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Showing posts with label Amartya Sen. Show all posts
Showing posts with label Amartya Sen. Show all posts
Friday, 8 May 2015
2015 HDCA Conference - Nussbaum, Heckman, Zedillo, Benhabib and more!!
Tuesday, 6 January 2015
Universal healthcare: the affordable dream - Amartya Sen
Universal healthcare: the affordable dream - Amartya Sen
Original post can be found on Guardian webpage here
Twenty-five hundred years ago, the young Gautama Buddha left his princely home, in the foothills of the Himalayas, in a state of agitation and agony. What was he so distressed about? We learn from his biography that he was moved in particular by seeing the penalties of ill health – by the sight of mortality (a dead body being taken to cremation), morbidity (a person severely afflicted by illness), and disability (a person reduced and ravaged by unaided old age). Health has been a primary concern of human beings throughout history. It should, therefore, come as no surprise that healthcare for all – “universal healthcare” (UHC) – has been a highly appealing social objective in most countries in the world, even in those that have not got very far in actually providing it.
The usual reason given for not attempting to provide universal healthcare in a country is poverty. The United States, which can certainly afford to provide healthcare at quite a high level for all Americans, is exceptional in terms of the popularity of the view that any kind of public establishment of universal healthcare must somehow involve unacceptable intrusions into private life. There is considerable political complexity in the resistance to UHC in the US, often led by medical business and fed by ideologues who want “the government to be out of our lives”, and also in the systematic cultivation of a deep suspicion of any kind of national health service, as is standard in Europe (“socialised medicine” is now a term of horror in the US).
One of the oddities in the contemporary world is our astonishing failure to make adequate use of policy lessons that can be drawn from the diversity of experiences that the heterogeneous world already provides. There is much evidence of the big contributions that UHC can make in advancing the lives of people, and also (and this is very important) in enhancing economic and social opportunities – including facilitating the possibility of sustained economic growth (as has been firmly demonstrated in the experience of south-east Asian countries, such as Japan, South Korea, Taiwan, Singapore and, more recently, China).
Further, a number of poor countries have shown, through their pioneering public policies, that basic healthcare for all can be provided at a remarkably good level at very low cost if the society, including the political and intellectual leadership, can get its act together. There are many examples of such success across the world. None of these individual examples are flawless and each country can learn from the experiences of others. Nevertheless, the lessons that can be derived from these pioneering departures provide a solid basis for the presumption that, in general, the provision of universal healthcare is an achievable goal even in the poorer countries. An Uncertain Glory: India and its Contradictions, my book written jointly with Jean Drèze, discusses how the country’s predominantly messy healthcare system can be vastly improved by learning lessons from high-performing nations abroad, and also from the contrasting performances of different states within India that have pursued different health policies.
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Over the last three decades various studies have investigated the experiences of countries where effective healthcare is provided at low cost to the bulk of the population. The places that first received detailed attention included China, Sri Lanka, Costa Rica, Cuba and the Indian state of Kerala. Since then examples of successful UHC – or something close to that – have expanded, and have been critically scrutinised by health experts and empirical economists. Good results of universal care without bankrupting the economy – in fact quite the opposite – can be seen in the experience of many other countries. This includes the remarkable achievements of Thailand, which has had for the last decade and a half a powerful political commitment to providing inexpensive, reliable healthcare for all.
Thailand’s experience in universal healthcare is exemplary, both in advancing health achievements across the board and in reducing inequalities between classes and regions. Prior to the introduction of UHC in 2001, there was reasonably good insurance coverage for about a quarter of the population. This privileged group included well-placed government servants, who qualified for a civil service medical benefit scheme, and employees in the privately owned organised sector, which had a mandatory social security scheme from 1990 onwards, and received some government subsidy. In the 1990s some further schemes of government subsidy did emerge, however they proved woefully inadequate. The bulk of the population had to continue to rely largely on out-of-pocket payments for medical care. However, in 2001 the government introduced a “30 baht universal coverage programme” that, for the first time, covered all the population, with a guarantee that a patient would not have to pay more than 30 baht (about 60p) per visit for medical care (there is exemption for all charges for the poorer sections – about a quarter – of the population).
The result of universal health coverage in Thailand has been a significant fall in mortality (particularly infant and child mortality, with infant mortality as low as 11 per 1,000) and a remarkable rise in life expectancy, which is now more than 74 years at birth – major achievements for a poor country. There has also been an astonishing removal of historic disparities in infant mortality between the poorer and richer regions of Thailand; so much so that Thailand’s low infant mortality rate is now shared by the poorer and richer parts of the country.
There are also powerful lessons to learn from what has been achieved in Rwanda, where health gains from universal coverage have been astonishingly rapid. Devastated by genocide in 1994, the country has rebuilt itself and established an inclusive health system for all with equity-oriented national policies focusing on social cohesion and people-centred development. Premature mortality has fallen sharply and life expectancy has actually doubled since the mid-1990s. Following pilot experiments in three districts with community-based health insurance and performance-based financing systems, the health coverage was scaled up to cover the whole nation in 2004 and 2005. As the Rwandan minister of health Agnes Binagwaho, the US medical anthropologist Paul Farmer and their co-authors discuss in Rwanda 20 Years on: Investing in Life, a paper published in the Lancet in July 2014: “Investing in health has stimulated shared economic growth as citizens live longer and with greater capacity to pursue the lives they value.”
The experiences of many other countries also offer good lessons, from Brazil and Mexico (which have recently implemented UHC with reasonable success) to Bangladesh and the Indian states of Himachal Pradesh and Tamil Nadu (with progress towards the universal coverage that has already been achieved by Kerala). Bangladesh’s progress, which has been rapid, makes clear the effectiveness of giving a significant role to women in the delivery of healthcare and education, combined with the part played by women employees in spreading knowledge about effective family planning (Bangladesh’s fertility rate has fallen sharply from being well above five children per couple to 2.2 – quite close to the replacement level of 2.1). To separate out another empirically observed influence, Tamil Nadu shows the rewards of having efficiently run public services for all, even when the services on offer may be relatively meagre. The population of Tamil Nadu has greatly benefited, for example, from its splendidly run mid-day meal service in schools and from its extensive system of nutrition and healthcare of pre-school children.
The message that striking rewards can be reaped from serious attempts at instituting – or even moving towards – universal healthcare is hard to miss. The critical ingredients of success that have emerged from these studies appear to include a firm political commitment to the provision of universal healthcare, running workable elementary healthcare and preventive services covering as much of the population as possible, paying serious attention to good administration in healthcare and ancillary public services and arranging effective school education for all. Perhaps most importantly, it means involving women in the delivery of health and education in a much larger way than is usual in the developing world.
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The question can, however, be asked: how does universal healthcare become affordable in poor countries? Indeed, how has UHC been afforded in those countries or states that have run against the widespread and entrenched belief that a poor country must first grow rich before it is able to meet the costs of healthcare for all? The alleged common-sense argument that if a country is poor it cannot provide UHC is, however, based on crude and faulty economic reasoning.
The first – and perhaps the most important – factor overlooked by the naysayers is the fact that at a basic level healthcare is a very labour-intensive activity, and in a poor country wages are low. A poor country may have less money to spend on healthcare, but it also needs to spend less to provide the same labour-intensive services (far less than what a richer – and higher-wage – economy would have to pay). Not to take into account the implications of large wage differences is a gross oversight that distorts the discussion of the affordability of labour-intensive activities such as healthcare and education in low-wage economies.
