair share of responsibilities in order to address the basic needs satisfaction of their compatriots. To identify health workers’ fair share of responsibilities, I first discussed the responsibilities of affluent countries, source country governments and individual health workers in the short-term to address the effects of critical shortages of health workers. I assumed that it is plausible to expect a 2–3 years compulsory service in the short-term from health workers, even if the other parties fulfil their fair share. I then discussed if health workers should do a reduced service, fulfil their fair share or even take up the slack and extend their service when the other duty-bearers, such as affluent countries or source countries, do not fulfil theirs. I contended that if they can effectively conduct their 2–3 years of service without incurring unreasonable costs, then it is fair that they do so. I showed that there are plausible reasons against health workers doing less or taking up the slack. While it is still fair to expect health workers fulfil their fair share given it is their responsibility towards relatively more disadvantage populations, taking up the slack might be unfair as well as potentially too demanding. In the case of health worker emigration, the unfairness is also heightened if non-complier parties implement measures to enforce health workers to take up the slack. For similar reasons, it is also unfair for source country governments to enforce 2–3 years compulsory service if they do not fulfil their fair share. Footnotes 1. Luis Cabrera (2011), with a more cosmopolitan outlook, asserts that it would be also unfair to put burdens on skilled workers in resource-poor countries that would not also routinely be asked of those in affluent countries. 2. I am thankful to Erik Malmqvist for this example and raising this issue. 3. This description includes physicians, nurses and midwives. 4. Arguably, one might claim that this also implies free international movement for everyone. However, Brock (2009) also claims that to approximate global justice, certain restrictions on movement might be justifiable—as in the case of health worker emigration. As mentioned, in the scope of this article, I assume that there are justifiable restrictions. 5. No doubt, it might be morally arbitrary to offer 2–3 but not 1–2 or 4–5 years of service. However, 2–3 years of service is generally acknowledged to be effective, viable and not too demanding (Brock and Blake, 2015). 6. One might argue that it would be every citizen’s collective duty to build that road under the conditions of partial compliance. Regardless, this would not fall on health workers alone. 7. A tangible method would be needed to measure and define the parameters of ‘doing proportionately less’ for a health worker. 8. Miller (2013) treats the issue of demandingness or extra costs different than a matter of fairness. He suggests that the demandingness issue might nonetheless outweigh the fairness if the costs are too high to fulfil one’s fair share. 9. One might claim that if the other agents do not fulfil their fair share of responsibilities towards certain populations, we can safely assume that they also did not fulfil their responsibilities towards health workers. This might arguably add another layer of unfairness and not only extra costs, which may or may not be reasonable. To what extent this makes it also unfair that health workers fulfil their fair share is open to question. The partial compliance debate in discussing refugee protection or CO2 emissions do not sufficiently take into account either that the states might have other responsibilities towards each other that they do not fulfil. However, there might still be situations where affluent countries do not fulfil their fair share and the local governments do (and also towards the health workers). This issue will be taken into account when I investigate if non-complier parties have a right to enforce health workers’ responsibility to fulfil their fair share. 10. Hohl and Roser (2011) respectively call these relative disadvantage and extra burdens interpretations of unfairness. 11. I am thankful to Andreas Cassee for this example. 12. No doubt, as discussed, this is not to say that the source country governments can permissibly restrict emigration of health workers with no concern of their rights or demandingness of the compulsory service. 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Available online at www.phe.oxfordjournals.org This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
Public Health Ethics – Oxford University Press
Published: Dec 11, 2019
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