Second, how much healthcare can be provided to all may well depend on the country’s economic means, but whatever is affordable within a country’s means can still be more effectively and more equitably provided through universal coverage. Given the hugely unequal distribution of incomes in many economies, there can be serious inefficiency as well as unfairness in leaving the distribution of healthcare entirely to people’s respective abilities to buy medical services. UHC can bring about not only greater equity, but also much larger overall health achievement for the nation, since the remedying of many of the most easily curable diseases and the prevention of readily avoidable ailments get left out under the out-of-pocket system, because of the inability of the poor to afford even very elementary healthcare and medical attention.
It is also worth noting here, as European examples richly illustrate, that providing UHC is compatible with allowing the purchase of extra services for the especially affluent (or those with extra health insurance), and the demands of UHC must be distinguished from the ethics of aiming at complete equality. This is not to deny that remedying inequality as much as possible is an important value – a subject on which I have written over many decades. Reduction of economic and social inequality also has instrumental relevance for good health. Definitive evidence of this is provided in the work of Michael Marmot, Richard Wilkinson and others on the “social determinants of health”, showing that gross inequalities harm the health of the underdogs of society, both by undermining their lifestyles and by making them prone to harmful behaviour patterns, such as smoking and excessive drinking. Nevertheless, the ethics of universal health coverage have to be distinguished from the value of eliminating inequalities in general, which would demand much more radical economic and social changes than UHC requires. Healthcare for all can be implemented with comparative ease, and it would be a shame to delay its achievement until such time as it can be combined with the more complex and difficult objective of eliminating all inequality.
Third, many medical and health services are shared, rather than being exclusively used by each individual separately. For example, an epidemiological intervention reaches many people who live in the same neighbourhood, rather than only one person at a time. Healthcare, thus, has strong components of what in economics is called a “collective good,” which typically is very inefficiently allocated by the pure market system, as has been extensively discussed by economists such as Paul Samuelson. Covering more people together can sometimes cost less than covering a smaller number individually.
Fourth, many diseases are infectious. Universal coverage prevents their spread and cuts costs through better epidemiological care. This point, as applied to individual regions, has been recognised for a very long time. The conquest of epidemics has, in fact, been achieved by not leaving anyone untreated in regions where the spread of infection is being tackled. The transmission of disease from region to region – and of course from country to country – has broadened the force of this argument in recent years.
Right now, the pandemic of Ebola is causing alarm even in parts of the world far away from its place of origin in west Africa. For example, the US has taken many expensive steps to prevent the spread of Ebola within its own borders. Had there been effective UHC in the countries of origin of the disease, this problem could have been mitigated or even eliminated. In addition, therefore, to the local benefits of having UHC in a country, there are global ones as well. The calculation of the ultimate economic costs and benefits of healthcare can be a far more complex process than the universality-deniers would have us believe.
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In the absence of a reasonably well-organised system of public healthcare for all, many people are afflicted by overpriced and inefficient private healthcare. As has been analysed by many economists, most notably Kenneth Arrow, there cannot be a well-informed competitive market equilibrium in the field of medical attention, because of what economists call “asymmetric information”. Patients do not typically know what treatment they need for their ailments, or what medicine would work, or even what exactly the doctor is giving to them as a remedy. Unlike in the market for many commodities, such as shirts or umbrellas, the buyer of medical treatment knows far less than what the seller – the doctor – does, and this vitiates the efficiency of market competition. This applies to the market for health insurance as well, since insurance companies cannot fully know what patients’ health conditions are. This makes markets for private health insurance inescapably inefficient, even in terms of the narrow logic of market allocation. And there is, in addition, the much bigger problem that private insurance companies, if unrestrained by regulations, have a strong financial interest in excluding patients who are taken to be “high-risk”. So one way or another, the government has to play an active part in making UHC work.
The problem of asymmetric information applies to the delivery of medical services itself. It makes the possibility of exploitation of the relatively ignorant a likely result even when there is plentiful market competition. And when medical personnel are scarce, so that there is not much competition either, it can make the predicament of the buyer of medical treatment even worse. Furthermore, when the provider of healthcare is not himself trained (as is often the case in many countries with deficient health systems), the situation becomes worse still. As a result, in the absence of a well-organised public health system covering all, many patients, denied any alternative, remain vulnerable to exploitation by unscrupulous individuals who robustly combine crookery and quackery.
While such lamentable conditions are seen in a number of countries, there are other countries (or states within countries) that, as has already been discussed, demonstrate the rewards of having a functioning universal public healthcare system – with better health achievements and also larger development of human capabilities. In some countries – for example India – we see both systems operating side by side in different states within the country. A state such as Kerala provides fairly reliable basic healthcare for all through public services – Kerala pioneered UHC in India several decades ago, through extensive public health services. As the population of Kerala has grown richer – partly as a result of universal healthcare and near-universal literacy – many people now choose to pay more and have additional private healthcare. But since these private services have to compete with what the state provides, and have to do even better to justify their charges in a region with widespread medical knowledge and medical opportunity, the quality of private medical services tends also to be better there than where there is no competition from public services and a low level of public education. In contrast, states such as Madhya Pradesh or Uttar Pradesh give plentiful examples of exploitative and inefficient healthcare for the bulk of the population. Not surprisingly, people who live in Kerala live much longer and have a much lower incidence of preventable illnesses than do people from states such as Madhya Pradesh or Uttar Pradesh.
A system of universal healthcare also has the advantage that it can focus on vitally needed – but often ignored – primary medical attention, and on relatively inexpensive outpatient care when a disease receives early attention. In the absence of systematic care for all, diseases are often allowed to develop, which makes it much more expensive to treat them, often involving inpatient treatment, such as surgery. Thailand’s experience clearly shows how the need for more expensive procedures may go down sharply with fuller coverage of preventive care and early intervention. Good healthcare demands systematic and comprehensive attention, and in the absence of affordable healthcare for all, illnesses become much harder and much more expensive to treat. If the advancement of equity is one of the rewards of well-organised universal healthcare, enhancement of efficiency in medical attention is surely another.
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The case for UHC is often underestimated because of inadequate appreciation of what well-organised and affordable healthcare for all can do to enrich and enhance human lives. It is one thing to accept that the world may not have the resources and the dexterity at this moment to provide the finest of medical care to all, but that is not a reason for eliminating our search for ways of proceeding towards just that, nor a ground for refusing to provide whatever can be easily provided right now for all. In this context it is also necessary to bear in mind an important reminder contained in Paul Farmer’s book Pathologies of Power: Health, Human Rights and the New War on the Poor: “Claims that we live in an era of limited resources fail to mention that these resources happen to be less limited now than ever before in human history.”
In addition, we have to take note of the dual role of healthcare in directly making our lives better – reducing our impoverishment in ways that matter to all human beings – as well as helping to remove poverty, assessed even in purely economic terms. Reduction of economic poverty occurs partly as a result of the greater productivity of a healthy and educated population, leading to higher wages and larger rewards from more effective work, but also because UHC makes it less likely that vulnerable, uninsured people would be made destitute by medical expenses far beyond their means. Here again, Thailand’s experience shows how penury caused by medical costs can fall rapidly once UHC is established.
The mutual support that healthcare and economic development can provide has been brought out very extensively by the results of UHC-oriented policies in south-east Asia, from Japan to Singapore. The complementary nature of health advancement and economic progress is also illustrated in the comparative experiences of different states within India. I remember being admonished 40 years ago, when I spoke in support of Kerala’s efforts to have state-supported healthcare for all. I was firmly told that this strategy could not possibly work, since Kerala was, then, one of the poorest states in India. The thesis of unaffordability was, however, wrongly argued for reasons already discussed. Despite its poverty, Kerala did manage to run an effective UHC programme that contributed greatly to its having, by some margin, the longest life expectancy in India and the lowest rates of infant and child mortality, among its other health accomplishments. But in addition to these so-called “social achievements”, it was possible to argue even in those early days – despite scorn from those who were opposed to UHC – that with the help of a more educated and healthier workforce, Kerala would also be able to grow faster in purely economic terms. After all, there are no influences as strong in raising the productivity of labour as health, education and skill formation – a foundational connection to which Adam Smith gave much attention.
This has actually happened. In fact, the previously poor state of Kerala, with its universal healthcare and universal schooling, now has the highest per capita income among all the states in India. Tamil Nadu and Himachal Pradesh, both of which have made substantial moves towards the provision of education and basic healthcare for all, have both progressed admirably and now belong solidly among the richer Indian states.
There is, thus, plenty of evidence that not only does universal healthcare powerfully enhance the health of people, its rewards go well beyond health. There is, indeed, a strong relationship between health and economic performance, and we have every reason to base public policy on a proper understanding of the nature and reach of what is clearly a positive interdependence. There is no mystery in all this given the centrality of health for better lives and for enhancing human capabilities.
Wednesday, 25 September 2013
India's Women: The mixed truth. - Amartya Sen
Originally posted by New York Review of Books. Find the original here.
India’s Women: The Mixed Truth
“I am not a boy, I am a girl,” wrote a twenty-one-year-old woman in Delhi, called Jyoti, who was studying at a medical college to be a physiotherapist. This was in a text message sent in December 2010 to a twenty-six-year-old man who worked in information technology and who had initially taken Jyoti to be a man. They met, and what began as a casual communication became a close friendship.
Two years later, on December 16, 2012, after they had seen a film, The Life of Pi, Jyoti was gang-raped with extreme brutality, and the man was severely beaten as he tried to protect her. They had been tricked into boarding a bus that seemed to be going their way and that had offered them a ride. It was a closed bus with darkened windows in which five determined rapists were waiting for their prey, with their impatience heightened, it is alleged, by the drugs they had taken. The battered bodies of the abused pair were dropped off on a lonely street, and by the time Jyoti received medical attention, she was on her way to death from the injuries, despite specialized medical care in Delhi, and later in Singapore.
The gang rape, including the violence accompanying it, not only got headlines in every serious Indian newspaper, it received continuous coverage around the clock on radio, television, and cable channels. It also led to large-scale public protests and demonstrations that continued for many days in Delhi as well as in other Indian cities, with agitated crowds—men and women—much larger than any seen before in protests of this kind. The insecurity of women, including their vulnerability to rape and abuse, became overnight a national issue in a way it had never been.
Public anger at gender inequality in India must be seen as an important—and long-overdue—social development, and it can certainly help in remedying the persistent inequalities from which Indian women suffer. It is, however, very important to understand the nature of female disadvantage in India, which can take many different forms. If the lack of safety of women is one aspect of it, the old phenomenon of “boy preference” in family decisions is surely another. Boy preference relates closely to the deep-rooted problem of what has been called “missing women,” which refers to the shortfall of the actual number of women from the number we would expect to see, given the size of the male population, and the female–male ratios that could be expected if there were symmetry in the treatment of women and men. There is, moreover, strong evidence that the economic and social options open to women are significantly fewer than those available to men; and going beyond women’s well-being, we have reason to ask also about women’s limited role in society and their ability to act independently, and how their initiatives and actions influence the lives of men as well as women, and boys as well as girls.
Numbers and Insecurity
One of the positive consequences of the agitation following the barbaric incident of December 16 has been to draw attention both to the prevalence of sexual brutality and rape in India, and to the failure of the media to report on it seriously, thereby limiting public discussion and the likelihood of social change. Even though Indians buy more newspapers every day than any other nation, the reporting of sexual assaults and sexual harassment had been quite rare in the widely circulated papers. It is, therefore, impressive and encouraging that newspapers in India, smarting from intense criticism of the negligence in their coverage, rapidly reinvented themselves as rape-reporting journals, and many of them have been devoting several pages every day to reports of rapes gathered together from all the different parts of India. This dramatic change is certainly a welcome development, but it can be asked whether the ongoing news reporting is well aimed and as helpful for public discussion as it could be.
How frequent is rape in India? If there are pages and pages of reports of rapes from across the country in the newspapers, the incidence must be high. There are, in fact, good reasons to believe that the majority of rapes go unreported in India, and the actual incidence of rape may be much higher (some estimates suggest that it is larger by a factor of five or more) than what gets recorded by the police. Based on the news coverage of rape across India, it has been argued, with some plausibility, that India has an extraordinarily high frequency of rape. To what extent is this the right way of thinking about India’s problem? Rape and brutality against women are not exactly unknown around the world. One question is whether rape is relatively more common in India than elsewhere, despite the increased attention it is now getting in Indian news reports.
In fact, if we go by the comparative statistics of reported rape, India has one of the lowest levels of rape in the world. The United Nations Office on Drugs and Crime found the incidence of rape in India for 2010 to be 1.8 per 100,000 people, compared with, for example, 27.3 in the US, 28.8 in the UK, 63.5 in Sweden, and 120.0 in South Africa. The number of recorded rapes in India is certainly a substantial underestimate, but even if we take five times—or ten times—that figure, the corrected and enlarged estimates of rapes would still be substantially lower in India than in the US, the UK, Sweden, or South Africa (even with the assumption that there is no underreporting in these other countries).
High frequency of rape may not be the real issue in India, but all the evidence suggests that India has a huge problem in seriously monitoring rape and taking steps to reduce it. The failure of the police to help rape victims and to ensure the safety of women is particularly lamentable. Following the December incident there were large clashes with the police by protesting crowds, not only because of the attempts by the police to break them up, but also because the demonstrators frequently confronted the police for their very poor record in dealing with this problem.
Even though the alleged rapists in the particular case on December 16 were picked up by the police quite quickly and promptly charged in court, the police were criticized for acting too slowly in giving emergency care when the raped victim and her beaten male friend were found lying on the street. Even in dealing with another terrible aspect of the December incident, the failure of people in passing cars to stop to help the victims (even though some of them did call the police), it was claimed that many passersby are afraid to get involved in a scene of criminal activity because of the fear that the police can—and often do—harass the good Samaritans who are found near the victims of crime, rather than searching diligently for the criminals who have fled the scene.
There was discussion also of the large number of cases in which the police seemed to doubt the credibility of a rape victim on the ground that the suspected rapist told a different story that seemed “equally credible” to the authorities. The Indian judicial system is itself extremely slow, and has not typically been able to rise to the challenge of bringing about speedy convictions of rapists and assaulters on the basis of the information provided by the victims. But the courts are certainly not well served by the unclear information provided by police reports on what exactly happened. From what we know, India’s problem may well lie not so much in a particularly high incidence of rapes, but in its inefficient policing, bad security arrangements, slow-moving judicial system, and, ultimately, the callousness of the society.
Legal Reform and Social Change
One of the salutary effects of the public agitation about women’s insecurity and the inadequacy of the law and policing was the appointment—within a week of the December 16 incident—of a Committee on Amendments to Criminal Law, chaired by a former chief justice of the Supreme Court of India, J.S. Verma, with two other leading jurists, Leila Seth and Gopal Subramanium, as members. Their report, which was thoroughly researched yet delivered in less than a month, led to a new law, enacted in Parliament by the end of March, aimed at providing more adequate, and quicker, legal remedy to violated or threatened women.
Some of the proposals of the Verma Committee were diluted in Parliament, and many human rights activists have plausibly criticized this weakening, including the continued failure to include among sexual offenses what is sometimes called “marital rape”—forced sexual activity with an unwilling partner. There are other gaps too in the parliamentary act; but taking everything into account, the new act is a substantial, though partial, step forward in dealing with gender injustice in India.
Four new provisions are important. First, the act has a broader and more inclusive definition of the crime of “sexual assault”: it includes, but goes beyond, what counts technically as rape. Second, there is a prima facie presumption of nonconsensual sex when the affected woman affirms (even if unilaterally) that there was no consent. Third, “sexual harassment”—common on the streets of some cities in India—is included among the list of criminal acts. Finally, there is a new emphasis on the criminality of the sexual trafficking of young women, mainly for the purpose of forced prostitution.
Such trafficking—sometimes even of very young girls—remains disturbingly common in India, although few serious statistics have been collected about it. There is, however, considerable evidence that the sex trade is indeed big business in India. And yet the newspapers are still shockingly negligent in their failure to investigate this area of darkness (unlike what has happened in the case of rape). Most cases of sexual trafficking involve young women from very poor families, and here the difficulty in getting authorities and journalists, among others, to cross class barriers in their care and concern—a distressingly general phenomenon in India—affects the zeal with which information is sought. There is a clear need for the new activism of newspapers to go well beyond the reporting and discussion of only rapes.
To some extent, the class barrier preventing information from being collected is a problem even in dealing with rapes, not just sex trafficking. Even though Jyoti came from a family of modest means (her father is a baggage loader at the airport), her family was upwardly mobile. It was easier for the Indian middle classes, including the educated middle classes, to take an immediate interest in the predicament of a young medical student than it would have been in the case of a rape of a poor and socially distant Dalit woman. There is a broad and urgent need to supplement the new provisions of the recently enacted law with ways to obtain and disseminate information about the treatment of women from the poorer classes.
There is also a regional dimension to the problem of women’s insecurity in India. It is clear that Delhi, where Jyoti’s rape occurred, has a very special problem that may not apply, in quite that form, to the other megacities in India. The rate of recorded rape per 100,000 people was 2.8 for Delhi in 2011, compared with 1.2 in Mumbai, 1.1 in Bangalore, 0.9 in Chennai, and 0.3 in Calcutta. Since there is nothing to indicate that keeping track of rape is much more efficient in Delhi than in the other cities, it is indeed remarkable that Delhi has a record that is more than nine times worse than Calcutta’s. No matter how unfriendly to women Indian society may be, huge differences exist between different regions of India, which apply to other kinds of gender inequality as well. In many ways India can be seen as a collection of distinct countries with diverse records, experiences, and problems.
Missing Women and Boy Preference
A distressing aspect of gender bias in India that shows little sign of going away is the preference for boys over girls. One of the most pernicious manifestations of this pro-male bias is the relatively higher mortality rates of girls compared with boys, not because girls are killed, but mainly because of the quiet violence of the neglect of their health and illness in comparison with the attention that male children receive. Studies have shown that male priority in care continues for adults as well as children, raising the mortality rates of adult women above those of men.
A distinct bias of “boy preference” can be found in countries extending from North Africa and West Asia to South Asia, including India, and East Asia, including China. That such discrimination has a place in a large part of the modern world is distressing: the number of “missing women” can be quite large. When I wrote on “missing women” in these pages in December 1990,* and also in the British Medical Journal, I based my conclusion on data available up to the 1980s. The missing women could be identified then as the result of the differences in mortality rates between men and women. These in turn reflected discrimination, mainly in health care, against girls and women.
Over the last couple of decades those kinds of discrimination have substantially declined in most of the countries I wrote about. Even though female mortality is still higher than male mortality for children in many Indian states, and the gap is even higher for infants in China, nevertheless in both China and India, and indeed in many of the other countries in the region, women now have a substantially higher life expectancy at birth than men.
However, since the 1980s, the wide use of new techniques such as sonograms for determining the sex of fetuses has led to huge—and growing—numbers of selective abortions of female fetuses, offsetting the gains in declining difference in mortality rates (as I discussed in the British Medical Journal in December 2003). Selective abortion of female fetuses—what can be called “natality discrimination”—is a kind of high-tech manifestation of preference for boys. Because of this counteracting influence, the proportion of missing women in the total population has not declined in many countries, including China and India. Women’s education, which has been a powerful force in reducing mortality discrimination against women and also in achieving other important social objectives such as the reduction of fertility rates, has not been able to eliminate—at least not yet—natality discrimination.
Still, we must not underestimate the effects of women’s education. There is definitive empirical evidence that women’s literacy and schooling cut down child mortality and work against the selective neglect of the health of girls. They are also the strongest influence, among all relevant causal factors, in cutting down fertility rates. The reduction of fertility that has taken place throughout India (and more sharply in Bangladesh) is clearly connected with the expansion of women’s literacy, which empowers women to have a stronger voice in family decisions. The lives that are most battered by excessive bearing and rearing of children are those of young women; any change that increases the force and impact of their voice, such as girls’ education and women’s ability to earn an independent income, has the effect of sharply reducing childbearing.
Bangladesh’s steep fall in total fertility rate from nearly seven children not long ago to 2.2 now (quite close to the replacement rate of 2.1) is strongly connected with the power of women to gain more control of their lives, and both girls’ education and women’s outside employment have done much to yield that result. I should also note here that even China’s shift from high fertility to below-replacement fertility can in many cases be more easily explained by women’s having more say, and more power, in family life—helped by education and greater economic independence—than by the draconian compulsions of its punitive “one-child policy.”
In India too, expansion of women’s schooling has contributed to its significant reduction in fertility rates. While the average of 2.4 children per family for the entire country is still above the replacement level of 2.1, this reflects a big fall from earlier rates, and nine of the twenty largest states of India have fertility rates now that are below the replacement level, which seems to reflect mainly the impact of the increased power of women to influence decisions about bearing children. Women’s education does not seem to be adequately effective in reducing discrimination against giving birth to girls; but it would be a mistake not to appreciate what female education clearly does achieve.
It is important to ask why women’s education and the corresponding enhancement of women’s voice and influence in family decisions have not done much to eliminate selective abortion of female fetuses. Educated mothers seem clearly less inclined to neglect girls compared with boys once they have been born; but they seem almost as keen on having boys rather than girls as uneducated mothers are. Here larger questions of enlightened understanding and scrutiny of traditional values become central and go beyond women’s role and influence in family decisions. There seems to be a lack of adequate awareness of the oddity of seeing girls as inferior to boys, and a lack of knowledge about what happens in other places where such discrimination against girls is not present.
An analogy can be drawn here with Adam Smith’s discussion, in The Theory of Moral Sentiments, of the willing acceptance of the alleged necessity of infanticide by intellectuals in ancient Greece. Smith quoted Plato and Aristotle in defense of infanticide. He thought that the hold of parochial values can be broken primarily by knowledge of what happens elsewhere and how other people think about the same problems. It was with respect to such parochialism that Smith emphasized the importance of considering how a local custom would look to people at “a certain distance from us,” which is a part of his thought experiment of invoking an “impartial spectator.” What is crucial here is not just freedom of action but also freedom of thought and the ability to overcome parochial boundaries of thinking.
In China and South Korea, the standard routes to women’s empowerment, such as female literacy and economic independence, have resulted in major achievements. But with the new techniques of sex determination of fetuses, discrimination through selective abortion of female fetuses became surprisingly common in both countries. This has led to organized public initiatives to make women aware of the value of having daughters and not just sons. Such efforts have had much more success in Korea than in China, where the female–male ratio at birth remains lower even than in India.
Contrasts Within India
While female education does not serve as a silver bullet to prevent discrimination against girls, other factors make the experience of the different regions within India quite diverse. In fact, there is a sharp regional divide. In the northern and western states, there is clear evidence of extensive use of selective abortion of female fetuses. In the states in the south and east of India, we do not typically find evidence of its widespread use.
Everywhere in the world more boys are born than girls, and the female–male ratio at conception is even more sharply biased in the direction of males (the standard ratio is often taken to be 910 conceptions of female fetuses compared with 1,000 male conceptions). But females do better than males in survival, if they have equal care, which they tend to get in the uterus. By the time births take place, the female–male ratio is around 940 to 950 females per 1,000 males in European countries. Between 2005 and 2010, the average ratio of females to males at birth for Europe as a whole was 943 females per 1,000 males.
There are variations within the European countries that cannot be plausibly attributed to the effects of presumed practices of sex-selective abortion; and so we have to accept a range of values for “normal” sex ratio at birth. Among the larger European countries, the female–male ratio at birth is 941 in Italy, 940 in Spain, 939 in Greece, and 935 in Ireland. If we take the ratio of 935 per 1,000 (the ratio for Ireland) as a standard against which to measure selective abortion of female fetuses, what can be said about the Indian states?
Since birth registration is incomplete in India, the ratios of girls to boys at birth are calculated by first looking at the actual numbers of girls and boys in the age group between zero and six (counted by the census), and then working backward to the female–male birth ratio by adjusting the zero to six figures for differences in mortality rates at specific ages between birth and age six. Using this method with the data provided by the 2011 census, it appears that all the states in the north and west of India, without exception, show absolutely clear evidence that sex-selective abortion is practiced to a much greater degree than is generally the case in the states in the east and south. Though many of the states even in the south and east have had some fall in female–male ratio among children between the censuses of 2001 and 2011, even in 2011 the female–male ratio at birth in the south and east of India remains not only substantially higher than in the north and the west, but also within the European range for such ratios.
Mike King
Estimated female-male ratio at birth, per 1,000 males
In fact, we can draw a dividing line to cut India into two halves (see the map above), with the states in the west and north (including Maharashtra, Gujarat, Madhya Pradesh, Uttar Pradesh, Rajasthan, Himachal Pradesh, Punjab, Haryana, Uttarkhand, and Jammu and Kashmir) showing clear evidence of widespread sex-selective abortion, with female–male ratios well below the cut-off line of 935 per 1,000 males. In fact, in all western and northern states this ratio actually is even below 920, and in many of these states well below 900.
This contrasts sharply with the figures for states in the east and south—Kerala, Karnataka, Tamil Nadu, Andhra Pradesh, Chhattisgarh, Jharkhand, Bihar, West Bengal, and Assam—all of which have ratios above 935 (with Odisha marginally so). In those states the use of sex-selective abortion, when present, is not on a scale to pull the female–male ratio below the cut-off line based on Irish figures. Incidentally, the data from Bangladesh, where the female–male ratio for the age-group zero to four years is 972, conform strongly to the pattern of eastern India, which it adjoins.
Why is there such a regional difference? I do not know of any convincing clear-cut answer to this question, even though the correspondence of these gender-specific differences with language groups and cultural practices offers fruitful lines of research. Any serious explanation will demand a much fuller understanding of the diversities between India’s different traditional cultures, as well differences in economic, political, and social influences.
While that important research must be done, there are many necessary actions that need not await the results of that research. There is a need for better policing and for greater media attention to neglected issues, including sexual trafficking and marital rape. There is an extremely powerful case for paying much more attention to schooling for girls, for more political and social discussion of the peculiarity—and the moral strangeness and inequity—of “boy preference,” and for more commitment by India’s mainstream political parties to address the issues central to gender inequality. There is a lot to do on the basis of what we do know, even as we remain engaged in finding out more about regional cultures and divergent behavior within India.
- *See my “ More Than 100 Million Women Are Missing,” The New York Review, December 20, 1990. ↩
Tuesday, 16 July 2013
Amartya Sen/ Jean Dreze new book An Uncertain Glory.
Original post can be found here
Amartya Sen: India's dirty fighter
Half of Indians have no toilet. It's one of many gigantic failures that have prompted Nobel prize-winning academic Amartya Sen to write a devastating critique of India's economic boom
The roses are blooming at the window in the immaculately kept gardens of Trinity College, Cambridge and Amartya Sen is comfortably ensconced in a cream armchair facing shelves of his neatly catalogued writings. There are plenty of reasons for satisfaction as he approaches his 80th birthday. Few intellectuals have combined academic respect and comparable influence on global policy. Few have garnered quite such an extensive harvest of accolades: in addition to his Nobel prize and more than 100 honorary degrees, last year he became the first non-US citizen to be awarded theNational Medal for the Humanities.
But Sen doesn't do satisfaction. He does outrage expressed in the most reasonable possible terms. What he wants to know is where more than 600 million Indians go to defecate.
"Half of all Indians have no toilet. In Delhi when you build a new condominium there are lots of planning requirements but none relating to the servants having toilets. It's a combination of class, caste and gender discrimination. It's absolutely shocking. Poor people have to use their ingenuity and for women that can mean only being able to relieve themselves after dark with all the safety issues that entails," says Sen, adding that Bangladesh is much poorer than India and yet only 8% don't have access to a toilet. "This is India's defective development."
Despite all the comfort and prestige of his status in the UK and the US – he teaches at Harvard – he hasn't forgotten the urgency of the plight of India's poor, which he first witnessed as a small child in the midst of the Bengal famine of 1943. His new book,An Uncertain Glory, co-written with his long-time colleague Jean Drèze, is a quietly excoriating critique of India's boom.
It's the 50% figure which – shockingly – keeps recurring. Fifty per cent of children are stunted, the vast majority due to undernourishment. Fifty per cent of women have anaemia for the same reason. In one survey, there was no evidence of any teaching activity in 50% of schools in seven big northern states, which explains terrible academic underachievement.
Despite considerable economic growth and increasing self-confidence as a major global player, modern India is a disaster zone in which millions of lives are wrecked by hunger and by pitiable investment in health and education services. Pockets of California amid sub-Saharan Africa, sum up Sen and Drèze.
The details are outrageous but the outlines of this story are familiar and Sen and Drèze are losing patience (they have collaborated on several previous books) and their last chapter is entitled The Need for Impatience. They want attention, particularly from the vast swath of the Indian middle classes who seem indifferent to the wretched lives of their neighbours. So they have aimed their critique at India's national amour-propre by drawing unfavourable comparisons, firstly with the great rival China but even more embarrassingly with a string of south Asian neighbours.
An Indian boy defecates in the open in one of New Delhi's slums. Photograph: AP Photo/Kevin Frayer
"There are reasons for India to hang its head in shame. Alongside the success, there have been gigantic failures," says Sen. He is making this critique loud and clear in the media on both sides of the Atlantic ahead of the book's launch in India this week. "India will prick up its ears when comparisons with China are made, but the comparison is not just tactical. China invested in massive expansion of education and healthcare in the 70s so that by 1979, life expectancy was 68 while in India it was only 54."
Sen and Drèze's argument is that these huge social investments have proved critical to sustaining China's impressive economic growth. Without comparable foundations, India's much lauded economic growth is faltering. Furthermore, they argue that India's overriding preoccupation with economic growth makes no sense without recognising that human development depends on how that wealth is used and distributed. What's the purpose of a development model that produces luxury shopping malls rather than sanitation systems that ensure millions of healthy lives, ask Drèze and Sen, accusing India of "unaimed opulence". India is caught in the absurd paradox of people having mobile phones but no toilets.
Even more stark is the comparison with Bangladesh. "Our hope is that India's public policymakers will be embarrassed by the comparison with Bangladesh. On a range of development indicators such as life expectancy, child immunisation and child mortality, Bangladesh has pulled ahead of India despite being poorer.'
What makes this comparison so powerful is that Bangladesh has targeted the position of women not just through government policy but also through the work of non-governmental organisations such as BRAC and the Grameen Bank. As a result, there have been astonishing successes, says Sen, such as a dramatic fall in fertility rate and girls now outnumbering boys in education. All this has been achieved despite having half the per capita income of India.
Other impoverished neighbours such as Nepal have made great strides, while even Sri Lanka has kept well ahead of India on key indicators despite a bitter civil war for much of the last 30 years. Drèze and Sen conclude in their book that India has "some of the worst human development indicators in the world" and features in the bottom 15 countries, along with Afghanistan, Yemen and Pakistan. Seven of the poorest Indian states account for the biggest concentration of deprivation on the globe.
Street scene in Delhi's Kathputli colony, where the houses have no running water, electricity or sanitation. Photograph: Donatella Giagnori/LatinContent/Getty Images
After this blizzard of facts and figures – and the book is stuffed with them – one might fear reader despair, but the reverse is true. This is a book about what India could do – and should do. Kerala, Tamil Nadu and Himachal Pradesh are held up as good examples of how social investments from the 60s to the 80s have reaped dividends in economic growth. What holds India back is not lack of resources but lack of clear-sighted, long-term policies and the political will to implement them. Sen (still an Indian citizen) is optimistic, pointing to the political mobilisation following the rape of a young woman student on a bus in Delhi last December, which led to the rapid adoption of new measures to combat violence against women. The consciences of the Indian middle classes can be stirred, and, when they are, political action follows.
But he admits "intellectual wonder" at how it is that more people can't see that economic growth without investment in human development is unsustainable – and unethical. What underpins the book is a deep faith in human reason, the roots of which he traces to India's long argumentative tradition going as far back as the Buddha. If enough evidence and careful analysis is brought to bear on this subject then one can win the argument, and it is this faith that has sustained him through more than five decades of writing on human development. It was his work which led to the development of the much cited UN's Human Development Index.
Influential he has certainly been, but he acknowledges he still hasn't won the argument. To his dismay, there are plenty of examples where people seem set on ignoring the kind of evidence he stacks up; in passing he asks: "How can anyone believe austerity with high levels of unemployment is intelligent policy for the UK?"
He laughingly comments that colleagues say his thinking hasn't evolved much, but he dismisses the idea of being frustrated. All he will concede is the astonishing admission that he wishes someone else had written this book on India. "There are a number of problems in philosophy which I would have preferred to tackle – such as problems with objectivity. But this book had to be written. I want these issues heard."
He says that the Nobel prize and the National Medal from President Obama may be "overrated" but they give him a platform, and he unashamedly uses it – giving time to media interviews and travelling all over the world to deliver speeches. That has led to compromises on the intellectual projects he would have liked to pursue, but life has been full of compromises ever since he narrowly survived cancer as an 18-year-old: there are all kinds of food he cannot eat as a result.
He is an extraordinary academic by any account – a member of both the philosophy and the economics faculties at Harvard – and is helping to develop a new course on maths while supervising PhDs in law and public health. He has plans for several more books and no plans to slow down. Mastery of multiple academic disciplines is rare enough but it's the dogged ethical preoccupation threading through all his work that is really remarkable. None of the erudition is used to intimidate; he is always the teacher.
Some argue that Sen is the last heir to a distinguished Bengali intellectual tradition that owed as much to poets as it did to scientists, politicians and philosophers. Sen is the true inheritor of Rabindranath Tagore, the great poet and thinker of the early decades of the 20th century. A family friend, he named Sen as a baby; the only photograph in Sen's Cambridge study is that of the striking Tagore with his flowing white beard.
But on one issue Sen admits he now parts company with Tagore, and instead he quotesKazi Nazrul Islam, Bengal's other great poet who became an iconic figure for the nation of Bangladesh. Tagore was too patient; Nazrul was the rebel urging action. And he repeats a quote he uses in the book: "Patience is a minor form of despair, disguised as a virtue." He wants change and that means he is about to embark on a demanding tour of Indian cities to promote the book. The doctors have told him that if he slows down it will be irrevocable, so he's decided not to. Retirement is not an option.
Monday, 18 March 2013
annual capabilities approach conference 9-12 September
The annual conference for the capabilities approach will be in Manuaga Nicaragua this year. Philosophers such as Joshua Cohen, Martha Nussbaum, and Amartya Sen will be speaking.
Deadline April 8th.
- NEW Extended Deadline for HDCA 2013 Conference Proposals: April 8th
The HDCA 2013 Conference will be held from
September 9-12 in Managua, Nicaragua, hosted by the Universidad Centroamericana.
The theme is Human Development: Inclusion, Vulnerability and Well-being. Please
visit the conference website to download the Call for Papers and get further
details: www.hdca2013.org
Below are the submission and registration
deadlines. Registration will open in the coming weeks – please watch the
conference and HDCA websites for more details.
Submission of
proposals: April 8, 2013
Announcement of acceptance/rejection: May 8, 2013
Registration with early–bird-fee: July 1, 2013
Submission full papers/posters: July 31, 2013
Registration with latecomer-fee: August 1, 2013
Announcement of acceptance/rejection: May 8, 2013
Registration with early–bird-fee: July 1, 2013
Submission full papers/posters: July 31, 2013
Registration with latecomer-fee: August 1, 2013
Latin America is a continent marked by entrenched inequality which
generates vulnerability. People have fewer opportunities to satisfy their basic
needs and cannot exercise or sustain valuable capabilities. For example,
inequality in access to education and basic social services limits people’s
opportunities to participate actively in economic, social and political life.
Therefore, reducing inequality requires an in-depth analysis of the causes and
persistence of social exclusion, particularly of specific social groups. The
design of social inclusion policies is central to human development and people’s
wellbeing. The 2013 HDCA International Conference aims at establishing
conceptual frameworks and programmes of action to reduce inequality,
vulnerability and social exclusion.
More information at:
Friday, 23 November 2012
Amartya Sen on social determinants of health
Johns Hopkins University
Provost's Symposium on the Social Determinants of Health
Amartya Sen's Keynote Address May 2012
Monday, 22 October 2012
Amartya Sen on Hume and global justice, etc.
Published on The New Republic (http://www.tnr.com) Original location here
The Boundaries of Justice
David Hume and our world.
- Amartya Sen
- December 14, 2011 | 9:31 pm
David Hume was born three hundred years ago, in 1711. The world has changed radically since his time, and yet many of his ideas and admonitions remain deeply relevant, though rather neglected, in the contemporary world. These Humean insights include the central role of information and knowledge for adequate ethical scrutiny, and the importance of reasoning without disowning the pertinence of powerful sentiments. They also include such practical concerns as our responsibilities to those who are located far away from us elsewhere on the globe, or in the future.
Hume's influence on the nature and reach of modern thinking has been monumental. From epistemology to practical reason, from aesthetics to religion, from political economy to philosophy, from social and cultural studies to history and historiography, the intellectual world was transformed by the enlightening power of his mind. In his own time, Hume’s ideas encountered considerable resistance from more orthodox thinkers. One result of this was his being rejected for philosophy chairs first at Edinburgh University and then at the University of Glasgow. Yet the influence of Hume’s ideas has grown steadily and powerfully over time. Indeed, as Nicholas Phillipson remarks in his insightful biography David Hume: The Philosopher as Historian: “David Hume’s reputation has never been higher.”
And yet some of Hume’s central but more iconoclastic ideas have not been brought adequately into contemporary discussion. This neglect continues despite the veneration of Hume as the quintessential “grand philosopher” of the Enlightenment. Many of Hume’s widely cited statements, which are often seen as “David Hume in summary,” fail to capture the largeness of the “understanding”—to use one of his favorite words—that Hume presented to us. The job is not made any easier by Hume’s tendency to make occasional remarks that suggest that he is “forgetting, or mis-stating, his [own] normative beliefs,” as Derek Parfit has recently pointed out in his farreaching philosophical work On What Matters. The issue is of importance, since some of the points that Hume seems to overlook in his occasional remarks had received decisive argumentative support in his own writings.
I BEGIN WITH a perspicacious remark that Hume made in 1751, in an essay called “Of Justice,” to be published later in An Enquiry Concerning the Principles of Morals. In the early days of the increasing globalization in which Hume lived, with new trade routes and expanding economic relations across the world, Hume talked about the growing need to think afresh about the nature of justice, as we come to know more about people living elsewhere, with whom we have come to develop new relations:
Again suppose, that several distinct societies maintain a kind of intercourse for mutual convenience and advantage, the boundaries of justice still grow larger, in proportion to the largeness of men’s views, and the force of their mutual connexions. History, experience, reason sufficiently instruct us in this natural progress of human sentiments, and in the gradual enlargement of our regards to justice, in proportion as we become acquainted with the extensive utility of that virtue.
The remark is of interest in itself, and also helps us to understand the general idea of justice, and its particular application to global justice, that can be seen to be part of the Humean line of analysis. But it can also be used to illustrate Hume’s general arguments for the need to interrelate ethics and epistemology, and moral reasoning and human sentiments.
The underlying approach to justice here contrasts with the influential view of Hobbes, according to which there has to be a sovereign state for us to entertain any coherent idea of justice. Hobbes was moved by the idea that institutional demands of justice can be met only within the limits of a functioning sovereign state, which is needed to establish and support the required institutions. While Hume was deeply concerned about the importance of institutions, on which he made many penetrating observations, he was reluctant to allow the idea of justice to be narrowed by the boundaries of sovereignty, as if there were no issues of global justice that could take us beyond our national borders.
The overarching concern in the idea of justice is the need to have just relations with others—and even to have appropriate sentiments about others; and what motivates the search is the diagnosis of injustice in ongoing arrangements. In some cases, this might demand the need to change an existing boundary of sovereignty—a concern that motivated Hume’s staunchly anti-colonial position. (He once remarked, “Oh! How I long to see America and the East Indies revolted totally & finally.”) Or it might relate to the Humean recognition that as we expand trade and other relations with foreign countries, our sentiments as well as our reasoning have to take note of the recognition that “the boundaries of justice still grow larger,” without the necessity to place all the people involved in our conception of justice within the confines of one sovereign state.
As it happens, contemporary theories of justice have largely followed the Hobbesian route rather than the Humean one. They have tended to limit their considerations of justice within the boundaries of a particular state. In an important essay in 2005 called “The Problem of Global Justice,” Thomas Nagel explained that “if Hobbes is right, the idea of global justice without a world government is a chimera.” The most influential modern theory of justice, namely John Rawls’s theory of “justice as fairness,” presented in his epoch-making book A Theory of Justice, concentrates on the identification of appropriate “principles of justice” that fix the “basic institutional structure” of a society, in the form of a cluster of ideal institutions for a sovereign state. This confines the principles of justice to the members of a particular sovereign state. It is worth noting that in a later work, The Law of Peoples, Rawls invokes a kind of “supplement” to this one-country pursuit of the demands of justice—but in dealing with people elsewhere, Rawls’s focus is not on justice, but on the basic demands of civilized and humane behavior across the borders.
Nagel, too, confines his analysis of global propriety not to the demands of justice, but to a “minimal humanitarian morality,” since he, too, takes the view that it is “very difficult to resist Hobbes’s claim about the relation between justice and sovereignty.” Hume’s exploration of how “the boundaries of justice” must “grow larger” in a more globalized world contrasts quite sharply with the Hobbesian way of thinking, and thus differs from the approach chosen by most of the contemporary theorists of justice. His approach has many implications for the way we should explore the idea of justice (a question I have attempted to address in my book The Idea of Justice, which draws also on other Enlightenment thinkers, particularly Adam Smith, Condorcet, and Mary Wollstonecraft).
THE REMARK BY HUME that I have cited throws light also on other parts of the understanding of ethics, epistemology, and practical reasoning that Hume presented. First, the remark fits well with Hume’s general argument that the understanding of justice must depend on what we know—that it is hard to make ethics stand free of epistemology. If there is a “gradual enlargement of our regards to justice” resulting from our expanding global contacts, this relates to Hume’s insistence that we cannot treat ethics as a freestanding field, dissociated from our understanding of the world, including what we know about each other. If we know nothing, or almost nothing, about a group of people, it is hard to talk about their needs, entitlements, or freedoms. We have good reason to pay more attention to the lives of others as we acquire greater knowledge of their lives, along with our growing connections with them.
Moreover, this understanding is not only important for ethics as a discipline, it tends also to be reflected, Hume argued, in people’s sentiments about whether we must take note of the lives of distant people as we come to know more about them. Hume clearly thought that this was a reasonable thing to do, and also that people’s sentiments would actually be influenced in precisely such a direction through the impact of their greater knowledge about others elsewhere. Hume’s understanding that the broadening of our concern is not only what reason demands, but what will affect our actual sentiments, makes such broadening difficult to brush off, since (as he put it in dealing with a related issue) “what affects us, we conclude can never be a chimera; and as our passion is engag’d on the one side or the other, we naturally think that the question lies within human comprehension; which, in other cases of this nature, we are apt to entertain some doubt of.”
The congruence of reason and sentiment, in this case, is in line with a general claim that Hume made elsewhere, in a somewhat exaggerated form (a form that he never seemed to spurn): that “reason and sentiment concur in almost all moral determinations and conclusions.” That such a concurrence could easily occur is worth noting partly because Hume also discussed cases in which there was no such concurrence (at least not spontaneously), and also because many formulations of “Hume in summary” concentrate almost exclusively on Hume’s remarks denigrating the role of reason in morality, in favor of sentiments, without noting that he did see them to be interrelated.
In the “summary Hume” that is frequently aired, it is also quite common to quote Hume against the possibility of reasoned ethics—for example, his speculation that reason is a “slave to the passions,” or his observation that “the rules of morality ... are not conclusions of our reason.” There are so many different things that Hume said on the relation between reason and ethics that it would be presumptuous of me to search here for some kind of definitive clarification of his overall position on the connections involved. But it is worth noting that immediately preceding the remark just quoted, about rules of morality not being conclusions of reason, Hume declares: “Morals excite passions, and produce or prevent actions. Reason of itself is utterly impotent in this particular.” (The italics are added.) The qualification “of itself” is important to note. This is, in fact, not an argument that reason is unimportant for morality or for motivating action. It argues only that reason cannot accomplish this entirely on its own.
Reason has to be about something, and clearly other factors, such as our knowledge of facts, are also involved in morality and practical reasoning (on which Hume wrote extensively). For reasoning to be influential in our lives and decisions, moreover, it has to sway people’s actual sentiments. (On this Hume also said a great deal.) This understanding can be seen in the context of delineating the way reasoning can work. These exercises of delineation do not in themselves undermine the important role of reasoning in ethics, nor entail any denial of the usefulness of reasoned argument about what we actually do know, or what our sentiments really are, or what they could be expected to be after critical scrutiny.
Hume had much use for reason whenever it could be sensibly deployed. The totality of his works richly illustrates his reason-dependent approach. While Hume expressed his frustration that “avidity alone, of acquiring goods and possessions for ourselves and our nearest friends” might well be “insatiable, perpetual, universal, and directly destructive of society,” or that people very often are too guided by self-interest in their thinking about justice, he also argued that there could be “moderation and abstinence” based on a reasoned understanding of the mutual dependence of people on each other. He points out, for example, that people “pull the oars of a boat by common convention for common interest, without any promise or contract,” and that their sense of justice is developed by thinking in “company and conversation.” The recognition that much of practical reasoning is conducted in company—a point that Gramsci would emphasize powerfully in his essays inL’Ordine Nuovo two centuries later—does not undermine the role of reasoning, but helps to characterize how it tends to occur.
The characterization also includes Hume’s treatment of what he called “experimental reasoning … which we possess in common with beasts, and on which the whole conduct of life depends.” At one level, this is, as Hume argued, “nothing but a species of instinct or mechanical power.” But experimental reasoning does not imply any absence of reasoning. The instinct that makes a person reluctant to put his or her hand into the fire is, as Hume discussed, both an instinct and an example of a species of reasoning. The instinct to keep our hand out of the fire is not unrelated to our seeing—and learning from others—what happens if an object like a hand happens to go into the fire, and this is what experimental reasoning is about. The net effect of this dual role is to extend the reach of reasoning—even to animals (the discussion cited here comes in an essay called “Of the Reason of Animals”)—rather than to deny that this type of decision could be compatible with any kind of reasoning since it is, in an immediate sense, just an instinct.
SIMILARLY, HUME’S insistence that the reach of ethical reasoning is, of necessity, limited is also a part of this delineation. Indeed, Hume thought that reasoning has a confined reach even in central issues of epistemology. We may not ever be able, as Hume points out, to “satisfy ourselves concerning any determination, which we may form, with regard to the origin of worlds, and the situation of nature, from, and to eternity.” But this did not prevent Hume from trying to see what can be sorted out through reasoning. Indeed, it is these efforts of reasoning that made Hume such a suspicious character to the religious establishment of his time. We have reason to pursue knowledge to the extent we can, undeterred by the recognition that we may not be able to resolve all the issues that arouse our interest and curiosity.
Great harm has been done to contemporary decision theory and the theory of rational choice by the presumption that reasoning can be given a role only if it is able to resolve every decisional problem. Indeed, understanding the incompleteness of our ordered information about the world, or stopping at incomplete—but articulate—orderings of alternative courses of action, is an integral part of human reasoning. The large subject of learning to rely on partial resolution, which is quite crucial in modern social choice theory, clearly has Humean antecedents. The usefulness of reasoning is not dependent on its being able to solve every problem at hand.
This understanding, which is still inadequately appreciated in decisional analysis, was championed already by Hume more than a quarter of a millennium ago. And I should add here that even the Hobbesian insistence on the need for a sovereign state for the possibility of saying anything coherent about justice, which allegedly makes any contemporary statements on “global justice” to be a “chimera,” closely relates to the assumption that no idea of justice can be viable unless it is able to resolve every putative claim of injustice. In this “all or nothing” view, we cannot seek an enhancement of justice through preventing famines, genocides, or gross subjugation of women in the world until a global sovereign state starts functioning and can meet all the institutional needs of a globally just world. This is indeed a far cry from Hume’s understanding of the gradual enlargement of “the boundaries of justice” in the world. And that understanding remains critically relevant as we try to remove patent injustices that plague our world.
WE LIVE IN a world in which a global vision is of extraordinary importance, and many of Hume’s arguments—on the broadening of the boundaries of justice, on the importance of knowledge in ethics, on the diversity of forms that human reasoning can take—are of central importance to such a vision. Our interdependent lives make nationally isolated pursuits of justice (segregated through sovereign states, whether or not involving “sovereign debts”) altogether inadequate in the way that Hume already diagnosed them to be in his far less integrated world. Like his friend Adam Smith, he was much concerned with broadening the narrow limits of contemporary ethical thought—a need that remains alive today.There are many different implications of Hume’s arguments for the necessity of broadening the understanding of justice as our knowledge about other people expands. The connection between reasoned ethics and the “progress of human sentiments” may help to explain the emergence of the so-called “anti-globalization” movement as a search—despite its misleading name—for a new global ethics with rapidly expanding economic globalization. A sense of cross-border grievance about massive global inequalities, with a particular concentration on the lives of the most deprived people in the world, finds expression—often quite crude expression—in these typically disorderly movements, which bring citizens from rich and poor countries to assemble in protest, in one city after another, converging from across the world. If we see these cross-border agitations, despite their simplistic slogans and noisy protestation, as part of a groping for more global justice, broadly in line with Hume’s anticipation of a “natural progress of human sentiments,” then the underlying ethics of at least one large part of these movements becomes easier to understand.
The search for more justice in the global world can also benefit from the Humean admonition about the need for empirical knowledge, particularly—in this case—about what works and what does not work (a subject that is central to contemporary development economics). This applies not only, say, to different forms of aid and assistance, but also to the role of education and health care in advancing development, including economic progress. Empirical understanding is also relevant for assessing how the market economy works, what it achieves and what it does not. If the economic crisis of 2008 is at least partly a reflection of being misled by the pure theory of infallible markets, it brings out sharply the practical importance of real knowledge about how markets can be expected actually to work.
The Humean pointer to the growing “boundaries of justice” with our knowledge about distant people also has immediate bearing on inter-generational ethics, particularly on the importance of a clearer understanding of the long-run impact of our environmental behavior on the lives of future people. The expansion of knowledge about how the lives and the predicaments of future generations may be affected by environmental deterioration, or—to take a different example—through nuclear proliferation, can much broaden the demands on the “boundaries of justice.” The importance of epistemology for ethics—for example, about whether or not there is “global warming” and to what extent human behavior is contributing to it—has never been stronger. This is particularly worth emphasizing, since the pursuit of serious knowledge relevant to justice, varying from economic causation to environmental connections, seems to be under some threat in the contemporary world.
Our world and our future may well depend on the understanding that we bring to bear on the interconnections between what we know, what we can reasonably expect, what we feel, what we have reason to consider, how our reasoning can come in many different forms, and how we should think about justice and injustice. There can be few things that are more important than that right now—no less than it was in Hume’s own time.
Amartya Sen teaches economics and philosophy at Harvard University and received the Nobel Prize in Economics in 1998. He is the author, most recently, of The Idea of Justice (Harvard University Press). A different version of this essay was given as a tricentennial commemorative lecture at Edinburgh University. This article originally appeared in the December 29, 2011, issue of the magazine.
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